Normal Appearance of the Vaginal Cuff on Ultrasound

Normal vaginal cutoff on ultrasound (US) following hysterectomy.

The vaginal cuff is the apex of the vagina after hysterectomy where the upper walls are sutured together. It can be a site of recurrent malignancy after hysterectomy in patients with cervical or endoemtrial cancer, being more common in the former case.

The normal vaginal cuff is "small, symmetric, and homogeneously hypoechoic, with a thin central echogenic line that represents the vaginal mucosa." Bulky, nodular, or heterogeneous appearance may represent recurrent tumor or radiation fibrosis in a patient with history of cervical or endometrial cancer. The size of the normal cuff can be up to about 2 cm. There is no statistically significant difference in the size of the vaginal cuff in women with transabdominal hysterectomy compared to those with transvaginal hysterectomy.

Patients who have undergone supracervical hysterectomy have a cervical remnant and not a vaginal cuff. The cervical remnant is larger than the vaginal cuff, with mean transvaginal dimensions of about 3 cm.

Without knowing the history, a prominent soft tissue mass in the lower pelvis may be due to recurrence in a patient with abdominal or transvaginal hysterectomy or represent normal finding in a patient with a supracervical hysterectomy. Look for the vaginal mucosa to help determine if it's a vaginal remnant. Nabothian cysts will be seen in cervical remnants in patients with supracervical hysterectomy.

The image shown here is a normal vaginal cuff in a patient with a transabdominal hysterectomy for fibroids. We don't really see the echogenic vaginal mucosa, but the whole thing is within normal limits of size and is pretty homogeneous.

References

Stein MW, Grishina A, Shaw RJ, Roberts JH, Ricci ZJ, Adachi A, Freeman K, Koenigsberg M. Gray-scale and color Doppler sonographic features of the vaginal cuff and cervical remnant after hysterectomy. AJR Am J Roentgenol. 2006 Nov;187(5):1372-6.