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Normal Pelvis MRI Report Template (Female, Non-Obstetric)
Normal female pelvis MRI report template: uterine zonal anatomy, endometrial thickness, cervix, ovaries by volume and follicles, adnexa, bladder, rectum, pelvic nodes and bones, with notes on O-RADS MRI, adenomyosis and fibroid FIGO mapping.
EXAMINATION: MRI pelvis with and without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Pelvic pain”] COMPARISON: None available. TECHNIQUE: Multiplanar T2-weighted, axial T1, axial in- and opposed-phase, diffusion-weighted and dynamic post-contrast fat-suppressed T1 images of the pelvis after the intravenous administration of [x] mL of [gadolinium-based contrast agent]. Sagittal and oblique images were obtained along the uterine axis. FINDINGS: Uterus: [Anteverted, anteflexed.] Normal size, measuring [x] x [x] x [x] cm. Normal zonal anatomy with a distinct, uniformly thin junctional zone, measuring [x] mm. No fibroid or focal myometrial lesion. No evidence of adenomyosis. Endometrium: Normal thickness for [premenopausal / postmenopausal] status, measuring [x] mm. Homogeneous signal. No endometrial mass or fluid. Cervix: Normal zonal anatomy, with preserved low-signal fibrous stroma. No cervical mass. Nabothian cysts [absent / present, as expected]. Vagina: Unremarkable. Right ovary: Normal size and morphology, measuring [x] x [x] x [x] cm, with physiologic follicles. No adnexal mass. Left ovary: Normal size and morphology, measuring [x] x [x] x [x] cm, with physiologic follicles. No adnexal mass. Fallopian tubes: Not distended. No hydrosalpinx. Pelvic peritoneum: No free fluid beyond a trace physiologic amount in the cul-de-sac. No peritoneal nodularity, implant or endometriotic plaque. Bladder: Normal wall thickness. No intraluminal lesion. Rectum and sigmoid colon: Normal wall thickness. No mass. The rectouterine space is clear. Lymph nodes: No enlarged pelvic or inguinal lymph nodes. Bones and soft tissues: Normal marrow signal. No pelvic floor hernia. The visualized pelvic musculature is symmetric. IMPRESSION: 1. Normal MRI of the female pelvis. Normal uterus and ovaries. No adnexal mass, endometriosis or pelvic lymphadenopathy.
Dictation notes
- Report the junctional zone thickness and whether it is uniform — a junctional zone of 12 mm or more, or focal thickening with myometrial T2 cysts, is adenomyosis, and the distinction from a fibroid (well-circumscribed, mass effect) decides between hysterectomy and myomectomy.
- Map every fibroid by FIGO type (0-2 submucosal, 3-5 intramural, 6-7 subserosal, 8 other), size and T2 signal — a cellular, T2-bright fibroid responds to embolization and GnRH agonists, a degenerated one does not.
- Characterize any adnexal lesion with the O-RADS MRI score: cystic, fatty or endometriotic without enhancing solid tissue is O-RADS MRI 2; solid tissue with a time-intensity curve is scored by curve type, and the score replaces “indeterminate”.
- Endometrial thickness is read against menopausal status and bleeding; a postmenopausal endometrium above 5 mm with bleeding, or above 11 mm without, is a sampling recommendation.
- Deep endometriosis is a search, not a finding — torus uterinus, uterosacral ligaments, rectovaginal septum, bowel wall and bladder dome are each named as normal or involved, because the surgical team books the room by that map.
Related references
O-RADS ultrasound and MRI reference
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