Recording Location of a Left Posterior Uterine Fibroid
For a uterine fibroid on the left posterior wall, document it as "left posterior" along with its specific relationship to the myometrial layers using the FIGO classification system 1, 2, 3.
Standardized Documentation Approach
The location should be recorded systematically to ensure clear communication and treatment planning:
Essential Components to Document
1. Anatomical Position:
- Wall location: Left posterior (as in your case)
- Vertical position: Fundal, corporeal (body), or lower uterine segment
- Specific examples: "left posterofundal," "left posterior corporeal," or "left posterior lower segment" 4
2. FIGO Classification (Critical for Treatment Planning):
The FIGO system describes the fibroid's relationship to the endometrium and myometrium 2, 3:
- Type 0-2: Submucosal (extends into cavity)
- Type 3-4: Intramural with endometrial contact
- Type 5: Intramural (entirely within myometrium)
- Type 6: Subserosal (>50% intramural)
- Type 7: Subserosal (<50% intramural)
- Type 8: Pedunculated subserosal
Your documentation should read: "Left posterior [FIGO Type X] fibroid"
Additional Required Information
Per ACR guidelines 1, imaging reports must include:
- Size: Measure in three dimensions (length × width × height in cm)
- Number: Total count if multiple fibroids present
- Vascularity: Document on Doppler imaging 1
- Distance from serosa and endometrium: Particularly important for surgical planning 3
Imaging Modality Considerations
Transvaginal ultrasound (TVUS) should be your primary documentation tool, as it provides 90-99% sensitivity for detecting fibroids 1. The combination of transabdominal and transvaginal approaches gives the most complete assessment 1, 5.
For complex cases or surgical planning, MRI with contrast provides superior characterization of location, number, and fibroid characteristics 1.
Common Documentation Pitfalls to Avoid
- Don't use vague terms like "posterior wall fibroid" without specifying left/right and vertical position
- Don't omit FIGO classification - this directly impacts treatment selection, particularly for minimally invasive procedures 6, 3
- Don't forget to document relationship to adjacent structures - the cul-de-sac position is particularly relevant for posterior fibroids 5
Clinical Relevance
Posterior wall location matters because 4, 7:
- Posterofundal fibroids are most common in the 35-44 age group
- Posterior location may cause different pressure symptoms (rectal pressure, back pain)
- Surgical approach differs based on anterior versus posterior location
Bottom line: Write "Left posterior [specify fundal/corporeal/lower segment] FIGO Type [X] fibroid, measuring [dimensions], with [describe vascularity]" to provide complete, standardized documentation that guides treatment decisions.