CD B [RADIO]: FEMALE AND MALE GENITAL TRACT

MAY 2018

FEMALE GENITAL TRACT  US

 Ultrasound is the primary imaging modality for the evaluation of  Typically heterogeneous and vary from hypoechoic to
the female genital tract and pelvis hyperechoic
 Indications:
 Infertility MYOMAS
 Pelvic pain
 Disorders of menstruation
 Abnormal or limited physical examination
 Suspicion of mass or infection
 Localization of IUD

UTERUS
 Smoothly contoured pear shaped in postpubertal women
 Cigar shaped in prepubertal and infants
 Endometrium is distinctly more echogenic than the myometrium
 Maximum uterine dimensions in adult women: 9 cm (length), 6 cm
(width), 4 cm (AP diameter).
 Atrophies to 6 x 2 x 2 cm following menopause
 Positions of the uterus:
 Anteverted (most common) – tilted forward
 Retroverted – tilted backward toward the sacrum
 Anteflexed – folded anteriorly
 Retroflexed – folded posteriorly

MULTIPLE LEIOMYOMAS
 MRI
 A midsagittal T2WI of the pelvis demonstrates multiple
leiomyomas (L), which greatly enlarge and distort the uterus.
 The endometrial cavity (e) of the uterus and the cervix (c) are
clearly demonstrated. B, bladder; V, vagina.

LEIOMYOMAS (FIBROIDS)
 Common benign smooth muscle tumors of the myometrium
 Virtually always multiple
 May be completely within the myometrium, subserosal, or
submucosal
 Uncomplicated leiomyomas may be isoechoic, hypoechoic, or
hyperechoic compared to normal myometrium.
 May undergo atrophy, internal fibrosis, and calcification
correspondingly, they involute with menopause.
 The tumors are responsive to female hormones and pregnancy.
 Plain film radiograph:
 Popcorn pattern of calcification is characteristic and
definitive

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CD B: RADIO | FEMALE AND MALE GENITAL TRACT
MAY 2018

ADENOMYOSIS
 Benign disease of the uterus characterized by the presence of
ectopic endometrial glands and stroma within the myometrium,
eliciting surrounding myometrial hypertrophy.
 Presentation: dysmenorrhea or menorrhagia
 US: no definite nodule is seen.

NORMAL CORPUS LUTEA

 Formed by rupture and collapse of dominant follicle during
ovulation.
 Function: secrete progesterone and estrogen
 Initially appears as solid, vascular portion of the ovary (collapsed cyst
appearance)
 Forms small cystic mass (<3cm) often with internal echoes, fluid
ENDOMETRIUM
levels, or mesh like internal structure (hemorrhagic cyst appearance).
 US examination should always be correlated with the state of
 Walls are thicker than that of normal follicles
menstrual cycle.
 Color Doppler: intense vascular “ring of fire”

ADNEXA
 Refers to the ovaries, fallopian tubes, broad ligament, ovarian and k
 OVARIES
 US demonstrates the ovaries as oval soft tissue structures with
multiple cystic follicles and show characteristic morphological
changes during menstrual cycle
 Normal follicles range up to 15 mm in size, dominant follicle
may be 30 mm in diameter
 22 cc – maximum ovarian volume (adult)
 6 cc – maximum ovarian volume for postmenopausal
women
 FALLOPIAN TUBES FUNCTIONAL OVARIAN CYST
 Not visualized on US unless enlarged  Most common ovarian mass
 BROAD LIGAMENT  Normal: small cyst up to 3.0cm
 Clearly visualized when outlined by pelvic fluid  Pathologic: follicular cyst up to 20cm
 May rupture or undergo torsion
 Round, smooth, usually unilocular ovarian cyst that resolves in 1 or
2 menstrual cycles
 Anechoic thin–walled cysts (simple cysts) that fail to resolve after 2
menstrual cycles  maybe neoplasms (cystadenomas or benign
cystic teratomas)

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CD B: RADIO | FEMALE AND MALE GENITAL TRACT
MAY 2018

 Acute:
 US demonstrates a complex ill-defined adnexal mass that often
includes a dilated, pus-filled fallopian tube, swollen ovary, and
adhesions to adjacent structures.
 Echogenic, purulent, fluid is usually present in the cul-de-sac.
 Chronic:
 Manifest as hydrosalpinx or peritoneal inclusion cyst

HYDROSALPINX
 Can produce large complex cystic mass
 US:
 Thin- walled or thick-walled tubular mass that is commonly
HEMORRHAGIC OVARIAN CYSTS elongated and folded on itself
 Result from hemorrhage into a follicle or the corpus luteum.  Commonly caused by PID or endometriosis
 S/S: abrupt onset of pelvic pain, pelvic mass
 Common in premenopausal unless they are taking hormone-
replacement therapy
 Findings:
 Cystic mass with internal echoes
 Accentuated through – transmission reflects its cystic nature
 Wall thickness is variable (2-20mm)
 Blood flow in the wall is commonly prominent
 Internal echogenicity depends upon the physical state of the
hemorrhage
 The cyst may appear solid, but color flow US show no internal
blood vessels

 Hysterosalpingography
 Retroflexed uterus (U), with the fundus (f) directed posteriorly
and inferiorly.
Fine internal echoes with a fishnet appearance of thin, linear, fibrous strands (red  The left fallopian tube is occluded at the isthmus (black arrow).
arrows) characteristic of hemorrhage
 The right fallopian tube (open arrow) is massively dilated at its
Color doppler demonstrates lack of internal blood flow
distal end, forming a hydrosalpinx (HS).
 Occlusion of the right fallopian tube is confirmed by the
absence of peritoneal spill. The curved arrow indicates the
POST-MENOPAUSAL OVARIAN CYSTS
cervical cannula.
 Benign serous inclusion cysts
 US features:
 Small size less than 5 cm
 Smooth thin walls of uniform thickness less than 3 mm
 Anechoic fluid contents
 Absence of septation, nodules or any soft tissue component

PELVIC INFLAMMATORY DISEASE (PID)

 Refers to acute or chronic inflammation of the fallopian tubes,
ovaries, and pelvic peritoneum
 S\S: pain, fever , and vaginal discharge
 Causes: Gonococcus, chlamydia, anaerobic bacteria, and
tuberculosis

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CD B: RADIO | FEMALE AND MALE GENITAL TRACT
MAY 2018

 Diagnosis: confirmed by plain radiograph  demonstrates teeth or

bone
 CT or MR confirmation of fat content is definitive.

ENDOMETRIOSIS
 Occurrence of aberrant functional endometrial tissue outside the
uterus
 Common in ages 25-35 yrs and present with infertility and chronic
pelvic pain
 Tiny implants (1-2mm) of endometrial tissue on the peritoneum that
are not visualized by US.
 Larger deposits form cystic masses filled with old, echogenic blood
“Chocolate Cyst” or endometrioma
 Endometriomas: wide range of appearance as single, or OVARIAN MALIGNANCY
multiple, adnexal masses with diffuse low-level internal echoes.  A solid component to an ovarian lesion is the most significant
predictor of malignancy;
 Irregular thick wall and septa > 3mm;
 Doppler demonstration of central blood flow within a solid
component.

POLYCYSTIC OVARY SYNDROME

 Is a clinical and biochemical diagnosis based on findings of oligo-
OVARIAN TUMORS or anovulation, clinical and / or biochemical signs of
BENIGN CYSTIC TERATOMAS hyperandrogenism (hirsutism), and polycystic ovaries
 Also called Dermoid cysts  Patient with anovulatory menstrual cycles, especially young female
 Benign germ cell tumors athletes – may have ovaries with multiple follicles but lack clinical
 Common in aged 10-30 years features of polycystic ovary syndrome.
 Most common ovarian neoplasm
 Bilateral in 15-25% cases
 Predominantly cystic
 Presence of mature ectodermal elements a results in formation of
bone, teeth, and hair give them a complex and varied appearance
 3 most common appearances:
 Most characteristic appearance is a cystic mass with complex
fluid and a mural nodule  “ Dermoid plug”
 Fluid – fluid levels, representing fatty sebum floating on
aqueous liquid are common
 “Tip of the iceberg” appearance of an amorphous echogenic
Polycystic ovaries  enlarged and contain multiple follicles (> 12 follicles per
mass that fades into acoustic reverberation and shadowing
ovary); Visualized follicles are less than 10cc with no dominant follicle (>10cc)
 Multiple fine echogenic strands representing hair within the
present.
cyst cavity

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CD B: RADIO | FEMALE AND MALE GENITAL TRACT
MAY 2018
MALE GENITAL TRACT
TESTIS
 Oval sperm-producing gland having upper and lower poles
 It is suspended by the spermatic cord in the scrotal sac and is
covered by a tightly adherent fibrous capsule called the tunica
albuginea
 Tunica is thickened posteriorly and forms a fibrous septum –
mediastinum testis
 Multiple fibrous septae divide the testis into lobules.
 Tunica albuginea, mediastinum and fibrous septae connect to form
the support and internal architecture of the testis
 Normal US Anatomy
 The normal testes is ovoid and smooth, measuring
approximately 3.5 cm in length and 2.0 to 3.0 cm in diameter
 US demonstrates the testes to be homogeneous in
echogenicity
 Covered by the tunica albuginea
RADIOLOGY OF THE TESTIS
 Ultrasound
 Oval structures having a homogeneous granular echotexture
with uniform medium-level echoes
 Mediastinum may be identified as a linear echogenic band
running superolaterally
 Fibrous septae dividing the lobules may sometimes be
appreciated as linear echogenic thin bands running through
the testis.
 On longitudinal scans, the upper and lower poles are identified
 Vessels are often identified running through the testis and
hypoechoic linear structures
 Magnetic resonance imaging
 Tunica albuginea, mediastinum testis and fibrous septae are of
low signal intensity compared with the high signal intensity of
normal testicular tissue on T2-weighted imaging
 Testis is of homogeneous low signal intensity on T1-weighted
imaging
UNDESCENDED TESTIS
 3% of full-term newborns have an undescended testis
 Most will spontaneously descend by 1 year of age. Spontaneous
descent after 1 year of age is unlikely.
 To preserve fertility, orchiopexy is recommended by 2 years of age.
 May be located anywhere along the course of descent, from the
lower pole of the kidney to the superficial inguinal ring
 Most are identified by US and are within the inguinal canal (70% to
80%)
 Most undescended testes are atrophic, as small as 1 cm in size, and
appear hypoechoic compared to normal testis.
Longitudinal views of the normal testis and undescended show that the
undescended testis that is located in the inguinal canal is smaller
TESTICULAR TORSION
 Results from anomalous suspension of the testis by a long spermatic
cord with associated complete investment of the testis and
epididymis by the tunica vaginalis, resulting in the testis being not
securely anchored to the scrotum.
 This anatomic variant is usually bilateral and has been termed the
bell-clapper deformity
 Surgical correction within 6 hours of torsion will usually preserve
testicular function.
 Peak ages for testis torsion are the newborn period and ages 13 to
16 years
 US findings of acute torsion include:
 Enlargement of the testis and epididymis, with a diffuse but
sometimes heterogeneous decrease in echogenicity because
of edema.
 The spermatic cord is enlarged and the Doppler signal from the
spermatic cord is decreased or lost.
 Demonstration of normal flow on one side and absent or decreased
flow on the symptomatic side provides the most reliable evidence
of torsion and testicular ischemia
 Spectral Doppler
 Shows no evidence of blood flow within the testis (T).
 Careful examination with color flow US confirmed this finding.
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MAY 2018

SCROTUM EPIDIDYMIS
 Tunica vaginalis  Highly convoluted tubule that is tightly applied to the posterior
 A peritoneal membrane that forms a closed serous sac that aspect of the testis.
covers the medial, anterior, and lateral aspects of the testis and
the lateral aspect of the epididymis.  Head of the epididymis (globus major)
 This space normally contains 1 to 2 mL of fluid.  7- to 8-mm-diameter
 Excessive fluid in this space is termed a hydrocele.  Superior portion of the epididymis adjacent to the superior
 Spermatic cord pole of the testes.
 Formed at the internal inguinal ring, courses through the  Body of the epididymis
inguinal canal and abdominal wall, and suspends the testes in  1 to 2 mm in diameter
the scrotum.  Courses caudally along the posterolateral testis
 Consists of the ductus deferens; the testicular, deferential, and  Tail (globus minor)
external spermatic arteries; the pampiniform plexus of veins;  The pointed lower extremity of the epididymis at the lower pole
lymphatic vessels; and the covering cremaster muscle. of the testis.
 Enlargement of the pampiniform plexus of veins is termed
a varicocele. RADIOLOGY OF THE EPIDIDYMIS
 Ultrasound
 Head of the epididymis is seen resting on the upper pole
posteriorly
 Body of the epididymis is seen posterolateral to the testis
 Spermatic cord is medial to the epididymis

 Anatomy of the normal scrotum. Coronal MR images show that the

normal testis has intermediate signal intensity on T1-weighted
images (a) and high signal intensity on T2-weighted images (b),
with homogeneous enhancement on contrast-enhanced images(c).
 The tunica albuginea surrounds the testis and has low T1 and T2
signal intensity.
 The rete testis radiates from the mediastinum testis to the surface
of the tunica, best seen on contrast-enhanced images.
 The epididymis (arrowhead) is slightly heterogeneous and
isointense relative to the testis on T1-weighted images, hypointense
on T2-weighted images, and slightly hyperintense on contrast-
enhanced images.
 A normal amount of fluid surrounds the right testis; however, there
is a small left hydrocele (*). The corpora cavernosa (arrow) of the
penis are seen en face.

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CD B: RADIO | FEMALE AND MALE GENITAL TRACT
MAY 2018

SEMINAL VESICLES  Transrectal US

 Routinely viewed inverted.
 Transrectal US
 The transducer is at the bottom rather than the top of the
 Hypoechoic, lobulated, tubular structures (arrow) in the groove
image.
between the base of the bladder (B) and the base of the
 This sagittal image shows the normal peripheral zone (arrow)
prostate
to be slightly echogenic compared to the hypoechoic, more
heterogeneous central gland (G).

PROSTATE
 Normal US Anatomy  The central and peripheral zones are nearly equal in
 A rounded organ at the base of the bladder echogenicity and are usually distinguished mainly by position.
 Divided into three glandular zones surrounding the urethra  yields uniform, low level echoes
 Peripheral zone  It is useful to describe the gland on US as having peripheral
 Approximately 70% of the prostate tissue
zone and an inner gland comprised of central and transitional
 Most prostate cancers (70%) arise in this zone zones.
 Transitional zone
 The anterior fibromuscular stroma is seen as hypoechoic area
 Consists of two small areas of periurethral glandular
at the anterior superior aspect of the gland.
tissue - site of benign prostatic hypertrophy
 Ultrasound measurements are used to calculate the volume of
 Central zone
the prostate gland using the formula width x height x length
 Consists of the glandular tissue at the base of the
x 0.52.
prostate, through which course the ducts of the vas
deferens and seminal vesicles and the ejaculatory
ducts
 With aging, the transition zone hypertrophies and the central zone
atrophies.
 70% of prostatic cancers arise in the peripheral zone of the gland.
 Benign prostatic hypertrophy – affects the transition zone in the
central gland.
 Major indication for transrectal US of the prostate gland
 To guide needle biopsy for diagnosis of prostate cancer
 Additional indications for US:
 MRI
 Detection of abscess or infertility with suspicion of obstruction
 Excellent method of imaging the prostate.
of the ejaculatory ducts or atresia of the seminal vesicles
 Zonal anatomy is seen on the T2-weighted image.
 Examination of the posterior urethra
 The peripheral zone is of uniformly high intensity and contrasts
with the intermediate signal intensity of the transitional and
RADIOLOGY OF THE PROSTATE
central zones.
 On transabdominal US through the distended bladder
 Seminal vesicles are seen posterior to the prostate and bladder
 Prostate is seen as a rounded organ at the base of the bladder.
on axial and sagittal images.
 Enlargement of the prostate elevates the bladder base

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 CT scan
 Gland is seen as a round structure of soft-tissue density inferior
to the bladder.
 Poor for assessment of prostate zonal anatomy and pathology
 With adjusted window settings:
 Central zone appears hyperdense between 40-60HU
 Peripheral zone appears hypodense between 10-25HU
 Useful staging metastatic spread
 Seminal vesicles are convoluted structures above the prostate
between bladder and rectum.

BENIGN PROSTATIC HYPERTROPHY

 Nodular hypertrophy of the glandular tissue of the transitional zone,
usually beginning in the fifth decade of life
 Transitional zone becomes enlarged and heterogeneous and
compresses the urethra and the central zone
 The size of the prostate exceeds 30 g (mL).
 The prostatic urethra becomes elongated, tortuous, and
compressed, causing bladder outlet obstruction.

Source: PPT only!

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