Female

Reproductive System Imaging

sensitive thebest
primary firstchoice
 Methods of Radiologic Examination
I firstchoice 3 betterthan T.A.ggb c more
• Ultrasound (transabdominal or transvaginal) is detaismore
radiological
accepted as the primary imaging technique for anatomy endothicknes
examining the female pelvis. Currently, the main role
of ultrasound (US) in gynaecology includes
– Evaluation of a suspected pelvic mass
– Identification of endometrial abnormalities in a patient
with postmenopausal bleeding
– Characterization of ovarian masses
– Women with acute pelvic pain
confirm
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of urine

• CT is the most commonly used primary imaging

study for evaluating the extent of gynaecological
_TT
malignancy and for detecting persistent and
recurrent pelvic tumours
better thru CT forevacuation carcinoma
• MRI has been shown to be superior to CT in the
staging
work-up of uterine and cervical cancer and may be
a useful problem-solving tool in the evaluation of
ovarian cancer. In addition, there is evidence that
MRI may aid the differentiation of radiation fibrosis
from recurrent tumour
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Pelvic
 Abnormal Uterine Bleeding
• Excessive menstrual bleeding (menorrhagia)

• Nonmenstrual or intermenstrual bleeding

(metrorrhagia)

• Postmenopausal bleeding
 Common Causes
• PREMENOPAUSAL
Mostcommon • Ovulation (functional ovarian cysts) dysfunction in
• Cervicitis ovarian hormones
• Birth control pills oral Contraceptive
A• Leiomyoma fibroin
• Adenomyosis
simplecyst malignantcyst
• Malignancy defined
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 Common Causes
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• POSTMENOPAUSAL we can't differentiate b w them

maing a• Endometrial polyp in US so we have todofurther

• Endometrial hyperplasia investigation by Biopsy MRI SHG
9
• Endometrial cancer

appear as thickmint onUS

SHG
s
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Sonotysteography
of
transvaginal Us o d
transabdominal US
odd
 Ultrasound primary
• Combined transabdominal and transvaginal ultrasound
(TVUS) is the preferred initial imaging procedure for
detecting abnormalities of the female genital tract
• Sonohysterography: accuracy of US HSG exceeds that
of endovaginal US alone. US HSG can make a more
precise diagnosis in cases where endovaginal US only
shows abnormal thickening of the endometrium and can
differentiate intracavitary, endometrial and contrast 5 1
subendometrial pathology media in uterus
iue.int by
us
better than T v us

Magnetic resonance imaging MRI

•Very useful problem-solving tool (e.g., leiomyoma versus
uncaionalzone
adenomyosis)
A •Modality of choice for staging endometrial cancer
TU usat uterus showing
endometrial polyp

endometrial mass inside endometrialcavity

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 Infertility
Common Causes
• MALE FACTORS (40%)
• Deficient spermatogenesis
• Varicocele
• Cryptorchidism
• Retrograde ejaculation into the bladder
• Congenital anomalies
• FEMALE FACTORS (60%)
• Ovulatory dysfunction (20%)
• Tubal dysfunction (30%) diagnosed byHSG
• Cervical mucus dysfunction (5%)
• Other uterine abnormalities (5%)
 Hystrosalpingogrphy (HSG)
• Definition: imaging of the uterus and fallopian tubes by
injecting contrast media after cannulation of cervix with
special cannula
m in choiceis HSGIndications:
Ygethodft
g1. Infertility
tested
8
– Preferred imaging study for demonstrating
obstruction of the fallopian tubes (usually secondary
to scarring from pelvic inflammatory disease) and
uterine synechia (adhesions)

O
2. Repeated abortions
3. Abnormal uterine bleeding
O
4. Pelvic tumours
O
 Theraputic role
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 first choice for infertility

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Bilateral Hydro salpinx
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 Abnormal myometrium
• Fibroids: Maiay
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2.Intramural. minicam
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 urgical Hysterectomy

Normal ovarian appearance

I Just I
card
• Normal size = 3x2x2cm.
9
• Best by TVUS.
• Contain follicles (4-5mm). Es
• Prominent follicle (20-25mm). 2.5cm

or
Laffin follicle
which Rapture inmidcycle
 Normal ovary
transvaginal
t
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s so I 3

pf 08
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14 I f
henstraw
cycle
 l l il
Cyst
as simple f solidm s Soo Lttissue
s uv
Functional ovarian cyst cmis

disturbance
due to hormonal no pathology If
• Follicle fails to rupture.
• Thin wall. Clearcontent
Well define
• Unilocular. job's
• FUp to 5cm. Not more
 Polycystic ovaries
• Criteria of PCO syndrome.
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y• Oligomenorrhoea. ibid exsirehair
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• Hyperandrogen.f testestevoy
e I buckmus

• Ovarian enlargement in size.

• Multiple ovarian peripheral 2-9mm cysts.
of Androgen
All signs of increase
 Polycystic ovaries in event
in size

ululation
F
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multiple peripheral

p GIV j ovarian cyst

A size
 functional
Ovarian cysts 5cm not more
If
• Clinical presentation of ovarian cyst:
1.Asymptomatic pelvic mass. Josh 1 Suffering
2.Pain due to: torsion-rupture-haemrorhage-
infection.
acute abdomen simpTs I

if I
 Ibd IS
Ovarian cysts i I

exclusion of functional ovarian cyst functional W

O C
Checklist for ovarian cyst:
1.Measure
0 >O 5cm.
mainly
2.Unilocular or multilocular (malignant).
3.Solid component.
4.Wall thickness >3mm = malignant.
5.Nodule (malignant).
6.Contralateral ovary.
7.Ascites.
 Ovarian cysts mainly
fluid
simple content
•6 Functional cyst.
• Hyperstimulated ovary.
• Cystadenoma.
• Ectopic.
• Endometriouma.
• Peritoneal inclusion cyst.
 Ovarian cysts
Comp i infalo cyst7 t
malignancy nodule

cystbkfiiiaYL.com C
parent
mI oaiw
septation
more than 5cm
Solid component
 masswith
The
Solid component
Ovarian masses
• Fibroid.
• Fibroma.
• Secondaries.
• Abscess.
 Ovarian masses to
solid comp
witheystidegenration
ovarian

Consider as tumor
tuna

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Male Reproductive System
Imaging
Methods of Radiologic Examination
Superficial
• Ultrasound (US) continues to be the method
of initial choice for imaging the scrotal
Teng
contents. MRI has been assessed in patients
following an inconclusive US study.
• Computed tomography (CT) and MRI play a
major role in the staging
r
of testicular
malignancy and are used in the evaluation of

c
undescended testes that have not been
demonstrated sonographically

content
 normal Isestes
reptestes

trans recital US
epididymis
super
in one
in introit testes
port
• Radionuclide imaging is still employed in
some centres in the evaluation of acute
testicular torsion but, in practice, has now
r
E
been superseded by colour Doppler US
studies
• Contrast venography is undertaken to define
the anatomy of varicoceles
• Intravascular iodinated contrast media, both
venous and arterial, also play a part in the
assessment of male impotence but Doppler
US investigations may well be able to replace
many of these invasive investigations
 descended testes
Un
in inguinalligament

laboratory PSA markers

rien there
ifanymeat
pasta
examination or
prostate
 oScreening for Prostate
45

PSA tumor marker

Carcinoma o
sss To
Indications even
nunI see s

• If either the screening PSA study or the digital

rectal examination is abnormal, proceed
directly to Ultrasound trans rectal AMBI thebest abiopsy
• Screening prostate-specific antigen (PSA)
studies and digital rectal examination are
recommended for all men annually after age
s
50 (earlier if positive family history or genetic
screening)
e
Common Causes for increased PSA (>4ng/ml)
F cancer
1. Prostate
2. Benign prostatic hypertrophy
3. Prostatitis
4. Post prostate biopsy and surgery
trans rectal Ultrasound F I

• Signs suspicious but nonspecific for malignancy

include hypoechoic nodule in the peripheral zone,
asymmetric enlargement of the gland and areas of
increased vascularity on Doppler study
• Excellent for guiding systemic needle biopsy
rms rectal US is
not specific toA sizeof pr stye
T
MRI
•Magnetic resonance shows promise in localizing
prostate cancer for patients with elevated PSA
and repeated negative biopsies a
g
Radionuclide Scan bonyscan
•Single best modality for detecting skeletal
metastases (high frequency with prostate cancer)
 FREEBEE
HI
Undescended Testis
• Incomplete or improper prenatal descent of one
or both testes (occurs in about 3% of newborns;
most spontaneously descend, so that by age 1
the incidence is only 1%) Io
of I
followupafter Em sersionl it we
intunen
after aged I
• Long Term Complications:

get
– Infertility due to progressive failure of
spermatogenesis
– Increased risk of a malignant testicular neoplasm
developing
 61 Ultrasound
• Sensitive for demonstrating the often atrophic
undescended testis if it is located beyond the
internal inguinal ring.
• US is of no value if the testis is located in the pelvis
or abdomen
St
both for
Carcinomr CT and MRI
•CT scan most valuable for detecting the undescended
abdominal testis, but, it involves lot of radiation and
cannot detect an undescended testis smaller than 1 cm
MRI preferred approach for detecting undescended
Testes and for demonstrating all complications
(especially inflammatory or neoplastic)
Undescended testes in inghinalring
 Mainly do 1 Painless
lot pain
get
Scrotal Mass (Acute Pain)
fer e

s
Common Causes
• Testicular torsion (usually in patients younger than
age 20; characterized by more acute onset)
• Acute epididymo-orchitis (most common after age
20; more gradual onset, often with pyuria)
• Trauma
• Strangulated, incarcerated hernia
• Testicular cancer (10% of testicular cancers
present with acute pain)
asymptomatic
mainlyPainless
assessment of the vascularity
US with
 Ultrasound with Color Doppler
• Torsion: decreased or absent flow on the
0th symptomatic side No color Twisting cutting blood
i7coF supply
tn Acute
• Epididymo-orchitis: diffuse increase in blood flow
otm
on the affected side inflamation
sweoling
abd
g r na l
Morecolor Gf blood
supply on st
sodium
Dietscmn
gamannennan
Radionuclide Study IV
testicuin Sam
•Indicated if ultrasound is equivocal DD b
TS
•Torsion: round cold area surrounded by a rim of
increased radionuclide activity reflecting hyperemia
(doughnut sign)
•Epididymo-orchitis: a generalized increase in
vascular flow to the affectedeside hot scan
I I
bsurely I I Lssionwith 9 is 6 Iu of
f Mbsupply Ho bi IE's
 Color dopplerUS assesbloodvessels

normal Cold
B sat scan
testes
in color enlarged
7
Doppler e
Us Pain testes
DX testechler torsion
Pain general increase
in B s iiiwallow
enlarge
testes
hot scan

DX acuteepididymorchitis
 DX
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0
e

testicular
scan
6014
area

brim
hyperemia
 90 I
Scrotal Mass (Painless)
Common Causes
without pain lo's withPain
• Testicular Cancermostly
• Spermatocele or epididymal cyst
• Hydrocele; most common cause
• Congenital: Patent Processus Vaginalis
• Acquired: Trauma, Infection, Tumor
• Varicocele
• Inguinal Hernia
 Ultrasound
• Primary imaging alongwith physical examination;
localizes a mass to the testis and characterizes its
internal composition
• Hydrocele: fluid collections surrounding one or both
testes on anterior and lateral aspects
• Epididymal Cysts: Epididymal cysts may be single
or multiple and are discrete, well-defined structures
usually containing nonreflective fluid simple 1clear
• Varicoceles: Multiple serpiginous tubules of more
than 2 mm diameter posterior to the testis. Color
flow may be demonstrated on colour doppler US
 Ultrasound
hypotensity
• Testicular Tumors: hyporeflective compared
with the surrounding parenchyma and are well-
defined and homogeneous but may be
heterogenous
• Inguinal Hernia: Herniated sac containing bowel
loops or mesentery seen

All US
 well defind mass Commonly
Containing DX testicular carcinoma
clearfluid for
furtherevolution

contain
multipe homogenous masses
Solite component reflected
hypoechoginisty
DX rtecatal
simple epididymal cyst Tenth
parenchyma
or spermatocele

DX
varicocele
ep irriguin
ed MT

abnormal
suture
 inguinal d
hernia
isnotmali.snsize
fly d in serotm testes
inquired
Congintent acuteinte
Traun

non
refletin
fluid
r w

I
ji
 EeCT and MRI
• Most effective staging procedure for demonstrating
the presence and extent of extratesticular spread of
tumor I l b i J B A G T estealn th ne r 4
Eg 9
q
u
• CT of the lungs is also recommended for early
detection of frequent pulmonary metastases

Internal Spermatic Venography

•Internal spermatic venography is not commonly used
for the diagnosis of varicoceles but is undertaken for
venous mapping in the treatment of varicoceles by
embolotherapy
finish
 Male Urethra
Imaging Methods

• Retrograde urethrogram (RUG)

• Voiding cystourethrogram (VCUG)
 Retrograde urethrogram
(RUG)
• Retrograde urethrogram (RUG) provides
excellent evaluation of the anterior urethra and
may be performed to evaluate for suspected
urethral injury, stricture, or fistula.
• To perform a RUG, the fossa navicularis is
cannulated with a sterile balloon-tipped catheter
that is inflated with 1–2 mL saline. Subsequently,
approximately 10 mL of contrast is hand-injected
under fluoroscopy.
 Voiding cystourethrogram
(VCUG)
• Voiding cystourethrogram (VCUG) best evaluates
the posterior urethra and is typically performed for
evaluation of bladder and voiding function
• To perform a VCUG, a Foley catheter is sterilely
placed in the bladder and subsequently contrast is
instilled into the bladder. The patient initiates
urination during fluoroscopy