Reproductive system

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Chapter 6 Reproductive system

Methods of imaging the female reproductive system

1. Plain abdominal film
2. Hysterosalpingography
3. Ultrasound (US) – transabdominal/transvaginal
4. Computerized tomography (CT)
5. Magnetic resonance imaging (MRI)
6. Arteriography (including embolization of fibroids).

Methods of imaging the scrotum and testes

1. US
2. MRI
3. Radionuclide imaging
4. Arteriography
5. Venography (including embolization of varices).

Further reading

Akin O., Mironov S., Pandit-Taskar N., et al. Imaging of uterine cancer. Radiol. Clin. North Am.. 2007;45(1):167-182.

Barakat R.R., Hricak H. What do we expect from imaging. Radiol. Clin. North Am.. 2002;40(3):521-526. vii

Fütterer J.J., Heijmink S.W., Spermon J.R. Imaging the male reproductive tract: current trends and future directions. Radiol. Clin. North Am.. 2008;46(1):133-147. vii

Hysterosalpingography

Indications

1. Infertility
2. Recurrent miscarriages: investigation of suspected incompetent cervix, suspected congenital anomaly
3. Following tubal surgery, post sterilization to confirm obstruction and prior to reversal of sterilization
4. Assessment of the integrity of a caesarean uterine scar (rare).

Contraindications

1. During menses
2. Pregnancy
3. A purulent discharge on inspection of the vulva or cervix, or diagnosed pelvic inflammatory disease (PID) in the preceding 6 months
4. Contrast sensitivity (relative).

Contrast medium

High osmolar contrast material (HOCM) or low osmolar contrast material (LOCM) 300/320. Volume 10–20 ml.

Equipment

1. Fluoroscopy unit with spot film device
2. Vaginal speculum
3. Vulsellum forceps
4. Uterine cannula, Leech-Wilkinson cannula, olive or 8-F paediatric Foley catheter or hysterosalpingography balloon catheter 5-F or 7-F.

Patient preparation

1. The patient should abstain from intercourse between booking the appointment and the time of the examination, unless she uses a reliable method of contraception and the appointment is made before day 21, or the examination can be booked between the 4th and 10th days in a patient with a regular 28-day cycle.
2. Apprehensive patients may need premedication.
3. Consent should be obtained.1

Preliminary film

Coned postero-anterior (PA) view of the pelvic cavity.

Technique

1. The patient lies supine on the table with knees flexed, legs abducted.
2. Using aseptic technique the operator inserts a speculum and cleans the vagina and cervix with chlorhexidine.
3. The anterior lip of the cervix is steadied (vulsellum forceps may be used but positioning the speculum can often achieve this) and the cannula is inserted into the cervical canal. If a Foley catheter is used, there is usually no need to grasp the cervix with the vulsellum forceps. The catheter should be left within the lower cervical canal if cervical incompetence is suspected.
4. Care must be taken to expel all air bubbles from the syringe and cannula, as these would otherwise cause confusion in interpretation. Contrast medium is injected slowly into the uterine cavity under intermittent fluoroscopic control.
5. Spasm of the uterine cornu may be relieved by intravenous (i.v.) glucagon.

N.B. Opiates increase pain by stimulating smooth muscle contraction.

Films

Using the undercouch tube:

1. Early, mid and full uterine filling
2. As the tubes begin to fill: isthmic and ampullary phases
3. When peritoneal spill has occurred and with all the instruments removed
4. If a balloon has been inflated in the cavity then this should be deflated or withdrawn and a further film taken to show the lower uterine cavity.

Aftercare

1. It must be ensured that the patient is in no serious discomfort nor has significant bleeding before she leaves.
2. The patient must be advised that she may have bleeding per vaginam for 1–2 days and pain may persist for up to 2 weeks.
3. Prophylactic antibiotics should be given for at-risk groups, e.g. hydrosalpinx or tubal adhesions.

Complications

Due to the contrast medium

Allergic phenomena – especially if contrast medium is forced into the circulation.

Due to the technique

1. Pain may occur at the following times:

a Using the vulsellum forceps
b During insertion of the cannula
c With tubal distension proximal to a block
d With distension of the uterus if there is tubal spasm
e With peritoneal irritation during the following day, and up to 2 weeks.

2. Bleeding from trauma to the uterus or cervix.
3. Transient nausea, vomiting and headache.
4. Intravasation of contrast medium into the venous system of the uterus results in a fine lace-like pattern within the uterine wall. When more extensive, intravasation outlines larger veins. It is of little significance when water-soluble contrast media are used. The following factors predispose to intravasation:

a Direct trauma to the endometrium
b Timing of the procedure near to menstruation
c Timing of the procedure within a few days after curettage
d Tubal occlusion because of the high pressures generated within the uterine cavity
e Uterine abnormalities, e.g. uterine tuberculosis, carcinoma and fibroids.

5. Infection – which may be delayed. Occurs in up to 2% of patients and more likely when there is a previous history of pelvic infection.
6. Abortion. The operator must ensure that the patient is not pregnant.

ULTRASOUND OF THE FEMALE REPRODUCTIVE SYSTEM

Indications

1. Pelvic mass
2. Pregnancy – normal and suspected ectopic
3. Precocious puberty or delayed puberty
4. Pelvic pain
5. Assessment of tubal patency
6. In assisted fertilization techniques
7. Postmenopausal bleeding
8. Menstrual problems.

Contraindications

None.

Patient preparation

1. Transabdominal – full bladder
Transvaginal – empty bladder
2. Patient consent.1
It is always advisable to have a chaperone.

Equipment

5–10-MHz transducers.
Colour Doppler is useful in the assessment of complex adnexal mass lesions helping to differentiate retracted clot from solid components with a blood supply.

Contrast medium

Galactose monosacharride microparticles (Echovist) are used as a specific contrast agent employed in the assessment of tubal patency; spillage of the microparticles into the peritoneal cavity infers patency.

Reference

1 General Medical Council. Consent: Patients and Doctors Making Decisions Together. London: General Medical Council, 2008.

Further reading

Ascher S.M., Reinhold C. Imaging of cancer of the endometrium. Radiol. Clin. North Am.. 2002;40(3):563-576.

Bates J. Practical Gynaecological Ultrasound, 2nd edn. Cambridge: Cambridge University Press, 2006.

Bhatt S., Ghazale H., Dogra V.S. Sonographic evaluation of ectopic pregnancy. Radiol. Clin. North Am.. 2007;45(3):549-560.

Funt S.A., Hann L.E. Detection and characterization of adnexal masses. Radiol. Clin. North Am.. 2002;40(3):591-608.

Ultrasound of the Scrotum

Indications

1. Suspected testicular tumour
2. Suspected epididymo-orchitis
3. Hydrocoele
4. Acute torsion. In boys or young men in whom this clinical diagnosis has been made and emergency surgical exploration is planned, US should not delay the operation. Although colour Doppler may show an absence of vessels in the ischaemic testis, it is possible that partial untwisting resulting in some blood flow could lead to a false-negative examination
5. Suspected varicocoele
6. Scrotal trauma.

Contraindications

None.

Patient preparation

Consent.

Equipment

7.5–15 MHz transducer. Linear array for optimum imaging. Stand-off may be helpful in some cases.

Technique

1. Patient supine with legs together. Some operators support the scrotum on a towel draped beneath it or in a gloved hand.
2. Both sides are examined with longitudinal and transverse scans enabling comparison to be made.
3. Real-time scanning enables the optimal oblique planes to be examined.
4. In comparing the ‘normal’ with the ‘abnormal’ side, the machine settings should be optimized for the normal side, especially for colour Doppler. They should not be changed until both sides have been compared.
5. Patient should also be scanned standing upright and a Valsalva manoeuvre can be performed if a varicocoele is suspected.

Further reading

Kim W., Rosen M.A., Langer J.E., et al. US MR imaging correlation in pathologic conditions of the scrotum. Radiographics. 2007;27(5):1239-1253.

Pearl M.S., Hill M.C. Ultrasound of the scrotum. Semin. Ultrasound CT MR.. 2007;28(4):225-248.

CT of the Reproductive System

Indications

1. Staging ovarian cancer
2. Staging germ cell tumours

Technique

See “routine staging scan” as described in chapter 5 (page 140).

MAGNETIC RESONANCE IMAGING OF THE REPRODUCTIVE SYSTEM

Indications

1. Staging of cervical and uterine cancer
2. Characterization of complex ovarian mass
3. Suspected Mullerian tract anomalies
4. Investigation of endometriosis
5. Staging of ovarian cancer, although CT is often preferred
6. Assessment of pelvic floor
7. Scrotal MR can be used, generally after US, to further characterize a mass as intra or extra testicular and to determine the location of intra-abdominal undescended testis
8. Localization and morphology of uterine fibroids prior to consideration for uterine artery embolization.

Artifacts

Artifact from small-bowel peristalsis and, to a lesser extent, colonic peristalsis can occasionally be a problem in the pelvis and glucagon may be used to minimize this. Respiratory artifact is less of a problem in the pelvis than in the upper and mid abdomen. Movement from anterior abdominal wall fat can be suppressed using a saturation band.

Pulse sequences

For midline structures (uterus, cervix and vagina) sagittal T1-weighted and T2-weighted spin-echo sequences can be augmented with further axial sequences angled to regions of interest as required. Inclined axial images perpendicular to the long axis of the uterus or the long axis of the cervix are helpful for uterine and cervical abnormalities respectively.

The ovaries may be assessed with axial and coronal T1-weighted and T2-weighted spin-echo sequences. T1-weighted fat saturated sequences are used to identify haemorrhage (e.g. within endometriomas) and to help characterize fat-containing masses.

Perfusion imaging of the uterus can be used to assess the effectiveness of uterine fibroid therapy.

MRI is also used to measure the pelvic outlet in pelvimetry in order to avoid radiation dose.

Scrotal MR is generally performed with the scrotum supported as in US, using a surface coil. High-resolution axial, sagittal and coronal T2-weighted spin echo scans are obtained with a T1-weighted scan to identify haemorrhage. Large field-of-view (FOV) scans should be performed to assess the inguinal canal for the presence of a hernia. Gadolinium i.v. can be given if necessary to assess perfusion. Scans should include the pelvis and kidneys if an undescended testis is being investigated.

Further reading

Brown M.A., Martin D.R., Semelka R. Future directions in MR imaging of the female pelvis. Magn. Reson. Imaging Clin. N. Am.. 2006;14(4):431-437.

Burn P.R., McCall J.M., Chinn R.J., et al. Uterine fibroleiomyoma: MR imaging appearances before and after embolization of uterine arteries. Radiology. 2000;214(3):729-734.

Coakley F.V. Staging ovarian cancer: role of imaging. Radiol. Clin. North Am.. 2002;40(3):609-636.

Hamm B., Forstner R., Kim E.S., et al. MRI and CT of the female pelvis. J. Nucl. Med.. 2008;49(5):862.

Humphries P.D., Simpson J.C., Creighton S.M., et al. MRI in the assessment of congenital vaginal anomalies. Clin. Radiol.. 2008;63(4):442-448.

Martin D.R., Salman K., Wilmot C.C. MR imaging evaluation of the pelvic floor for the assessment of vaginal prolapse and urinary incontinence. Magn. Reson. Imaging. Clin. N. Am.. 2006;14(4):523-535.

Scheidler J., Heuck A.F. Imaging of cancer of the cervix. Radiol. Clin. North Am.. 2002;40(3):577-590.

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