Reproductive system

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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. Minimally invasive procedures including biopsies, cyst drainage, angiography, fibroid embolization

Methods of imaging the male reproductive system (scrotum and testes)

3. Radionuclide imaging

4. Venography (including embolization of varices) and angiography.

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, RR, Hricak, H. What do we expect from imaging. Radiol Clin North Am. 2002; 40(3):521–526.

Fütterer, JJ, Heijmink, SW, Spermon, JR. Imaging the male reproductive tract: current trends and future directions. Radiol Clin North Am. 2008; 46(1):133–147.

Hedgire, SS, Pargaonkar, VK, Elmi, A, et al. Male pelvic imaging. Radiol Clin North Am. 2012; 50(6):1015–1226.

Hysterosalpingography

Indications

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 menstruation

2. Pregnancy or unprotected intercourse during the cycle

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 iodinated contrast material (HOCM) or low osmolar iodinated contrast material (LOCM) 270/300 mg I ml^–1 10–20 ml.

Equipment

1. Fluoroscopy unit with spot film device

2. Vaginal speculum

3. Vulsellum forceps

4. Hysterosalpingography balloon catheter 5-F to 7-F. In patients with narrow cervix or stenosis of cervical os, Margolin HSG cannula may be used. It has a silicone tip and provides tight occlusion of the cervix for contrast injection.

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

Technique

1. The patient lies supine on the table with knees flexed, legs abducted.

2. The vulva can be cleaned with chlorhexidine or saline. A disposable speculum is then placed using sterile jelly and the cervix is exposed.

3. The cervical os is identified using a bright light and the HSG catheter is inserted into the cervical canal. It is usually not necessary to use a Vulsellum forceps to hold the cervix with a forceps, but occasionally this may be necessary. 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 observation.

5. Spasm of the uterine cornu may be relieved by intravenous (i.v.) glucagon if there is no tubal spill bilaterally.

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

Images

The radiation dose should be kept as low as possible. Intermittent screening should be performed to the minimal requirement. Images should demonstrate:

1. Endometrial cavity, demonstrating or excluding congenital abnormalities or filling defects

2. Full view of the tubes demonstrating spill. If occluded, show the extent and level of block

3. If there is abnormal loculation of contrast, a delayed view may be useful.

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 spotting or occasionally bleeding per vagina for 1–2 days and pain which may persist for up to 2 weeks.

3. Prophylactic antibiotics are routinely given in several centres and is good practice.

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) When using the speculum

(b) During insertion of the cannula or inflation of balloon, some patients may have develop vasovagal syncope – ‘cervical shock’

(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 medium is used. Intravasation may be precipitated by: direct trauma to the endometrium, timing of the procedure near to menstruation or curettage, tubal occlusion or congenital abnormalities

5. Infection – which may be delayed. Occurs in up to 2% of patients and is more likely when there is a previous history of pelvic infection.

Ultrasound of the female reproductive system

This can be performed transabdominal (TA) and/or transvaginal (TV).

Indications

2. Pregnancy – normal and suspected ectopic

3. Precocious puberty or delayed puberty

5. Assessment of tubal patency

6. In assisted fertilization techniques

7. Postmenopausal bleeding

8. Menstrual problems, location on IUD

9. Ovarian cancer screening.

Contraindications

Patient preparation

1. Transabdominal scan – full bladder

Transvaginal scan – empty bladder

2. Patient consent.¹

It is advisable to always have a chaperone.

Equipment

TA – 4–10-MHz curvilinear transducers TV 9–13-MHz endovaginal transducers.

Reporting gynaecological ultrasound

The following format may be useful to assess the female reproductive system:

1. Uterine size in three dimensions, note on any congenital anomalies, presence of fibroids (include size and location) or adenomyosis

2. Three-dimensional ovarian measurements and volume. Presence of features including polycystic ovaries, significant cysts or mass lesions. Colour Doppler is useful in the assessment of complex adnexal mass lesions helping to differentiate retracted clot from solid components with blood supply

3. Comment on adnexae for extra-ovarian lesions

4. Examine the cul-de-sac for presence of endometriotic deposits or mass lesions. Note presence of free fluid or ascites.

Several software enhancements are available to improve resolution. Tissue harmonic imaging is useful for interrogation of difficult patients. 3D and 4D ultrasound are also currently widely available and mainly used in obstetric imaging. In gynaecology, 3D endometrial imaging may be useful, but generally adds little clinical value.

Contrast medium

Galactose monosaccharide microparticles (Echovist) were used as a specific contrast agent in the assessment of tubal patency; spillage of the microparticles into the peritoneal cavity infers patency. However, this product has been withdrawn recently. Sonovue (sulphur hexafluoride microbubbles) is not currently licensed for intrafallopian use.² Hence fluoroscopic hysterosalpingography remains the most reliable and safe investigation currently.

References

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

2. Killick, S, Allison, G, Parker, P. The use of Sonovue for HyCoSy: UK experience to date. Ultrasound. 2011; 19:6–10.

Further Reading

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

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

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

Funt, SA, Hann, LE. 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

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 varicocele

6. Scrotal trauma.

Contraindications

Patient preparation

Explanation of procedure and verbal consent is usually obtained.

Equipment

7.5–15-MHz transducer. Linear array for optimum imaging.

Technique

1. Secure environment with patient privacy protected.

2. Patient supine with legs together. Some operators support the scrotum on a towel draped beneath it or in a gloved hand.

3. Both sides are examined with longitudinal and transverse scans enabling comparison to be made.

4. Real-time scanning enables the optimal oblique planes to be examined.

5. 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 using the same image settings.

6. Patient should also be scanned standing upright and a Valsalva manoeuvre can be performed if a varicocele is suspected.

7. Testicular size and volume, echogenicity and presence of focal lesions to be noted. Epididymes are seen posterolaterally. Presence of cysts and inflammatory changes needs to be noted. Also look for hydrocele evident as free fluid outside the testes in the tunica.

Further Reading

Kim, W, Rosen, MA, Langer, JE, et al. US MR imaging correlation in pathologic conditions of the scrotum. RadioGraphics. 2007; 27(5):1239–1253.

Pearl, MS, Hill, MC. Ultrasound of the scrotum. Semin Ultrasound CT MR. 2007; 28(4):225–248.

CT of the reproductive system

Indications

1. Staging ovarian, endometrial and cervical cancers.

2. To evaluate causes of raised CA125 levels.

3. In postoperative settings such as evaluation for intestinal obstruction or collections.

Technique

CT staging is usually performed with oral and i.v. contrast. Local staging in endometrial and cervical cancers is better performed with MRI. CT of thorax, abdomen and pelvis is indicated in endometrial cancers with advanced local disease, aggressive histology and in sarcomas. Local staging in cervical cancer is also performed with MRI, but CT of abdomen may be indicated in assessment of cephalad extent of nodal disease. CT of abdomen and pelvis is generally used for staging of ovarian cancer, but is of limited value in characterization of ovarian lesions, where MRI is more useful.

Magnetic resonance imaging of the reproductive system

Indications

1. Staging of cervical and endometrial cancer

2. Characterization of complex ovarian mass

3. Suspected Müllerian tract anomalies

4. Investigation of endometriosis

5. Staging of ovarian cancer (although CT is often necessary)

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 i.v. Buscopan 20 mg can be used to minimize this. Respiratory motion 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 T2-weighted spin-echo sequences can be supplemented 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. This technique is also mandatory for accurate local staging of uterine and cervical cancers.

The ovaries can 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 ionizing radiation.

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.

Gynaecological malignancy

There are two commonly used staging systems for gynaecological cancers, namely Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) and TNM; the former is recommended for use in current UK practice.¹

Cervical cancer

Initial diagnosis is made on clinical history, examination and biopsy. Regular cervical smears are recommended in disease prevention.

Staging

MRI is the technique of choice for staging of cervical cancer though it is of limited use in clinical stage less than 1B1. If the tumour is more than 4 cm, then it is staged as 1B2, and not suitable for surgery and would warrant radiotherapy. If there is spread of tumour outside the pelvis, CT scan may be necessary to evaluate distant metastatic disease. PET-CT may be useful if extensive pelvic exenteration surgery is needed. (The FIGO system does not consider lymph node status in staging so the presence of lymph nodes should be indicated in the final report.)

MRI sequences

1. Axial T1W – whole pelvis (slice thickness 5–7 mm)

2. Axial, coronal and sagittal T2W high resolution (3-mm slices).

Use of intravenous Buscopan or the other antiperistaltic agent may be useful to reduce artefacts from bowel movements.

Additional sequences may be necessary and be varied according to local protocol.

The presence of regional nodes – paracervical, parametrial, internal iliac, obturator, common iliac, external iliac, presacral, lateral sacral – should be assessed.

Follow-up

Clinical and imaging follow-up as appropriate and according to local protocol.

If recurrence is suspected, local spread is best assessed by MRI. More extensive and distant spread is assessed by CT. Treatment decisions are usually made in multi-disciplinary meetings.

Uterine carcinoma

Uterine cancer presents usually as postmenopausal bleeding. Initial evaluation is performed with ultrasound to assess endometrial thickness. Endometrial thickness greater than 4 mm in postmenopausal women warrants further investigation with hysteroscopy and biopsy.

MRI staging should be performed in biopsy-positive cases for local staging. However, in more histologically aggressive tumours, a CT scan of the thorax, abdomen and pelvis is necessary to assess for distant metastatic spread.

MRI staging

A surface coil is used for pelvic imaging. Intravenous Buscopan or other antiperistaltic agent may be given if necessary.

Suggested sequences are:

1. Axial and sagittal high-resolution 3-mm slices with small FOV

2. Axial T2 whole pelvis 5 mm thickness

3. Axial T1W whole pelvis 5–7 mm thickness

4. T1W fat-saturated GRE sagittal and axial dynamic at 30, 60 and 180 s post-i.v. gadolinium

5. Diffusion-weighted imaging may improve the overall staging accuracy.

Follow-up

Clinical and imaging follow-up in accordance with local protocol. The optimal imaging strategy should be determined following discussion in multi-disciplinary meetings.

Ovarian cancer

Ultrasound is the initial mode of investigation in evaluation of ovarian mass lesion. Most of the simple cysts may be characterized by transvaginal ultrasound.

Indeterminate cysts on ultrasound can be characterized by MR imaging. Additional fat saturated T1-W sequence may be useful in characterizing dermoid cysts, due to their fat content. Haemorrhagic cysts, which have high T1 signal, do not show suppression on fat-saturated sequences. Malignant cysts typically contain solid components that show post-contrast enhancement.

Highly raised CA125 levels suggest the possibility of metastatic disease and would warrant a CT scan.

Typical spread of ovarian cancer is to the omentum, retroperitoneal nodes and surface liver deposits. Diagnosis can be obtained by omental biopsy. It is not recommended to biopsy ovarian masses percutaneously, due to the risk of dissemination of disease into the peritoneum.

Reference

1. McCluggage, G, Hirschowitz, L, Ganesan, R, et al. Which staging system to use for gynaecological cancers: a survey with recommendations for practice in the UK. J Clin Pathol. 2010; 63(9):768–770.

Further Reading

Lewin, SN. Revised FIGO staging system for endometrial cancer. Clin Obstet Gynecol. 2011; 54(2):215–218.

Pecorelli, S. Revised FIGO staging for carcinoma of the vulva, cervix and endometrium. Int J Gynecol Obstet. 2009; 105(2):103–104.

Pecorelli, S, Zigliani, L, Odicino, F, et al. Revised FIGO staging for carcinoma of the cervix. Int J Gynaecol Obstet. 2009; 105(2):107–108.

Omental biopsy

Percutaneous omental biopsy has significantly reduced the need for diagnostic laparotomy and laparoscopic biopsies. Omental biopsy is usually best performed under ultrasound guidance or CT guidance. This can be performed as a day case or with overnight hospitalization.

Patient preparation

Full blood count and clotting needs should be performed to exclude coagulopathy. If patient has ascites, it should be drained. This allows better visualization of the omental mass and also makes the biopsy easier.

Written consent should be obtained. Risk of bleeding and injury to bowel should be explained.

Technique

The procedure can be performed under local anaesthesia. The largest and most superficial omental mass is chosen for biopsy. With ultrasound omental mass can be confused with bowel and procedure should be performed by an experienced radiologist. Omental mass is more hypoechoic than bowel, shows colour Doppler flow and on compression would not show peristalsis. (Correlation with recent CT imaging is often very helpful and if unsure, procedure should be performed under CT guidance.)

Procedure performed with an 18G Trucut biopsy needle. Usually 2–3 passes can be made to ensure adequate specimen. Care should be exercised to avoid injury to the small bowel as sometimes the tumour can be fixed to the bowel.

Aftercare

Patient need to be under observation for at least 6 h post procedure.

Further Reading

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

Burn, PR, McCall, JM, Chinn, RJ, et al. Uterine fibroleiomyoma: MR imaging appearances before and after embolization of uterine arteries. Radiology. 2000; 214(3):729–734.

Coakley, FV. Staging ovarian cancer: role of imaging. Radiol Clin North Am. 2002; 40(3):609–636.

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

Humphries, PD, Simpson, JC, Creighton, SM, et al. MRI in the assessment of congenital vaginal anomalies. Clin Radiol. 2008; 63(4):442–448.

Martin, DR, Salman, K, Wilmot, CC. 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.

Que, Y, Wang, X, Liu, Y, et al. Ultrasound-guided biopsy of greater omentum: an effective method to trace the origin of unclear ascites. Eur J Radiol. 2009; 70(2):331–335.

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

Spencer, JA, Swift, SE, Wilkinson, N, et al. Peritoneal carcinomatosis: image-guided peritoneal core biopsy for tumor type and patient care. Radiology. 2001; 221(1):173–177.

Spencer, JA, Weston, MJ, Saidi, SA, et al. Clinical utility of image-guided peritoneal and omental biopsy. Nat Rev Clin Oncol. 2010; 7(11):623–631.

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Chapman & Nakielnys Guide to Radiological Procedures