- •Contents
- •Contributors
- •1 Introduction
- •2.1 Posterior Compartment
- •2.2 Anterior Compartment
- •2.3 Middle Compartment
- •2.4 Perineal Body
- •3 Compartments
- •3.1 Posterior Compartment
- •3.1.1 Connective Tissue Structures
- •3.1.2 Muscles
- •3.1.3 Reinterpreted Anatomy and Clinical Relevance
- •3.2 Anterior Compartment
- •3.2.1 Connective Tissue Structures
- •3.2.2 Muscles
- •3.2.3 Reinterpreted Anatomy and Clinical Relevance
- •3.2.4 Important Vessels, Nerves, and Lymphatics of the Anterior Compartment
- •3.3 Middle Compartment
- •3.3.1 Connective Tissue Structures
- •3.3.2 Muscles
- •3.3.3 Reinterpreted Anatomy and Clinical Relevance
- •3.3.4 Important Vessels, Nerves, and Lymphatics of the Middle Compartment
- •4 Perineal Body
- •References
- •MR and CT Techniques
- •1 Introduction
- •2.1 Introduction
- •2.2.1 Spasmolytic Medication
- •2.3.2 Diffusion-Weighted Imaging
- •2.3.3 Dynamic Contrast Enhancement
- •3 CT Technique
- •3.1 Introduction
- •3.2 Technical Disadvantages
- •3.4 Oral and Rectal Contrast
- •References
- •Uterus: Normal Findings
- •1 Introduction
- •References
- •1 Clinical Background
- •1.1 Epidemiology
- •1.2 Clinical Presentation
- •1.3 Embryology
- •1.4 Pathology
- •2 Imaging
- •2.1 Technique
- •2.2.1 Class I Anomalies: Dysgenesis
- •2.2.2 Class II Anomalies: Unicornuate Uterus
- •2.2.3 Class III Anomalies: Uterus Didelphys
- •2.2.4 Class IV Anomalies: Bicornuate Uterus
- •2.2.5 Class V Anomalies: Septate Uterus
- •2.2.6 Class VI Anomalies: Arcuate Uterus
- •2.2.7 Class VII Anomalies
- •References
- •Benign Uterine Lesions
- •1 Background
- •1.1 Uterine Leiomyomas
- •1.1.1 Epidemiology
- •1.1.2 Pathogenesis
- •1.1.3 Histopathology
- •1.1.4 Clinical Presentation
- •1.1.5 Therapy
- •1.1.5.1 Indications
- •1.1.5.2 Medical Therapy and Ablation
- •1.1.5.3 Surgical Therapy
- •1.1.5.4 Uterine Artery Embolization (UAE)
- •1.1.5.5 Magnetic Resonance-Guided Focused Ultrasound
- •2 Adenomyosis of the Uterus
- •2.1 Epidemiology
- •2.2 Pathogenesis
- •2.3 Histopathology
- •2.4 Clinical Presentation
- •2.5 Therapy
- •3 Imaging
- •3.2 Magnetic Resonance Imaging
- •3.2.1 Magnetic Resonance Imaging: Technique
- •3.2.2 MR Appearance of Uterine Leiomyomas
- •3.2.3 Locations, Growth Patterns, and Imaging Characteristics
- •3.2.4 Histologic Subtypes and Forms of Degeneration
- •3.2.5 Differential Diagnosis
- •3.2.6 MR Appearance of Uterine Adenomyosis
- •3.2.7 Locations, Growth Patterns, and Imaging Characteristics
- •3.2.8 Differential Diagnosis
- •3.3 Computed Tomography
- •3.3.1 CT Technique
- •3.3.2 CT Appearance of Uterine Leiomyoma and Adenomyosis
- •3.3.3 Atypical Appearances on CT and Differential Diagnosis
- •4.1 Indications
- •4.2 Technique
- •Bibliography
- •Cervical Cancer
- •1 Background
- •1.1 Epidemiology
- •1.2 Pathogenesis
- •1.3 Screening
- •1.4 HPV Vaccination
- •1.5 Clinical Presentation
- •1.6 Histopathology
- •1.7 Staging
- •1.8 Growth Patterns
- •1.9 Treatment
- •1.9.1 Treatment of Microinvasive Cervical Cancer
- •1.9.2 Treatment of Grossly Invasive Cervical Carcinoma (FIGO IB-IVA)
- •1.9.3 Treatment of Recurrent Disease
- •1.9.4 Treatment of Cervical Cancer During Pregnancy
- •1.10 Prognosis
- •2 Imaging
- •2.1 Indications
- •2.1.1 Role of CT and MRI
- •2.2 Imaging Technique
- •2.2.2 Dynamic MRI
- •2.2.3 Coil Technique
- •2.2.4 Vaginal Opacification
- •2.3 Staging
- •2.3.1 General MR Appearance
- •2.3.2 Rare Histologic Types
- •2.3.3 Tumor Size
- •2.3.4 Local Staging
- •2.3.4.1 Stage IA
- •2.3.4.2 Stage IB
- •2.3.4.3 Stage IIA
- •2.3.4.4 Stage IIB
- •2.3.4.5 Stage IIIA
- •2.3.4.6 Stage IIIB
- •2.3.4.7 Stage IVA
- •2.3.4.8 Stage IVB
- •2.3.5 Lymph Node Staging
- •2.3.6 Distant Metastases
- •2.4 Specific Diagnostic Queries
- •2.4.1 Preoperative Imaging
- •2.4.2 Imaging Before Radiotherapy
- •2.5 Follow-Up
- •2.5.1 Findings After Surgery
- •2.5.2 Findings After Chemotherapy
- •2.5.3 Findings After Radiotherapy
- •2.5.4 Recurrent Cervical Cancer
- •2.6.1 Ultrasound
- •2.7.1 Metastasis
- •2.7.2 Malignant Melanoma
- •2.7.3 Lymphoma
- •2.8 Benign Lesions of the Cervix
- •2.8.1 Nabothian Cyst
- •2.8.2 Leiomyoma
- •2.8.3 Polyps
- •2.8.4 Rare Benign Tumors
- •2.8.5 Cervicitis
- •2.8.6 Endometriosis
- •2.8.7 Ectopic Cervical Pregnancy
- •References
- •Endometrial Cancer
- •1.1 Epidemiology
- •1.2 Pathology and Risk Factors
- •1.3 Symptoms and Diagnosis
- •2 Endometrial Cancer Staging
- •2.1 MR Protocol for Staging Endometrial Carcinoma
- •2.2.1 Stage I Disease
- •2.2.2 Stage II Disease
- •2.2.3 Stage III Disease
- •2.2.4 Stage IV Disease
- •4 Therapeutic Approaches
- •4.1 Surgery
- •4.2 Adjuvant Treatment
- •4.3 Fertility-Sparing Treatment
- •5.1 Treatment of Recurrence
- •6 Prognosis
- •References
- •Uterine Sarcomas
- •1 Epidemiology
- •2 Pathology
- •2.1 Smooth Muscle Tumours
- •2.2 Endometrial Stromal Tumours
- •3 Clinical Background
- •4 Staging
- •5 Imaging
- •5.1 Leiomyosarcoma
- •5.2.3 Undifferentiated Uterine Sarcoma
- •5.3 Adenosarcoma
- •6 Prognosis and Treatment
- •References
- •1.1 Anatomical Relationships
- •1.4 Pelvic Fluid
- •2 Developmental Anomalies
- •2.1 Congenital Abnormalities
- •2.2 Ovarian Maldescent
- •3 Ovarian Transposition
- •References
- •1 Introduction
- •4 Benign Adnexal Lesions
- •4.1.1 Physiological Ovarian Cysts: Follicular and Corpus Luteum Cysts
- •4.1.1.1 Imaging Findings in Physiological Ovarian Cysts
- •4.1.1.2 Differential Diagnosis
- •4.1.2 Paraovarian Cysts
- •4.1.2.1 Imaging Findings
- •4.1.2.2 Differential Diagnosis
- •4.1.3 Peritoneal Inclusion Cysts
- •4.1.3.1 Imaging Findings
- •4.1.3.2 Differential Diagnosis
- •4.1.4 Theca Lutein Cysts
- •4.1.4.1 Imaging Findings
- •4.1.4.2 Differential Diagnosis
- •4.1.5 Polycystic Ovary Syndrome
- •4.1.5.1 Imaging Findings
- •4.1.5.2 Differential Diagnosis
- •4.2.1 Cystadenoma
- •4.2.1.1 Imaging Findings
- •4.2.1.2 Differential Diagnosis
- •4.2.2 Cystadenofibroma
- •4.2.2.1 Imaging Features
- •4.2.3 Mature Teratoma
- •4.2.3.1 Mature Cystic Teratoma
- •Imaging Findings
- •Differential Diagnosis
- •4.2.3.2 Monodermal Teratoma
- •Imaging Findings
- •4.2.4 Benign Sex Cord-Stromal Tumors
- •4.2.4.1 Fibroma and Thecoma
- •Imaging Findings
- •4.2.4.2 Sclerosing Stromal Tumor
- •Imaging Findings
- •4.2.5 Brenner Tumors
- •4.2.5.1 Imaging Findings
- •4.2.5.2 Differential Diagnosis
- •5 Functioning Ovarian Tumors
- •References
- •1 Introduction
- •2.1 Context
- •2.2.2 Indications According to Simple Rules
- •References
- •CT and MRI in Ovarian Carcinoma
- •1 Introduction
- •2.1 Familial or Hereditary Ovarian Cancers
- •3 Screening for Ovarian Cancer
- •5 Tumor Markers
- •6 Clinical Presentation
- •7 Imaging of Ovarian Cancer
- •7.1.2 Peritoneal Carcinomatosis
- •7.1.3 Ascites
- •7.3 Staging of Ovarian Cancer
- •7.3.1 Staging by CT and MRI
- •Imaging Findings According to Tumor Stages
- •Value of Imaging
- •7.3.2 Prediction of Resectability
- •7.4 Tumor Types
- •7.4.1 Epithelial Ovarian Cancer
- •High-Grade Serous Ovarian Cancer
- •Low-Grade Serous Ovarian Cancer
- •Mucinous Epithelial Ovarian Cancer
- •Endometrioid Ovarian Carcinomas
- •Clear Cell Carcinomas
- •Imaging Findings of Epithelial Ovarian Cancers
- •Differential Diagnosis
- •Borderline Tumors
- •Imaging Findings
- •Differential Diagnosis
- •Recurrent Ovarian Cancer
- •Imaging Findings
- •Differential Diagnosis
- •Value of Imaging
- •Malignant Germ Cell Tumors
- •Dysgerminomas
- •Imaging Findings
- •Differential Diagnosis
- •Immature Teratomas
- •Imaging Findings
- •Malignant Transformation in Benign Teratoma
- •Imaging Findings
- •Differential Diagnosis
- •Sex-Cord Stromal Tumors
- •Granulosa Cell Tumors
- •Imaging Findings
- •Sertoli-Leydig Cell Tumor
- •Imaging Findings
- •Ovarian Lymphoma
- •Imaging Findings
- •Differential Diagnosis
- •7.4.3 Ovarian Metastases
- •Imaging Findings
- •Differential Diagnosis
- •7.5 Fallopian Tube Cancer
- •7.5.1 Imaging Findings
- •Differential Diagnosis
- •References
- •Endometriosis
- •1 Introduction
- •2.1 Sonography
- •3 MR Imaging Findings
- •References
- •Vagina and Vulva
- •1 Introduction
- •3.1 CT Appearance
- •3.2 MRI Protocol
- •3.3 MRI Appearance
- •4.1 Imperforate Hymen
- •4.2 Congenital Vaginal Septa
- •4.3 Vaginal Agenesis
- •5.1 Vaginal Cysts
- •5.1.1 Gardner Duct Cyst (Mesonephric Cyst)
- •5.1.2 Bartholin Gland Cyst
- •5.2.1 Vaginal Infections
- •5.2.1.1 Vulvar Infections
- •5.2.1.2 Vulvar Thrombophlebitis
- •5.3 Vulvar Trauma
- •5.4 Vaginal Fistula
- •5.5 Post-Radiation Changes
- •5.6 Benign Tumors
- •6.1 Vaginal Malignancies
- •6.1.1 Primary Vaginal Carcinoma
- •6.1.1.1 MRI Findings
- •6.1.1.2 Lymph Node Drainage
- •6.1.1.3 Recurrence and Complications
- •6.1.2 Non-squamous Cell Carcinomas of the Vagina
- •6.1.2.1 Adenocarcinoma
- •6.1.2.2 Melanoma
- •6.1.2.3 Sarcomas
- •6.1.2.4 Lymphoma
- •6.2 Vulvar Malignancies
- •6.2.1 Vulvar Carcinoma
- •6.2.2 Melanoma
- •6.2.3 Lymphoma
- •6.2.4 Aggressive Angiomyxoma of the Vulva
- •7 Vaginal Cuff Disease
- •7.1 MRI Findings
- •8 Foreign Bodies
- •References
- •Imaging of Lymph Nodes
- •1 Background
- •3 Technique
- •3.1.1 Intravenous Unspecific Contrast Agents
- •3.1.2 Intravenous Tissue-Specific Contrast Agents
- •References
- •1 Introduction
- •2.1.1 Imaging Findings
- •2.1.2 Differential Diagnosis
- •2.1.3 Value of Imaging
- •2.2 Pelvic Inflammatory
- •2.2.1 Imaging Findings
- •2.3 Hydropyosalpinx
- •2.3.1 Imaging Findings
- •2.3.2 Differential Diagnosis
- •2.4 Tubo-ovarian Abscess
- •2.4.1 Imaging Findings
- •2.4.2 Differential Diagnosis
- •2.4.3 Value of Imaging
- •2.5 Ovarian Torsion
- •2.5.1 Imaging Findings
- •2.5.2 Differential Diagnosis
- •2.5.3 Diagnostic Value
- •2.6 Ectopic Pregnancy
- •2.6.1 Imaging Findings
- •2.6.2 Differential Diagnosis
- •2.6.3 Value of Imaging
- •3.1 Pelvic Congestion Syndrome
- •3.1.1 Imaging Findings
- •3.1.2 Differential Diagnosis
- •3.1.3 Value of Imaging
- •3.2 Ovarian Vein Thrombosis
- •3.2.1 Imaging Findings
- •3.2.2 Differential Diagnosis
- •3.2.3 Value of Imaging
- •3.3 Appendicitis
- •3.3.1 Imaging Findings
- •3.3.2 Value of Imaging
- •3.4 Diverticulitis
- •3.4.1 Imaging Findings
- •3.4.2 Differential Diagnosis
- •3.4.3 Value of Imaging
- •3.5 Epiploic Appendagitis
- •3.5.1 Imaging Findings
- •3.5.2 Differential Diagnosis
- •3.5.3 Value of Imaging
- •3.6 Crohn’s Disease
- •3.6.1 Imaging Findings
- •3.6.2 Differential Diagnosis
- •3.6.3 Value of Imaging
- •3.7 Rectus Sheath Hematoma
- •3.7.1 Imaging Findings
- •3.7.2 Differential Diagnosis
- •3.7.3 Value of Imaging
- •References
- •MRI of the Pelvic Floor
- •1 Introduction
- •2 Imaging Techniques
- •3.1 Indications
- •3.2 Patient Preparation
- •3.3 Patient Instruction
- •3.4 Patient Positioning
- •3.5 Organ Opacification
- •3.6 Sequence Protocols
- •4 MR Image Analysis
- •4.1 Bony Pelvis
- •5 Typical Findings
- •5.1 Anterior Compartment
- •5.2 Middle Compartment
- •5.3 Posterior Compartment
- •5.4 Levator Ani Muscle
- •References
- •Evaluation of Infertility
- •1 Introduction
- •2 Imaging Techniques
- •2.1 Hysterosalpingography
- •2.1.1 Cycle Considerations
- •2.1.2 Technical Considerations
- •2.1.3 Side Effects and Complications
- •2.1.5 Pathological Findings
- •2.1.6 Limitations of HSG
- •2.2.1 Cycle Considerations
- •2.2.2 Technical Considerations
- •2.2.2.1 Normal and Abnormal Anatomy
- •2.2.3 Accuracy
- •2.2.4 Side Effects and Complications
- •2.2.5 Limitations of Sono-HSG
- •2.3 Magnetic Resonance Imaging
- •2.3.1 Indications
- •2.3.2 Technical Considerations
- •2.3.3 Limitations
- •3 Ovulatory Dysfunction
- •4 Pituitary Adenoma
- •5 Polycystic Ovarian Syndrome
- •7 Uterine Disorders
- •7.1 Müllerian Duct Anomalies
- •7.1.1 Class I: Hypoplasia or Agenesis
- •7.1.2 Class II: Unicornuate
- •7.1.3 Class III: Didelphys
- •7.1.4 Class IV: Bicornuate
- •7.1.5 Class V: Septate
- •7.1.6 Class VI: Arcuate
- •7.1.7 Class VII: Diethylstilbestrol Related
- •7.2 Adenomyosis
- •7.3 Leiomyoma
- •7.4 Endometriosis
- •References
- •MR Pelvimetry
- •1 Clinical Background
- •1.3.1 Diagnosis
- •1.3.2.1 Cephalopelvic Disproportion
- •1.3.4 Inadequate Progression of Labor due to Inefficient Contraction (“the Powers”)
- •2.2 Palpation of the Pelvis
- •3 MR Pelvimetry
- •3.2 MR Imaging Protocol
- •3.3 Image Analysis
- •3.4 Reference Values for MR Pelvimetry
- •5 Indications for Pelvimetry
- •References
- •MR Imaging of the Placenta
- •2 Imaging of the Placenta
- •3 MRI Protocol
- •4 Normal Appearance
- •4.1 Placenta Variants
- •5 Placenta Adhesive Disorders
- •6 Placenta Abruption
- •7 Solid Placental Masses
- •9 Future Directions
- •References
- •Erratum to: Endometrial Cancer
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reported to be more frequent when involvement of the myometrium by adenomyosis exceeds 80% of the diameter of the uterine wall (Nishida 1991).
2.5\ Therapy
Hysterectomy is still considered the definitive treatment in patients with symptomatic adenomyosis. However, less invasive therapeutic options should be considered initially taking into account the patient’s age, symptom severity, and desire of future fertility as well as the presence of associated disorders such as leiomyomas and endometriosis. Symptom relief can be achieved with nonsteroidal anti-inflammatory drugs but suppression of the endometrium may be needed. A broad range of suppressive hormonal treatments are applied which induce regression of adenomyosis and improve symptoms (Pontis et al. 2016). Intrauterine devices (IUD) which release levonorgestrel have been shown to be effective in controlling menorrhagia caused by adenomyosis although symptoms return once the IUD is removed (Fedele et al. 1997). Endometrial ablation or resection denudes the endometrial layer of the uterus and is an option for women with predominantly abnormal uterine bleeding. Adenomyosis of the superficial type with less than 2 mm penetration responds better than deep- infiltrating adenomyosis to endometrial ablation (McCausland and McCausland 1996).
Uterus-conserving surgery is hampered by the lack of a clearly defined dissection plane but may be of value in the infertile patient (Ozaki et al. 1999). Laparoscopic resection of adenomyosis has been shown to reduce pain, menorrhagia, and dysmenorrhea in small case series with limited fol- low-up (Wood et al. 1994; Morita et al. 2004). Uterine artery embolization (UAE) has been reported to be successful in relieving menorrhagia and dysmenorrhea at short term. The long-term results are encouraging with improvement rates for dysmenorrhea and menorrhagia reported to be 70.4% and 68.8%, respectively, at 5-year followup. After 7 years of follow-up, in 82% of UAEtreated patients with symptomatic adenomyosis a hysterectomy could be avoided (Siskin et al. 2001; Kim et al. 2004; Pelage et al. 2005; Kitamura et al. 2006; Zhou et al. 2016; de Bruijn et al. 2017).
3\ Imaging
3.1\ Diagnostic Imaging
for Uterine Leiomyomas
and Adenomyosis: Overview
Uterine leiomyomas and adenomyosis cannot be reliably differentiated on the basis of clinical grounds because both conditions cause similar symptoms.
Leiomyomas of the uterus, once they have reached a certain size, can be palpated and differentiated from the uterine wall as solid tumors that tend to be mobile. Bimanual palpation is typically supplemented by transvaginal ultrasound (TVUS) or, in patients with a markedly enlarged uterus, transabdominal ultrasound. The ultrasound examination allows assessment of the uterus and especially TVUS provides additional information on the endometrium and ovaries. TVUS is the primary imaging modality in the diagnostic workup of women with uterine leiomyomas. Ultrasound (US) depicts leiomyomas as hypoechoic round lesions which are sharply demarcated from the remainder of the uterus (Fig. 6). Anechoic cystic portions and degenerative changes with a heterogeneous echo pattern within the lesions are quite common. US enables reliable assessment of the location of leiomyomas and their topographic relationship to surrounding
Fig. 6 Transvaginal ultrasound (TVUS) of uterine leiomyoma. TVUS demonstrates a well-defined subserosal leiomyoma (arrow) distorting the outer contour of the uterine wall. The leiomyoma shows a heterogeneous echotexture and is hypoechoic compared to the adjacent myometrium and endometrium. The endometrium is seen as a hyperechoic stripe
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as their relationship to neighboring structures such as the tubes and ovaries (Figs. 8 and 9).
The unique soft-tissue contrast afforded by MRI enables good delineation of the leiomyomas from adjacent myometrium, the junctional
Fig.7 Transvaginal ultrasound of leiomyoma. Transvaginal color-coded duplex ultrasound demonstrates the perifibroid plexus vessels surrounding the leiomyoma
structures, and in particular the uterine cavity, in most cases. Additional Doppler US will depict tumor vascularity and demonstrate typical features such as a central vessel or a marginal vascular network (Fig. 7). Hysterosonography with the instillation of fluid into the uterine cavity improves the diagnostic accuracy of TVUS in detecting submucosal leiomyomas, differentiating from endometrial polyps, and determining depth of myometrial (uterine wall) involvement (Dueholm et al. 2002a).
Endoscopic procedures such as laparoscopy or hysteroscopy have a role in patients with suspected leiomyomas and inconclusive US findings. Moreover, hysteroscopy is performed in conjunction with endometrial sampling in women with abnormal menstrual bleeding and for specific diagnostic purposes such as evaluation of the uterine cavity and tubes in infertile women with leiomyomas. In patients with known uterine leiomyomas, laparoscopy and hysteroscopy have their main role as therapeutic procedures for the uterus-sparing resection of known uterine leiomyomas.
Magnetic resonance imaging (MRI) is the most accurate diagnostic modality for assessing uterine leiomyomas (Dueholm et al. 2002b). MRI enables assessment of the uterus in multiplanar orientation and without interference from superimposed structures. MRI provides accurate information not only on the number and size of leiomyomas but also on their location within the uterus (cervix, corpus, fundus) and within the wall (submucosal, intramural, subserosal) as well
Fig. 8 MRI of leiomyoma—locations. Transaxial T2-weighted image depicts multiple, mainly subserosal uterine leiomyoma. There is mild distortion of the uterine cavity by a transmural (full thickness) leiomyoma (arrow)
Fig. 9 MRI of leiomyoma—locations. T2-weighted coronal image of a polyfibroid uterus. A subserosal pedunculated uterine fibroid (white arrow) is easily identified by its low signal intensity and continuity with the right lateral aspect of the uterine fundus while sonographically the lesion could not be separated from the right ovary (black arrow) (reproduced with permission from reference 840, Kröncke TJ, Hamm B (2003) Role of magnetic resonance imaging (MRI) in establishing the indication for planning and following up uterine artery embolization (UAE) for treating symptomatic leiomyomas of the uterus [article in German]. Radiologe 43:624–633)
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zone, which is important for the differential diagnosis, and the endometrium. It also enables evaluation of the internal make-up of leiomyomas including secondary degenerative changes. These features thus make MRI superior to all other imaging modalities in characterizing uterine leiomyomas. MRI is of use in patients with inconclusive US findings with regard to the differential diagnosis of a pelvic lesion or the origin of a lesion from the uterus or the ovary (Scoutt et al. 1994; Weinreb et al. 1990). MRI is increasingly being used to evaluate the feasibility of uterus-sparing surgical therapy or a radiologic intervention (Dudiak et al. 1988). To establish the indication for hysteroscopic or laparoscopic resection, it is necessary to know the number and size of leiomyomas as well as their precise position, in particular their relationship to the uterine cavity and their depth within the wall (Dueholm et al. 2002c; Hurst et al. 2005). In evaluating potential candidates for UAE, MRI provides information on the size of the individual leiomyomas, the presence of pedunculated or parasitic leiomyomas, the nature of degenerative changes, the degree of leiomyoma vascularization, and the vascular supply of the uterus.
Computed tomography (CT) with its poor soft-tissue contrast is of limited value in diagnosing benign changes of the uterus. CT does not allow adequate differentiation of the different uterine layers and hence fails to reliably assign uterine lesions to a specific layer. Intravenous contrast medium administration improves the differentiation of adjacent structures but does not improve the differential diagnosis (Fig. 10). On CT scans, uterine leiomyomas are isodense with muscle and can occasionally be identified by the presence of typical calcifications on unenhanced images. There are no specific CT criteria for the presence of adenomyosis.
Adenomyosis—when severe—causes enlargement of the uterus but differs from leiomyoma- related enlargement in that the uterus is soft on palpation. TVUS will depict areas of reduced echogenicity or a heterogeneous appearance in
Fig. 10 CT of uterine leiomyoma. Contrast-enhanced CT of the pelvis in a 39-year-old women with a known uterine leiomyoma shows a large oval mass within the uterus with heterogeneous enhancement (asterisk) which displaces the hypodense right ovary (arrow) and distends the abdomen
about 75% of patients with adenomyosis (Reinhold et al. 1995; Brosens et al. 1995; Fedele et al. 1992). Apart from asymmetric thickening of the myometrium in the presence of focal adenomyosis, other morphologic features that are indicative of adenomyosis are a poor definition of the endomyometrial junction, presence of myometrial cysts (<5 mm) in up to 50% of affected patients, as well as echogenic lines or spots within the myometrium (Fedele et al. 1992; Iribarne et al. 1994). Circumscribed lesions are absent in the majority of cases. Good diagnostic performance can be expected if diagnostic criteria as described above are combined and real-time examination is used. An increased vascularization demonstrated by color duplex US is indicative of adenomyosis (Hirai et al. 1995; Chiang et al. 1999). Transvaginal ultrasound has a reported sensitivity of 53–89% and a specificity ranging from 50 to 99% (Reinhold et al. 1995; Brosens et al. 1995; Fedele et al. 1992; Ascher et al. 1994). The wide variation is primarily attributable to the examiner dependence of US. The diagnostic accuracy is limited in the presence of leiomyomas (Bazot et al. 2001). Many of the features of adenomyosis seen on US are depicted more clearly on T2-weighted MR images, which clearly show changes in zonal anatomy based on the excellent