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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 14 Male Pelvis Scanning Protocol for the Prostate Gland, Scrotum, and Penis 349
Sonographic Appearance
Prostate Gland and Seminal Vesicles
Prostate Gland
• The majority of the parenchyma of the prostate appears homoge-
neous and midgray, with medium-level echoes. The periurethral
glandular stroma that surrounds the urethra is slightly hypoechoic
relative to surrounding prostatic parenchyma. At the midline of
the gland the prostatic urethra walls appear echogenic.
• A normal prostate gland should appear symmetrical with a smooth
contour and well-defined margins.
• Calcifications may be seen throughout the gland in older patients.
• The central and transition zones of the prostate are not normally
distinctive. The peripheral zone appears homogeneous and slightly
hyperechoic relative to adjacent parenchyma.
Seminal Vesicles
• These are identified as ovoid structures with low-level echoes, just
superior to the prostate gland. They appear hypoechoic relative to
the prostate gland.
• They should appear symmetric in size, shape, and echogenicity.
• They are horizontally oriented, therefore, they are seen in long axis
on transverse plane scans.
• They are easier to visualize when the urinary bladder is partially
filled.
• The vas deferens and ejaculatory ducts may be difficult to distinguish
from surrounding structures. However, when seen, the vas deferens is medial to, and has an echo texture similar to, the seminal
vesicles. The ejaculatory duct will appear as bright double lines.
Scrotum and Testicles
Scrotum
• Various layers of the scrotum are not normally differentiated on
ultrasound. The combination of the scrotal wall layers typically
appear as a single, bright, echogenic stripe.
• The highly echogenic spermatic cord may be visualized as it courses
through the inguinal canal. As mentioned, the ductus deferens
may be difficult to appreciate sonographically. Color flow Doppler
is useful in identifying the blood vessels within the cord.
Testicles
• The parenchyma is homogeneous with medium-level echoes similar
to those of the thyroid gland. Echo texture and size of each testicle
should be compared to its opposite side.
• The mediastinum testis appears as a bright line running along the
long axis of the testis.
350 PART IV Pelvic Scanning Protocols
TRANSTEST
ART
CENT.
ART
M. T.
Figure 14-4 Testicular Vascular Normal Variant. The transtesticular artery runs in a direction oppo-
site the centripetal arteries. See Color Plate 1.
• A few millimeters of anechoic fluid visualized between the two
layers of the tunica vaginalis is a normal finding.
• The epididymis appears isosonic/isoechoic or slightly hyperechoic
relative to the testicle. The texture of the epididymis, however, is
generally more course in appearance. Echo texture and size of each
epididymis should be compared to its opposite side.
• A testicular vascular normal variant identified sonographically in
10% to 20% of cases is the transtesticular artery coursing through
the testis in a direction opposite the centripetal arteries (Figure 14-4).
• Color Doppler technical considerations:
• Confirm intratesticular and epididymal flow using both color
and conventional waveform analysis. Use the mediastinum testis
as a point of reference when demonstrating intratesticular flow.
With acute torsion less than 6 hours or chronic torsion more
than 24 hours, there is absent intratesticular flow and increased
peristesticular flow. Color Doppler cannot differentiate malignant hypervascularity from inflammatory hypervascularity.
Color flow image and waveform of intratesticular arteries.
See Color Plate 2.
CHAPTER 14 Male Pelvis Scanning Protocol for the Prostate Gland, Scrotum, and Penis 351
Capsular artery
• Color Doppler arterial/venous flow characteristics:
• The testis has low vascular resistance. Testicular, capsular, centripetal, and recurrent rami arteries have low resistance flow.
Their waveforms are characterized by broad systolic peaks and
high levels of diastolic flow similar to the internal carotid artery.
Cremasteric and deferential arteries have high systolic peaks and
lower levels of diastolic flow similar to the external carotid artery.
Cremasteric artery
Testicular artery
Recurrent rami artery
Deferential artery
Transtesticular artery
and vein
Centripetal artery
• Intratesticular veins accompany companion arteries. Their
waveform is continuous or phasic.
• Spermatic cord/pampiniform plexus has minimal to moderate
flow.
Color flow image of spermatic cord. See Color Plate 3.
352 PART IV Pelvic Scanning Protocols
• The epididymis has a very slight flicker or dashes of flow.
Color flow image of epididymis. See Color Plate 4.
• Testicular, deferential cremasteric, centripetal, and capsular arteries
have moderate flow.
A
CENT.
ART.
CENT. A
RRA
RRA
C. A.
M. T.
B
Color flow images of intratesticular arteries. A, See Color Plate 5. B, See
Color Plate 6.
Penis
• Corpus spongiosum and corpora cavernosa appear homogeneous with
medium-level echoes.
• The single corpus spongiosum:
• In axial sections, is identified at the midline surrounding the
urethra, which appears slightly hyperechoic compared to the
corpus spongiosum.
• Compressed by the transducer, it will appear elliptical in shape.
• The 2 corpora cavernosa:
• Are surrounded by the tunica albuginea, which appears bright
and distinctive.
CHAPTER 14 Male Pelvis Scanning Protocol for the Prostate Gland, Scrotum, and Penis 353
Tape
Rolled towel
• Are posterior to the corpus spongiosum and appear symmetrical,
round or oval, with bright borders from the tunica albuginea.
• In short axis sections, the axial, anechoic lumen of the cavernosal
artery is easily identified in the center of each corpus cavernosum;
their pulsations can be seen in real time.
• In longitudinal sections they appear divided by the central, linear,
bright appearance of the cavernosal arterial walls.
Preparation
Patient Prep
Prostate Gland
Endorectal Sonography
The prostate gland is best evaluated by endorectal (or transrectal)
sonography. Transabdominal male pelvis examinations to evaluate the prostate gland are rarely performed now because the high
frequency endorectal transducer can be placed closer to the area of
interest and produce superior, highly detailed images.
• The patient should have a self-administered enema before the
examination. If for some reason the patient cannot have the
enema, the study should still be attempted.
• Explain the examination to the patient. Verbal or written consent
is required and the examination should be witnessed by another
health-care professional. The initials of the witness should be part
of the film labeling.
• The sonographer or physician inserts the transducer.
Scrotum
Towel
354 PART IV Pelvic Scanning Protocols
Figure 14-5 The sonographer’s thumb and fingers are easily identified when scanning the scrotum
and can be used as reference points for localizing scrotal lesions.
• The scrotum should be supported on a rolled towel placed between
the patient’s thighs to isolate and immobilize the scrotum for
scanning. Cover the penis with a towel and tape the towel to the
abdominal wall.
• Explain the examination to the patient. The examination should
be witnessed by another health-care professional and their initials
should be part of the film labeling.
• Use warm gel as a scanning couplant.
• To scan the scrotum the sonographer’s gloved fingers should be
placed underneath the scrotum and the thumb over the top of the
scrotum. This hand position further stabilizes the scrotum and has
the advantage of allowing correlation between a palpable mass and
its sonographic findings. Also, the sonographer’s fingers are easily
identified as they appear bright and highly reflective and are used
as reference points for localizing masses (Figure 14-5).
THUMB
Penis
• The penis should be supported on a rolled towel placed between
the patient’s thighs to isolate and immobilize the penis for
scanning.
• Explain the examination to the patient. The examination should
be witnessed by another health-care professional and their initials
should be part of the film labeling.
• Use warm gel as a scanning couplant.
CHAPTER 14 Male Pelvis Scanning Protocol for the Prostate Gland, Scrotum, and Penis 355
Transducer
Prostate Gland
Endorectal Sonography
• 5.0 MHz or higher.
• Preparing the transducer includes providing a water path. Preparation
includes one of the following 3 options:
1. Some transducer manufacturers provide a finger-like sheath that
slides onto the transducer head. The sheath is secured by a small
rubber band, and 20 or 30 mL of nonionized water is injected
into the sheath through a pathway inside the transducer handle. Tip the transducer down and tap the water-filled sheath so
any air bubbles will rise to the top and can be aspirated. Fill a
condom half full with sonographic gel, then insert the sheathed
transducer. Apply additional lubrication to the outside of the
condom before insertion. A small rubber hose can be attached
to the transducer pathway to introduce or aspirate water from
the sheath to adjust for any air bubbles that might occur and
cause artifacts.
2. Apply gel to the end of the transducer, then cover it with a
condom. Secure the condom with a rubber band and make sure
there are no air bubbles at the tip. Apply additional lubrication
to the outside of the condom before insertion. Use an inner
balloon filled with 30 to 50 mL of nonionized water as a water
path.
3. Cover a transducer with a disposable sheath or condom and
secure it with a rubber band; lubricate the outside; then insert
the transducer into the rectum. Fill the sheath or condom with
30 to 50 mL of an unionized water for a water path.
• Following the examination, any tubing or stopcocks and the dis-
posable sheath or condom covering the endorectal probe should
be disposed. The probe should be soaked in an antimicrobial solution. Follow manufacturer’s instructions and infectious disease
recommendations for solution type and soak time. If the sheath or
condom was torn during the procedure, the probe’s fluid channels
must be flushed with the antimicrobial solution.
Scrotum
• 5.0 MHz or higher, real-time, linear or a curved linear
transducer.
• 7.0 MHz to 10.0 MHz is preferable for pediatric applications.
• 3.5 MHz to 7.0 MHz conventional Doppler with color flow imag-
ing (low flow filter, scale, and optimized resolution).
• If necessary, use a gel standoff pad to improve imaging. They can
be helpful when evaluating anterior lesions.
356 PART IV Pelvic Scanning Protocols
Right
r
TRANSVERSE
Penis
• 5.0 MHz, high resolution, real-time, linear transducer.
• 7.5 MHz, 10.0 MHz.
• Conventional Doppler with color flow imaging (low flow filter,
scale, and optimized color gain).
• In some cases, a gel standoff pad may improve imaging.
Patient Position
Prostate Gland
Endorectal Sonography
• Left lateral decubitus with knees bent toward the chest.
• Lithotomy position.
Scrotum
• Supine with the legs slightly spread or in a semi frog-legged
position.
• Upright.
Penis
• Supine with the legs slightly spread or in a semi frog-legged
position.
• Upright.
Prostate Gland Survey
Anterior
Image
Posterior
(rectum)
Left Superior
Anterior
Image
Posterior
(rectum)
SAGITTAL
Inferio
CHAPTER 14 Male Pelvis Scanning Protocol for the Prostate Gland, Scrotum, and Penis 357
Symphysis pubis
Prostate
Rectum
Seminal
NOTE: If a male pelvis transabdominal study is ordered, the examination
is systematically evaluated and documented in the same manner as the
female pelvis transabdominal studies. Sagittal plane surveys extend from
one side of the pelvic cavity to the other. Transverse plane surveys extend
from the symphysis pubis to the umbilicus. The prostate gland is examined from an inferior transducer angle at the level of the symphysis pubis.
Patient prep, patient position, and transducer choices are the same as
those for the female pelvis. See Chapter 11 for specifics.
NOTE: While surveying the prostate evaluate the periprostatic fat and
vessels for asymmetry and any disruption in echogenicity. Also evaluate
the perirectal space, especially the area where the prostate and perirectal tissue abut. The rectal wall and lumen should be evaluated in cases
where rectal pathology is clinically suspected.
Prostate • Axial Survey
Transverse Plane • Rectal Approach
NOTE: To survey the prostate in short axis, the transducer is inserted into
the rectum and then withdrawn sequentially to examine the prostate
superiorly (base) to inferiorly (apex).
1. With the transducer inserted, the survey begins at the level of the
seminal vesicles.
2. After the seminal vesicles have been evaluated, slowly withdraw
the transducer to scan through the prostate from its superior to
inferior margins. The lateral margins should be well defined. Note
the size, shape, and symmetry of the prostate.
Urinary
bladder
vesicle
Urethra
gland
Transducer
358 PART IV Pelvic Scanning Protocols
Symphysis pubis
Prostate
TransducerRectum
Seminal
Prostate • Longitudinal Survey
Sagittal Plane • Rectal Approach
NOTE: To survey the prostate longitudinally the transducer is rotated
clockwise, and counterclockwise to examine the prostate from one lateral
edge to the other.
1. Begin at the midline of the prostate. The superior and inferior margins should be well defined and the prostatic urethra visualized.
2. To examine the lateral aspects of the prostate and seminal vesicles
slowly rotate the transducer clockwise and counterclockwise.
Urinary
bladder
Vesicle
Urethra
gland
Prostate Gland Required Images*
NOTE: The required images are a small representation of what a sonog-
rapher visualizes during a study. Therefore, the images should provide
the interpreting physician with the most telling and technically accurate
information available.
* Images in this section are by courtesy the Ultrasound Department of Methodist
Hospital, Houston, Texas.