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10.9 Female Genit als
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bc
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Fig. 10.52 Different stages of uterine development. ( a – c ) Longitudinal section: ( a ) neona-
tal shape, ( b ) infantile appearance, ( c ) prepubertal configuration. ( d , e ) Axial section: ( d )
pubertal uterus with prominent ovarian follicles, ( e ) adult uterus with prominent
endometrium
387
• Useful measurement for assessing maturity: index made from corpus to cervix
length. Cervix longer in neonates, corpus longer in mature girls.
Vagina: tubular muscular structure with central lumen, reaching from cervix to
external orifi ce/vulva:
• For assessing patency/duplications, fi lling of vagina with saline infusion
necessary.
Adnexae: fallopian tube/adnexa often poorly visualised unless ascites or
hydrosalpinx.
Ovaries: undergo stepwise development, being relatively prominent in neonate
(maternal hormones) with multiple follicles that create cyst-like appearance:
• Remember: ovary = “cystic organ” – ovarian “cysts” usually represent normal
follicles.
• In neonates ovaries positioned throughout abdominal cavity, sometimes at unsuspected high location, may have large cysts (Fig. 10.53 ).
• In infancy/childhood during “silent” phase – ovaries small, often diffi cult to
depict.
• With onset of hormonal activity/(pre-/peri-) puberty – ovaries grow, manifest as
typical “multicystic” retrovesical organs lateral to uterus – more peripheral
follicles, some central tissue. Follicles vary in size, neonatally far more than
1 cm, in infants usually less than 5 mm, in puberty – depending on phase of cycle
– up to 4 cm.
388
10 Ultrasound of the Urogenital Tract
Fig. 10.53 Normal neonatal “cystic” ovary. ( a ) Typical large “multicystic” neonatal ovary ( 1 +....+)
that may be positioned relatively high and ventrally. ( b ) Ovary during childhood – smaller, more
diffi cult to fi nd (full bladder mandatory), in this case exhibiting physiologic follicles that may not
be depictable in many cases. ( c ) Pubertal/adult ovaries with multiple follicles (physiologically a
“multicystic organ”), observe large paravaginal/retro-uterine cyst and some ascites. ( d ) Ovarian
“functional” cyst (not always able to be differentiated from a cystic teratoma on single US exam)
a
c
b
d
10.9.5.1 Sonogenitography
Assessment of internal genitalia after vaginal fi lling via small fl exible catheter with
saline infusion (see Fig . 2.4 and 2.5):
• Bladder also needs to be full/fi lled.
• Sometimes simultaneous rectal saline enema may be helpful (prove absence of
uterus/vagina, depict fi stulae).
TIP : Rinse catheter before inserting to avoid introducing obscuring air in vagina.
For further details see Chap. 2 .
10.9.6 Pathologic Findings
10.9.6.1 Congenital Malformations
Vaginal Septum and Duplications
Midline anomalies – most commonly only recognised if outfl ow occluded: cystic
formation manifests. Alternatively fi lling by saline infusion after careful catheterisation may support diagnosis, additionally may help detect potential connections,
particularly when supported by ce-US and perineal US:
• Echogenic septum dividing vagina will become visible.
• Echogenic US-CM may pass from one to another cavity through potential
opening.
10.9 Female Genit als
389
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b
c
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Fig. 10.54 Vaginal atresia. ( a – c ) School-age girl with “pelvic tumour”: inhomogeneously echo-
genic cystic-tubular mass that may exhibit sedimentations ( b , sagittal view) in anatomic location
of vagina; small residual uterus sitting on top ( c , ....+,). ( d ) Perineal US exhibits thick distal occlu-
sion of vagina in vaginal atresia. ( e ) US genitography with US-CM: vaginal duplication in a child
with uterine duplication, hemivaginas not connected; the noncontrast-fi lled (anechoic) vagina is
atretic
Vaginal Atresia
Atretic (single/duplex) vagina – usually thick membrane, leads to hydro-/
haematocolpos:
• To be differentiated from hymenal atresia by thickness of septum (hymen – thin
membrane).
US Findings
Diffi cult to evaluate without fi lling of obstructed vagina.
Obstruction manifests as more or less prominent tubular-ovoid space occupying
lesion in midline below bladder in anatomic area of vagina (Fig. 10.54 ):
• Sonomorphologic aspect depends on content (fl uid, haemorrhage, sedimentation, etc.).
• Can become huge, may also include cervix/uterus – then uterus seen by meticulous assessment as (often small) pear-shaped end of “cyst”, connecting fl uidfi lled cavity to salpinx (hydrosalpinx) (Fig. 10.54 ).
• Secondary ascites. Associated with uterine duplication if duplex vagina.
Vaginal Fistula
Remnant of disturbed fetal development. Often associated with urogenital/cloacal
malformations:
• Also after trauma, infection, surgery.
Commonly connect to distal urethra (urogenital sinus) or (additionally) rectum (cloacal malformation):
• This combination only seen in phenotypic female babies.
390
10 Ultrasound of the Urogenital Tract
Fistula to more proximal parts of vagina/bladder usually have acquired
origin:
• Ectopic ureteral insertion into vagina (even via ureterocele) possible – often
associated with renal dysplasia/obstruction.
US Findings
Indirect signs: fl uid-fi lled vagina, potentially change in fi lling/size before or after
voiding/with variable bladder fi lling:
• Fistula tract more easily visualised after fi lling of bladder/vagina
(sonogenitography).
• Fistula to rectum may be visible by gas bubbles coursing through rectal wall into
vagina.
• Perineal US most helpful for these queries.
Other Vaginal Malformations
Cystic changes rare. May be remnants from Müllerian/Wallerian duct or secondary
to hypoplastic vagina:
• Cysts in vaginal wall (e.g. Bartholin cysts).
• Other paravaginal cysts may also manifest secondarily (infection, after surgery,
etc.).
DDx
Para-urethral cyst, urethral diverticula, ectopic ureterocele, cystic teratoma
(rare).
US Finding
• Typical visualisation of more or less complex cyst.
• No further specifi c imaging features.
Vaginal Aplasia
Rare. Potentially combined with aplasia of uterus.
Only clearly outlined after fi lling of bladder/urethra (during voiding) and rectum
and supplementing perineal US:
• Vaginal remnants in phenotypical boys also occur – may be missed if no assessment before AND during/after voiding. VCUG/fl uoroscopic genitography may
be helpful.
Uterine Malformations
Number of uterine malformations: aplasia/hypoplasia, unicornuate/bicornuate/
duplex (didelphis)/arcuate/(sub-)septated uterus, cervical atresia.
Usually seen either neonatally or at beginning of puberty, hardly detectable dur-
ing infancy/early childhood due to physiologic smallness without hormonal
stimulation.
US may depict abnormalities, particularly if more severe – actively search for,
more easily seen on transverse sections, best on (reconstructed) coronal views
(Fig. 10.55 , 1.33 ):
• Exact classifi cation often needs 3DUS and/or sonographic colpography after
instillation of saline (the latter not performed in childhood) (see Fig. 1.33 ).
10.9 Female Genit als
391
ab
Fig. 10.55 Uterine duplication. ( a , b ) Uterine duplication – more diffi cult to see during hormon-
ally inactive infancy ( a , +....+) than in neonates/during puberty (hormonal stimulation enlarges
uterus and causes endometrial prominence) ( b )
NOTE : If uterine malformation depicted/suspected: always assess entire urinary
tract – as well as vice versa (e.g. in urinary tract malformations, always meticulously assess genitalia).
Ovarian Malformations
Agenesis / dysgenesis may occur with various syndromes/hormonal conditions, par-
ticularly in intersex queries.
NOTE : Hypo-/dysplastic ovaries very diffi cult to visualise, even with MRI, as they
lack typical shape/size/(echo-)structure (e.g. do not contain follicles/cysts). Can be
found in quite unusual locations (e.g. labia, inguinal canal, far latero-cranial in pelvis, even in abdomen/ventrally).
• Multicystic ovary : usually manifest later – exhibit multiple large follicles in sig-
nifi cantly enlarged ovary.
• Ectopic ovary : usually no problem in childhood – only in intersex queries, hor-
monal imbalances, secondary torsion. In adulthood may be associated with infertility/ectopic pregnancy.
NOTE : In neonates/early childhood, ovary relatively mobile, can be found even in
mid-abdomen, may herniate into open inguinal canal – then tend to become twisted/
congested and may exhibit somewhat unusual US fi ndings similar to torsion
(see below).
10.9.6.2 Inflammatory Conditions of Female Genitalia
Vaginal infl ammation : may occur, usually with/as DDx for recurrent UTI:
• Secondary fungal infection due to antibiotic therapy, urinary infl ux, with foreign
bodies, rarely with polluted bath/pool water
Usually diagnosed clinically – do not pose a sonographic query:
• Particularly if recurrent/persistent potentially associated with intraluminal foreign bodies (inserted when playing) or yet unrecognised malformation (with fi stula) which often can easily be assessed by US. Thus proper assessment of vagina
from transabdominal (potentially perineal) approach should be part of every
investigation presenting with recurrent UTI.
392
10 Ultrasound of the Urogenital Tract
Ovarian / adnexal / uterine infection : extremely rare in childhood, only associated
with malformations – usually only start with onset of sexual activity:
• Then resemble appearance in adults (e.g. pyosalpinx, ovarian abscess)
• Exception: chronic appendicitis/intestinal disease with secondary involvement
of ovary
NOTE : If depicted earlier in younger children – always consider sexual abuse.
US Findings
• Vaginal infection : some complex fl uid with echoes seen within vaginal lumen,
wall may be thickened and hyperaemic.
• Foreign bodies : have typical US appearance (as anywhere else) from more or
less echogenic with complete shadowing to very mixed appearance. May be
associated with recurrent/protracted UTI in small children.
• Uterine infl ammation : fi ndings nonspecifi c – no major role in diagnosing endo-
metritis except for ruling out associated/causative malformations, helping
with DDx.
• Infl ammation of ovary , salpinx / adnexa : usually occur only beyond puberty or in
complex malformations, as well as with sexual abuse.
– US fi ndings do not differ from adults. May include severe hydrosalpinx/
abscess formation. Depending on content tube signifi cantly enlarged, thickened, may exhibit complex fl uid with pseudotumourous formation; may also
cause secondary cul-de- sac abscess.
– Hyperaemia on CDS.
NOTE : Always try to differentiate these fi ndings (particularly on the right side)
from appendicitis/intestinal disease and its complications, as well as haemorraghic/
necrotic atypical tumours. Do not confuse with old missed torsion or haemorrhagic
(ruptured) ovarian cyst:
• Also think of rare conditions such as childhood endometriosis and early (ectopic) pregnancy, which need to be considered as DDx particularly in (peri-/post)
pubertal age group.
10.9.6.3 Genital Tumours and Space-Occupying Lesions
Cysts
May occur in any organ – particularly in ovary; cysts pathologic only above 4 cm
(otherwise represent prominent/haemorrhagic) follicles:
• There may be echoes from haemorrhage, may cause torsion or may rupture.
US fi ndings
• Nonspecifi c, exhibit common fi ndings of simple/complicated cyst:
• If complicated – particularly mural nodules, thick wall, septations: consider cystic teratoma/tumour.
NOTE : For large haemorrhagic, but otherwise uncomplicated (neonatal) ovarian
cysts, US-guided puncture may be a therapeutic option, usually after a fi rst followup (from 4 weeks to 3 months).
Teratoma
Usually benign, may be primarily or secondarily malignant:
• The more solid tissue/the less cystic, the higher probability of malignancy.
10.9 Female Genit als
abc
Fig. 10.56 Ovarian childhood tumours. ( a ) Complex septated cystic mass in right ovary (axial
section): complicated dysfunctional cyst. ( b ) Sedimented echoes in large cystic structure with
septae – was found to be a haemorrhaged cystic ovarian teratoma. ( c ) Complex partially cystic
ovarian tumour – histopathology showed dysgerminoma
Otherwise teratoma of ovary/uterus/vagina exhibits same features as teratoma anywhere else:
• May present parts of all three embryonic layers
Other Genital Tumours
Embryonal carcinoma, gonadoblastoma, dysgerminoma, also involvement in systemic disease.
Usually not easily differentiated by US, commonly only depicted in later stage
(often huge tumours arising from pelvis reaching to mid-abdomen, retroperitoneal
nodes at diagnosis – search entire abdomen for metastases, include pleural space for
effusion):
• Often inhomogeneous, exhibit necrotic/haemorrhagic/cystic areas (Fig.
10.56 )
Entity defi ned by biochemical/laboratory fi ndings and histology:
• Sectional imaging for staging/preoperative assessment mostly indispensable,
particularly if large.
• On follow-up meticulously assess areas of potential metastases, particularly
along the path of ovarian venous drainage into (left) renal vein.
NOTE : Ovary often involved in systemic disease (leukaemia, lymphoma) and may
serve as disease reservoir after treatment and remission – thus ovarian US should be
included in routine follow-up of patients after leukaemia/lymphoma so as not to
miss enlarged, usually somewhat inhomogeneous ovary with disrupted architecture
indicating ovarian recurrence (the same applies for the testis).
393
Rhabdomyosarcoma
Typically arising from bladder, vagina, prostate and pelvic fl oor muscles.
More or less inhomogeneous, usually more hypoechoic, well-circumscribed tumour:
• When growing intraluminally (baldder ...), may exhibit caulifl ower-like appearance.
• May contain haemorrhage although commonly solid.
• May exhibit marked vascularisation on CDS.
US again nonspecifi c, but typical location and features may enable a suggestive
diagnosis.
394
10 Ultrasound of the Urogenital Tract
a
Fig. 10.57 Ovarian torsion. ( a ) Acute ovarian torsion: signifi cantly enlarged echogenic ovary
with peripheral small follicles that may be masked due to intraluminal haemorrhage (“haemorrhagic infarction”). ( b ) No fl ow seen by CDS in this late stage after missed torsion with a necrotic
ovary that is increasingly liquefi ed: note that CDS is not reliable for diagnosing ovarian torsion
(different to testis); the necrotic-liquid nature is indicated by the increased thorough transmission
behind the ovary
b
10.9.6.4 Traumatic Changes
Rarely relevant for paediatric US, most often associated with sexual/child abuse.
10.9.6.5 Other Specific Important Entities of Female Genitalia
in Childhood
Ovarian Torsion
Clinically typical sudden onset of severe pain, often present as “appendicitis” if on
right side. Fever, vomiting, may have laboratory changes.
NOTE : In suspected cases, emergent US must be performed – if equivocal (not
defi nitely completely normal/symmetrical ovary or defi nite other diagnosis), emergent surgery/laparoscopy must performed to salvage potentially torsed ovary.
US Findings
Signifi cantly enlarged, echogenic ovary with small, peripheral, cyst-like follicles
that may exhibit echoes and sedimentation due to follicular haemorrhage (torsion
= haemorrhagic infarction) (Fig. 10.57 ):
• Often ascites, ovary displaced (usually uterus too).
• Sometimes cyst/teratoma/preexisting malignant infi ltration causes torsion – then
features of underlying condition may mask typical fi ndings of torsion. However,
fi ndings such as enlargement or complicated cysts – in combination with typical
clinical manifestation – may indicate prompt laparoscopy/surgery.
In persistent, recurrent or partial torsion, US shows more pseudotumourous fi ndings: inhomogeneous parenchyma, focal necrosis/haemorrhage and radial prominent follicles.
10.9 Female Genit als
395
Role of CDS
May show lack of perfusion – but value of CDS restricted due to dual supply of
ovary/physiologic low perfusion of prepubertal ovary (depiction of intraovarian
fl ow usually diffi cult).
NOTE : CDS not reliable for excluding/diagnosing torsion maybe a potential appli-
cation of ce-US.
Pregnancy
Increasingly earlier onset of menarche/pubarche/sexual activity and secondary to
abuse – childhood pregnancy occurs more frequently, needs to be mentioned:
• US features do not differ from obstetric US, will not be discussed in detail.
• Most prominent features: cyst-like appearance of lumen of enlarged uterus with
thick endometrium, potentially foetus within cyst-like fl uid (cardiac motion?),
corpus luteum cyst in dominant follicle.
NOTE : If no fetal structures found in uterine cavity – consider ectopic pregnancy;
also vice-versa, if unusual preganacy-like cyst found somewhere in abdomen.
10.9.6.6 Role of US/Additional Investigations
Primary imaging for assessment of childhood internal genitalia:
• Most aspects addressable, particularly using meticulous technique, perineal
access, fi lling techniques by saline infusion/US genitography.
• 3DUS and ce-US = helpful supplements.
Additional Imaging
For detail assessment/detection of fi stulae – conventional fl uoroscopic genitography:
• Increasingly replaced by dedicated MR genitography also using catheters/fi lling
techniques and applying high-resolution isotropic sequences.
• Associated conditions commonly indicate VCUG.
• Sometimes nuclear medicine/MR of pelvis and spine.
NOTE : CT rarely used, unless MR unavailable and detailed anatomic assessment
preoperatively necessary, e.g. complex cloacal malformation/pelvic bones (as in
bladder exstrophy). Then also apply dedicated fi lling techniques and IV contrast.
Tumourous conditions: sectional imaging part of all oncology protocols for
initial assessment/staging, preoperative information and follow-up.
Small Part and Hip Ultrasound
11
Michael Riccabona , Brian Coley , and Gerolf Schweintzger
Contents
11.1 Hip US ............................................................................................................................. 398
11.1.1 General Remarks ............................................................................................... 398
11.1.2 Examination Technique ..................................................................................... 399
11.1.3 Normal Anatomy .............................................................................................. 402
11.1.4 Pathologic Findings ........................................................................................... 404
11.2 Other Conditions of Hip Joint ......................................................................................... 407
11.2.1 Arthritis and Infl ammation of Hip Joint ............................................................ 407
11.2.2 (Femoral Head) Epiphysiolysis/Slipped
(Capital Femoral) Epiphysis ............................................................................. 408
11.2.3 Perthes Disease ................................................................................................. 409
11.3 Investigation of Bones, Joints, Tendons .......................................................................... 410
11.3.1 Requisites and Technique .................................................................................. 410
11.3.2 Typical Normal Findings .................................................................................. 411
11.3.3 Pathologic Findings ........................................................................................... 412
11.4 US for Peripheral Vessels ................................................................................................ 424
11.5 US-Guided Interventions ................................................................................................ 424
M. Riccabona ()
Division of Pediatric Radiology, Department of Radiology,
University Hospital Graz,
Auenbruggerplatz 34, Graz 8036, Austria
e-mail: michael.riccabona@klinikum-greaz.at
B. Coley
Department of Radiology, ML5031,
Cincinnati Children’s Hospital Medical Center,
3333 Burnet Avenue, Cincinnati OH 45229, USA
G. Schweintzger
Abteilung fur Kinder und Jugendliche Neonatologische und padiatrische Intensivstation,
LKH Leoben/Eisenerz, Vordernbergerstr. 42, Leoben 8700, Austria
M. Riccabona, Pediatric Ultrasound,
DOI 10.1007/978-3-642-39156-9_11, © Springer Berlin Heidelberg 2014
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