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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5795_Библиотеки_им_академика_М_И_Перельмана.pdf
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
Fig. 15.51 Microlithiasis. (a) Diffuse microlithiasis. (b) Bicolour mode conspicuously enhances
testicular calcications
Fig. 15.52 (Epididymo-)orchitis. Asymmetrically
enlarged swollen testis with vivid hypervascularity
of testis
(and epididymis) on CDS
451
US/CDS Finding
Orchitis: unilateral increase of size of affected scrotum, may be hyperechoic.
• Reactive hydrocele, scrotal wall thickening. Secondary abscess/necrosis possible.
• Hypervascularisation with hyperemic diastolic ow on spectral analysis (low RI)
(Fig.15.52).
Epididymitis: Epididymis enlarged, more or less echogenic, potentially
inhomogeneous.
Exhibits signicant hypervascularisation without hyperperfusion of testis itself.
Often associated complex hydrocele:
• May also manifest combined with orchitis (epididymo-orchitis).
Rarer in children, always think of associated urological problems/ascending
Note
infections from prostatic ducts, particularly in urethral obstruction.
Paratesticular inammation may arise from descending infection from peritoneal
cavity (peritonitis) or septicemic involvement. Similar ndings seen after inguinal
surgery with haemorrhage/secondary infection:
452
M. Riccabona
• Typical paediatric entity: echogenic complex material in scrotum around testis—
potentially with calcication after meconium peritonitis in newborn.
Complications
Particularly in orchitis: abscess, necrosis, segmental infarction—can be
depicted on US.
Note Differentiation of necrosis versus abscess may be difcult, particularly in
early phases.
15.8.5 Scrotal Trauma
US used to assess contusion versus haematoma versus rupture.
• Contusion: focal inhomogeneous parenchyma seen with swelling of testis, but no
parenchymal disruption; continuity of the outer border maintained.
• Haematoma: (intra- or extratesticular) easily depicted—CDS allows assessment
of viable testicular parenchyma (Fig.15.53).
• Testicular rupture: dened by discontinuity of tunica and intrascrotal haema-
toma. Viability of different testicular components assessed by CDS, helping to
decide on surgery.
– Penis fracture not addressed, as not a query in childhood (sometimes in ado-
lescents)—but well suited for assessment by US (visualisation of haematoma
and disruption of tunica).
15.8.6 Torsion
Clinically typical acute onset of pain, swelling.
Two different types: neonatal extra-/supravaginal torsion; intravaginal torsion
common during puberty—usually no impact on therapy except for delayed diagnosis in neonates (often has happened much earlier, e.g. during birth/fetally—then no
emergency surgery!).
Fig. 15.53 Scrotal trauma. Testicular
trauma with haemorrhage into
scrotal sack and injured, partially
destroyed testis—obviously
with disrupted tunica and
irregular contour
bc
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
453
a
d
Fig. 15.54 Testicular and hydatid torsion. (a) Enlarged testis with hypoechoic (necrotic) paren-
chyma—no perfusion on CDS in older testicular torsion. (b, c) Echogenic testicular appendix (b)
without ow on CDS (c), consistent with hydatid torsion. (d) Whirlpool sign in testicular torsion—
note that CDS visibility of vessels is only granted if there is some residual perfusion
Note Often adolescent presents delayed because of shyness about seeking care.
Thus “missed torsion” with completely necrotic testis not uncommon.
US Finding
Superiorly positioned, swollen, homogeneously hyperechoic testis—in peracute
phase. Some accompanying hydrocele, swelling of scrotal wall (Fig.15.54).
Whirlpool sign/spiral like twisting of spermatic vessels in inguinal canal at entry
into scrotum.
In longer duration/late torsion echogenicity of testis decreases, may become
more inhomogeneous—eventually anechoic when necrotic; secondary abscess formation possible. More complex appearance of associated hydrocele uid.
CDS
Asymmetric ow or lack of intratesticular vessels.
Twist of vascular pedicle when following it into inguinal canal (“whirl pool”
appearance as in volvulus):
• Partial torsion may exhibit residual but asymmetric perfusion—rstly affecting
veins (haemorrhagic infarction).
• After (spontaneous) detorsion, transient hyperaemia may be seen.
454
M. Riccabona
Note Mandatory to depict intratesticular ow and prove symmetry with spectral
Doppler analysis—torsion can only be excluded when symmetric intraparenchymal
ow prole in arterial and venous compartment is depictable. In every suspicion of
torsion on US, emergent surgical exploration mandatory.
US-guided detorsion/manual relief of torsion: detwisting testis by rotation in
steps of 180°, checking for reappearance of perfusion—does not obviate surgery as
partial detorsion may still exist (reactive hyperaemia will always show some asymmetric perfusion—thus residual partial torsion cannot be ruled out).
15.8.6.1 Torsion ofAppendages
Quite common. Important DDx for testicular torsion/inammation (clinical ndings may be similar) or inguinal hernia.
US Finding
Enlarged appendage (hydatid) with lack of perfusion, hyperaemia of adjacent structures, but always symmetric intratesticular perfusion. Often some hydrocele, scrotal
swelling, epididymitis-like changes observed (Fig.15.54b, c).
After appendiceal torsion extratesticular calcications often present.
DDx Criteria
Scrotal oedema, normal testis, hydrocele, increased vascularisation. No inguinal hernia.
15.8.6.2 Inguinal Hernia
If inguinal hernia detected, try to follow through inguinal canal, assess inner ring
and describe content (mesentery, uid, intestines—potentially with peristalsis, perfused bowel wall?) Other rare hernia contents: parts of bladder, in girls ovaries/uterus.
Particularly if incarcerated—confusing images seen; sometimes spermatic cord
vessels compromised, thus endangering testis.
May sometimes only be seen with increased intra-abdominal pressure—consider
provocative manoeuvres (imaging while crying/straining, Valsalva, image with
patient standing).
A “soft”/open inguinal canal physiologic in preterm newborns; movement of
Note
mobile testis or entrance of bowel commonly observed—no worry if transient.
15.8.7 Testicular Tumours
Rather rare in childhood, most commonly germ cell tumours or teratoma.
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
a bc
+
+
455
+
de
Fig. 15.55 Testicular tumours and DDx: (a) Small tumour (+…+) slightly resembling a cystic
dysplasia of the rete testis. (b) Larger testicular tumour x … x), nicely outlined by hypervascularisation on CDS (c). (d) Testicular teratoma with a solid component (…) on CDS. (e) Huge haemorrhagic spermatocele only entirely imageable by a curved array
US Findings
Typically appearance of ovoid space occupying lesion. May be cystic, particularly
in teratoma/epidermoids, or completely solid. May have more complex cystic
appearance with septae (Fig.15.55)
• Often mild associated hydrocele. Denition of underlying entity rarely
achievable.
• Always assess pelvic/retroperitoneal lymph nodes, and perform abdomi-
nal survey.
+
Secondary involvement in systemic diseases (e.g. leukaemia/lymphoma, neuroblastoma) where testis can even serve as host region for recurrence, involvement
may be uni- or bilateral.
DDx
Intratesticular cysts, dermoids, septated hydroceles, epithelial cysts, cystic dysplasia of rete testis, intratesticular ectopic adrenal tissue, infection/abscesses/necrosis,
posttraumatic alteration.
Note Rhabdomyosarcoma in male pelvis mostly from pelvic oor muscles, pros-
tate, seminal vesicles, or bladder, rarer in scrotum.
456
No other sonographically important aspects of prostate need to be addressed in
childhood; only sometimes after infection prostate calcication may be seen, as
well as an atypical appearance of enlarged seminal vesicles in cystic dysplasia and
then often combined with other urogenital malformations.
M. Riccabona
15.8.8 Role ofUS andAdditional Imaging
US—ideal initial imaging tool with high reliability, when performed skillfully.
Supplementing Investigations
• Scintigraphy and MRI have been performed for torsion—but potential time delay
usually demands early surgery in unclear cases.
• In tumours: staging by CT/MR.
• Assessment of ectopic testis/cryptorchidism: may benet from MRI, although
small dysplastic testis in abdominal cavity may be difcult to depict—many
centres perform laparoscopy if testis not found in pelvis/inguinal region
directly.
• Assessment of complex genital (cloacal)/intersex states: may benet from MRI/
ce-CT and uoroscopy/genitography.
• Angiography of spermatic vein only performed in complex/recurrent varicocele
for therapeutic reasons (embolisation in the same session).
15.9 Female Genitals
15.9.1 Indications
Suspected genital malformation/disease by clinical ndings on inspection, ambiguous gender, associated urogenital malformation, hormonal abnormality (e.g. precocious puberty, adrenogenital syndrome).
15.9.2 Requisites
Sufciently lled bladder mandatory for detailed assessment.
Perineal approach very helpful—looking at vagina/pelvic oor/rectum (cloacal
malformation):
• In unclear ndings/obvious pathology, lling of the bladder and vagina with
saline helpful (“Sonogenitography”) (see respective chapter).
• For depiction of stulae, optional/additional UCA instillation.
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
457
15.9.3 Transducers
Particularly in neonates, high-resolution linear/micro-curved arrays applied.
Otherwise use curved linear areas with highest applicable frequency.
Transvaginal investigations usually only performed after puberty:
• Some centres perform transrectal investigations.
15.9.4 How toPerform Investigation
Consecutive longitudinal and axial sections through region of genital organs behind
bladder by rotating transducer into respective organ axis of fallopian tube, ovaries, uterus.
Take size measurements, document ndings:
• Always include entire US of all other pelvic structures/urinary tract, include
adrenal glands.
Measurements particularly important in suspected hypodysplasia or early onset
of puberty:
• Compare results to tables with normal values.
Always try to assess detailed structure of ovary (size? follicles present?) and
uterus (size, shape, horns, wall structure/endometrium?):
• In older girls additional assessment of breast valuable for complete work-up in
hormonal imbalance.
15.9.5 Normal Findings
Uterus Changes during growth/development (Fig.15.56):
• In neonate (stimulated by maternal hormones): rather large, with long cervix,
endometrium nicely differentiated.
• In infancy/early childhood: small, difcult to assess.
• With onset of peri-/prepuberty/hormonal activity: uterus grows again. Eventually
becomes shape of typical adult uterus—pear shaped= relatively short cervix,
large body, exhibits well-differential wall/endometrium (varies throughout cycle).
Uterus muscle rather hypoechoic, with clear contour. Thickness of endometrium
depends on hormonal situation. Often positioned not strictly sagittal/in midline—
some deviation physiological:
458
Fig. 15.56 Different stages of uterine development. (a–c) Longitudinal section: (a) neonatal
shape, (b) infantile appearance, (c) prepubertal conguration. (d, e) Axial section: (d) pubertal
uterus with prominent ovarian follicles, (e) adult uterus with prominent endometrium
M. Riccabona
• 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 orice/vulva
• For assessing patency/duplications, lling of vagina with saline infusion
necessary.
• Distal portion only visible by perineal US, once symphysis ossied. This
approach also useful for distal vaginal atresia—imperforated hymen.
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 unsus-
pected high location, may have large cysts (Fig.15.57).
ab
cd
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
Fig. 15.57 Normal neonatal “cystic” ovary. (a) Typical large “multicystic” neonatal ovary
(
+ …+) that may be positioned relatively high and ventrally. (b) Ovary during childhood—
1
smaller, more difcult to 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 a
single US exam)
459
• In infancy/childhood during “silent” phase—ovaries small, often difcult
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 1cm, in
infants usually less than 5mm, in puberty—depending on phase of cycle—up
to 4cm.
15.9.5.1 Sonogenitography
Assessment of internal genitalia after vaginal lling via small exible catheter with
saline infusion (for further details see respective chapter):
• Bladder also needs to be full/lled.
• Sometimes simultaneous rectal saline enema may be helpful (prove absence of
uterus/vagina, depict stulae).
Tip Rinse catheter before inserting to avoid introducing obscuring air
into vagina.
460
M. Riccabona
15.9.6 Pathologic Findings
15.9.6.1 Congenital Malformations
Vaginal Septum andDuplications
Midline anomalies—most commonly only recognised if outow occluded: cystic
formation manifests. Alternatively 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 ultrasound contrast agents (UCA) may pass from one to another cavity through potential opening.
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
Difcult to evaluate without lling of obstructed vagina.
Obstruction manifests as more or less prominent tubular-ovoid space occupying
lesion in midline below bladder in anatomic area of the vagina (Fig.15.58):
• Sonomorphologic aspect depends on content (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 uidlled cavity to salpinx (hydrosalpinx) (Fig.15.58).
• Secondary ascites. Associated with uterine duplication if duplex vagina.
Vaginal Fistula
Remnant of disturbed foetal 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.
Fistula to more proximal parts of the vagina/bladder usually have acquired origin: