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15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
Fig. 15.58 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 occlusion of the vagina in vaginal atresia. (e) US genitography with UCA: vaginal duplication in a child
with uterine duplication, hemivaginas not connected; the noncontrast-lled (anechoic) vagina
is atretic
461
• Ectopic ureteral insertion into the vagina (even via ureterocele) possible—often
associated with renal dysplasia/obstruction.
US Findings
Indirect signs: uid-lled vagina, potentially change in lling/size before or after
voiding/with variable bladder lling:
• Fistula tract more easily visualised after lling of bladder/vagina (sonogenitography)—US contrast agent very helpful in this query.
• Fistula to rectum may be visible by gas bubbles coursing through rectal wall
into vagina.
• Perineal US most helpful for these queries.
Tip For nding these pathologies well-lled bladder and uid lled rectum help-
ful—consider lling by saline using a catheter/rectal tube to grant sufcient access
and discrimination of structures.
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.).
462
M. Riccabona
DDx
Para-urethral cyst, urethral diverticula, ectopic ureterocele, cystic teratoma (rare).
US Finding
• Typical visualisation of more or less complex cyst.
• No further specic imaging features.
Vaginal Aplasia
Rare. Potentially combined with aplasia of uterus.
Only clearly outlined after lling of the 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/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 the beginning of puberty, hardly detectable
during 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 (Fig.15.59), best on (reconstructed) coronal
views using 3DUS as known from adults (see respective chapter).
• Exact classication often needs 3DUS and/or sonographic colpography after
instillation of saline (the latter not performed in childhood).
ab
Fig. 15.59 Uterine duplication. (a, b) Uterine duplication—more difcult to see during hormon-
ally inactive infancy (a, +…+) than in neonates/during puberty (hormonal stimulation enlarges
uterus and causes endometrial prominence) (b)
a
b
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
463
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, particularly in intersex queries.
Note Hypo-/dysplastic ovaries very difcult 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 signicantly enlarged ovary.
• Polycystic Ovary Syndrome: metabolic disease that affects ovaries (oligo−/
amenorrhoea, hirsutism, acne, obesity, diabetes, insulin resistance, high prolactin or androgen levels=hormonal imbalance,…); disease of adulthood/adolescents—diagnosis not based only on US ndings. However, often large ovaries
with numerous peripheral, rather small follicular cysts seen, with broad echogenic central stroma (Fig.15.60a). Denition (in adolescent and adult females—
“Rotterdam criteria”):
– Ovarian volume >10cm3/ovarian area 5.5cm2.
– >12 follicles per ovary, <9mm cyst diameter
– DDx—peripubertal changes due to yet imbalanced hormones/physiological
hormonal disturbances.
• Ectopic ovary: usually no problem in childhood—only in intersex queries, hormonal imbalances, secondary torsion. In adulthood may be associated with infertility/ectopic pregnancy.
Fig. 15.60 (a) Echogenic broad stroma with many peripheral cysts. (b) Hydrosalpinx (+…+) and
chronic recurrent salpingitis and in a girl after cloacal malformation with numerous operations
464
M. Riccabona
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 ndings similar to torsion
(see below).
15.9.6.2 Inflammatory Conditions ofFemale Genitalia
Vaginal inammation: may occur, usually with/as DDx for recurrent UTI:
• Secondary fungal infection due to antibiotic therapy, urinary inux, 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 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.
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 the ovary.
Note If depicted earlier in younger children—always consider sexual abuse.
US Findings
• Vaginal infection: some complex uid with echoes seen within vaginal lumen,
wall may be thickened and hyperaemic. Search for foreign bodies actively.
• 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 inammation: ndings nonspecic—no major role in diagnosing endometritis except for ruling out associated/causative malformations, helping
with DDx.
• Inammation of ovary, salpinx/adnexa: usually occur only beyond puberty or in
complex malformations, as well as with sexual abuse.
– US ndings do not differ from adults.
– May include severe hydrosalpinx/abscess formation (Fig15.60b). Depending
on content tube signicantly enlarged, thickened, may exhibit complex uid
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
465
with pseudotumourous formation; may also cause secondary cul-de-sac
abscess.
– Hyperaemia on CDS.
Note Always try to differentiate these ndings (particularly on the right side) from
appendicitis/intestinal disease and its complications, as well as haemorrhagic/
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. In unexplained infection, also consider sexual abuse.
15.9.6.3 Genital Tumours andSpace Occupying Lesions
Cysts
May occur in any organ—particularly in ovary; cysts pathologic only above 4cm
(otherwise represent prominent/haemorrhagic) follicles. Very often physiologically
seen in neonates from maternal hormonal stimulation—no need to worry, as ovaries
are “cystic organs”; if not too large also no need to follow-up. Same applies to
breast-fed infants.
• There may be echoes from haemorrhage, may cause torsion or may rupture.
US Findings
• Nonspecic, exhibit common ndings of simple/complicated cyst.
• If complicated—particularly mural nodules, thick wall, septations: consider cystic teratoma/tumour.
• US appearance can be quite confusing and very heterogeneous—consider US
follow-up before staring further imaging.
For large haemorrhagic, but otherwise uncomplicated (neonatal) ovarian
Note
cysts, US-guided puncture may be a therapeutic option, usually after a rst follow up (from 4weeks to 3months).
Teratoma
Usually benign, may be primarily or secondarily malignant.
• The more solid tissue and the less cystic, the higher probability of malignancy.
Otherwise teratoma of ovary/uterus/vagina exhibits same features as teratoma
anywhere else:
• May present parts of all three embryonic layers.
466
M. Riccabona
Other Genital Tumours
Embryonal carcinoma, gonadoblastoma, dysgerminoma, also involvement in systemic disease.
Usually not easily differentiated by US, commonly only depicted in the 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.15.61).
Entity dened by biochemical/laboratory 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).
Rhabdomyosarcoma
Typically arising from bladder, vagina, prostate, and pelvic oor muscles.
More or less inhomogeneous, usually more hypoechoic, well-circumscribed
tumour (Fig.15.62)
• When growing intraluminally (bladder…), may exhibit cauliower-like
appearance.
Fig. 15.61 Ovarian childhood tumours. (a) Complex septated cystic mass in the 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
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
Fig. 15.62 Pelvic oor rhabdomyoma (possibly
deriving from prostate) inltrating the urinary
bladder and obstructing urethra in a 2-year-old
boy with voiding problems
• May contain haemorrhage although commonly solid.
• May exhibit marked vascularisation on CDS.
US again nonspecic, but typical location and features may enable a suggestive
diagnosis.
15.9.6.4 Traumatic Changes
Rarely relevant for paediatric US, most often associated with sexual/child abuse.
15.9.6.5 Other Specific Important Entities ofFemale Genitalia
inChildhood
467
Ovarian Torsion
Clinically typical sudden onset of severe pain, often present as “appendicitis” if on
the right side. Fever, vomiting, may have laboratory changes.
Note In suspected cases, emergent US must be performed—if equivocal (not de-
nitely completely normal/symmetrical ovary or denite other diagnosis), emergent
surgery/laparoscopy must performed to salvage potentially torsed ovary.
US Findings
Signicantly enlarged, echogenic ovary with small, peripheral, cyst-like follicles
that may exhibit echoes and sedimentation due to follicular haemorrhage (torsion=haemorrhagic infarction) (Fig.15.63):
• Often ascites, ovary displaced (usually uterus too).
• Sometimes cyst/teratoma/preexisting malignant inltration causes torsion—then
features of underlying condition may mask typical ndings of torsion. However,
ndings such as enlargement or complicated cysts—in combination with typical
clinical manifestation—may indicate prompt laparoscopy/surgery.
468
Fig. 15.63 Ovarian torsion. (a) Acute ovarian torsion: signicantly enlarged echogenic ovary
with peripheral small follicles that may be masked due to intraluminal haemorrhage (“haemorrhagic infarction”). (b) No ow seen by CDS in this late stage after missed torsion with a necrotic
ovary that is increasingly liqueed: 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
M. Riccabona
In persistent, recurrent or partial torsion, US shows more pseudotumourous nd-
ings: inhomogeneous parenchyma, focal necrosis/haemorrhage, and radial prominent follicles.
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
ow usually difcult).
Note CDS not reliable for excluding/diagnosing torsion maybe a potential applica-
tion 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 uid (cardiac motion?),
corpus luteum cyst in dominant follicle.
Note
If no foetal structures found in uterine cavity—consider (ectopic) pregnancy;
also vice-versa, if unusual pregnancy-like cyst found somewhere in abdomen. Also
consider other rare tumours (mole, etc.), particularly when girls are getting into
adolescents. These ndings can be sometimes confusing and difcult to differentiate form other entities (Fig.15.64).
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
Fig. 15.64 Huge, partially cystic para-uterine
and para-ovarian tumour (*), surgically conrmed
as teratoma, with acute ovarian torsion and
haemorrhagic infraction in a 16-year-old girl—
imaged using panoramic imaging.
Bl=urinary bladder
*
469
Bl
15.9.6.6 Role ofUS/Additional Investigations
Primary imaging for assessment of childhood internal genitalia:
• Most aspects addressable, particularly using meticulous technique, perineal
access, lling techniques by saline infusion/US genitography.
• 3DUS and ce-US=helpful supplements.
Additional Imaging
For detail assessment/detection of stulae—conventional uoroscopic
genitography:
• Increasingly replaced by dedicated MR and MR-genitography also using catheters/lling techniques and applying high-resolution isotropic sequences.
• Associated conditions commonly indicate ce-VUS and/or 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 lling techniques and IV contrast.
Tumourous conditions: sectional imaging part of all oncology protocols for ini-
tial assessment/staging, preoperative information, and follow-up. MRI preferred
over CT for ration protection considerations.
Neonatal andPaediatric Hip US
16
GerolfSchweintzger, BrianColey, andMichaelRiccabona
16.1 General Remarks
Various methods on how to perform hip US. Two main queries with different
techniques:
• Assessment in neonates and infants: developmental hip dysplasia (DDH).
• Assessment throughout childhood: hip effusion, capsular thickening, other
pathology (e.g. irregularity of bony structures).
Indications
Hip US performed for:
• General or selective screening (e.g. familial risk, breach presentation, endemic
dysplasia, and all girls and boys only with risk factors, preterms).
• Clinically suspicious scenario (typical hip instability, clicks, foetal malposition,
impaired mobility, neurological impairment, etc.).
• Incidentally—as part of a work-up (?).
• Examination of a painful hip.
G. Schweintzger (*)
Abteilung fur Kinder und Jugendliche Neonatologische und Padiatrische Intensivstation,
LKH Leoben/Eisenerz, Leoben, Austria
e-mail: gerolf.schweintzger@lkh-leoben.at
B. Coley
Department of Radiology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, OH, USA
M. Riccabona
Department of Radiology, Division of Pediatric Radiology, Medical University Graz
and University Hospital Graz, Graz, Austria
e-mail: michael.riccabona@medunigraz.at
© Springer Nature Switzerland AG 2020
M. Riccabona (ed.), Pediatric Ultrasound,
https://doi.org/10.1007/978-3-030-47910-7_16
471