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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5802_Библиотеки_им_академика_М_И_Перельмана.pdf
Genital tract
96
FURTHER READING
Carter SSC, Shinohara K, Lipshultz LI. Transrectal ultrasonography
in disorders of the seminal vesicles and ejaculatory ducts. Urol
Clin North Am. 1989; 16:773–789.
Terasaki T, Watanabe H, Kamoi K, Naya Y. Seminal vesicle
parameters at 10-year intervals measured by transrectal
ultrasonography. J Urol. 1993; 150:914–916.
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Genital tract
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Penis
PREPARATION
None.
POSITION
Patient is supine, and the penis is examined on the dorsal aspect.
TRANSDUCER
7.5–10.0 MHz linear transducer.
APPEARANCE
The body of the penis consists of two paired corpora cavernosa and the
corpus spongiosum (containing the urethra), which lies on the ventral
surface of the fused corpora cavernosa. The cavernosal artery and the
dorsal artery supply the penis. Color and spectral Doppler ultrasound,
with the addition of a pharmacological stimulant to produce an erection, allows for the assessment of arterial ow disorders as well as of
venous leakage in erectile dysfunction.
METHOD
The penis is imaged longitudinally and horizontally in the accid
state to detect areas of brosis and calcication to indicate Peyronie’s
disease. A baseline assessment of the spectral Doppler waveform of
the right cavernosal artery, as close to the base of the penis as possible (the peno-scrotal junction), should be attempted to achieve the
optimal angle of insonation (< 60°) and to reduce the effect of distal
arterial variants. The baseline peak systolic velocity (PSV) in a longitudinal plane is recorded. Following the intracavernosal injection of
20 micrograms Prostaglandin E1 (PGE1), measurements of the PSV
and end-diastolic velocity (EDV) are made every 5 minutes for 20–25
minutes at the same level in the right cavernosal artery. If a sub-optimal response to pharmacological stimulation is identied, administration of the intracavernosal alpha-adrenergic antagonist phentolamine
(2 mg), which blocks the increased sympathetic drive in the anxious
patient, may supplement the examination.
MEASUREMENTS
Increased systolic and diastolic ow early in tumescence, which
decreases with eventual reversed diastolic ow as veno-occlusion
occurs, would be expected following pharmaco-stimulation in a normal study. A guide to differentiation among arteriogenic, venogenic,
Penis
A transverse image through the paired corpora cavernosum, with the paired central
cavernosal arteries (arrows) present centrally. The right or left cavernosal artery is targeted
in a longitudinal view to measure the velocity.
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A spectral Doppler gate is placed over the cavernosal artery 20 minutes after
pharmacostimulation with the spectral Doppler waveform indicating a normal response;
elevation of the peak systolic velocity and reversal of diastolic ow.
Genital tract
100
and nonvascular dysfunction assessed 25 minutes after cavernous stimulation with 20 micrograms PGE1 is illustrated in the following table:
Type of dysfunction Peak systolic velocity End diastolic velocity
Arterial insufciency < 25 cm/sec —
Venogenic impotence > 35 cm/sec > 5 cm/sec
Normal values > 25 cm/sec < 5 cm/sec
FURTHER READING
Andresen R, Wegner HEH. Assessment of the penile
vascular system with color-coded duplex sonography and
pharmacocavernosometry and -graphy in impotent men. Acta
Radiologica. 1997; 38:303–308.
Benson CB, Aruny JE, Vickers MA. Correlation of duplex
sonography with arteriography in patients with erectile
dysfunction. AJR Am J Roentgenol. 1993; 160:71–73.
Halls J, Bydawell G, Patel U. Erectile dysfunction: The role of penile
Doppler ultrasound in diagnosis. Abdominal Imaging. 2009;
34:712–725.
Quam JP, King BF, James EM, Lewis RW, Brakke DM, Ilstrup
DM, Parulkar BG, Hattery RR. Duplex and color sonographic
evaluation of vasculogenic impotence. AJR Am J Roentgenol.
1989; 153:1141–1147.
Wilkins CJ, Sriprasad S, Sidhu PS. Colour Doppler ultrasound of the
penis. Clin Radiol. 2003; 58:514–523.
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Genital tract
102
FEMALE GENITAL TRACT
Ovarian volume (transvaginal sonography)
PREPARATION
Empty bladder prior to the examination.
POSITION
Lithotomy position on adapted examination couch.
TRANSDUCER
8.4 MHz curved transvaginal transducer.
METHOD
The longest diameter of the ovary is obtained (d1).
Maximum anteroposterior diameter (d2) is obtained perpendicular to d1.
The transducer is then rotated 90°, and d3 is measured perpendicular
to d2.
Ovarian volume = d1 × d2 × d3 × 0.523cm
APPEARANCE
Ovoid structure between the uterus and muscular pelvic sidewall. The
internal iliac vessels are posterior to the ovaries. The presence of follicles
is the hallmark of their identication. These could be multiple developing follicles, one or more dominant follicles, or a corpus luteum. The
postmenopausal ovary is small and homogenous in echo-texture.
MEASUREMENT
Ovarian volume = d1 × d2 × d3 × 0.523cm
3
3
Age (years)
< 30 6.6 ± 0.19
30–39 6.1 ± 0.06
40–49 4.8 ± 0.03
50–59 2.6 ± 0.01
60–69 2.1 ± 0.01
> 70 1.8 ± 0.01
Mean volume (cm3) ± SD
Ovarian volume (transvaginal sonography)
Longitudinal image of a reproductive age group ovary with measurements d1 and d2.
A follicle (arrow) is the hallmark of a reproductive ovary.
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Mean ovarian volume of reproductive age group women: 4.9 ± 0.03
3
cm
(upper limit 20 cm3)
Mean ovarian volume of postmenopausal women: 2.2 ± 0.01 cm
(upper limit 10 cm
3
)
FURTHER READING
Bruchim I, Aviram R, Halevy RS, Beyth Y, Tepper R. Contribution
of sonographic measurement of ovarian volume to diagnosing
ovarian tumors in postmenopausal women. J Clin Ultrasound.
2004; 2:107–114.
Pavlik EJ, DePriest PD, Gallion HH, Ueland FR, Reedy MB, Kryscio
RJ, van Nagell JR Jr. Ovarian volume related to age. Gynecol
Oncol. 2001; 80:333–334.
3
Genital tract
104
Ovarian follicles (transvaginal sonography)
PREPARATION
Empty bladder prior to the examination.
POSITION
Lithotomy position on adapted examination couch.
TRANSDUCER
8.4 MHz curved transvaginal transducer.
METHOD
Maximum diameter of follicle is obtained.
APPEARANCE
Ovarian follicles are thin and smooth walled, round or oval, anechoic
spaces in ovaries, without ow by means of color Doppler ultrasound.
Corpus luteum is a cyst with diffusely thick walls and crenulated inner
margins with a ring of vascularity at the periphery. Hemorrhage may
result in internal echoes within the corpus luteum, without internal
ow on color Doppler.
MEASUREMENT
Reproductive age group Maximum diameter
Dominant follicle 3 cm*
Nondominant follicle 1.4 cm
Corpus luteum 3 cm*
*Maximum diameter of a dominant follicle and a corpus luteum
cyst is taken as 3 cm but according to the Society of Radiologists in
Ultrasound criteria 2010, simple ovarian cysts are also taken as almost
certainly benign and do not need follow-up in this age group.
Maximum number of follicles per ovary should be < 12 in reproductive
age group.
Postmenopausal age group Maximum diameter
Ovarian cyst 1 cm
Ovarian follicles (transvaginal sonography)
Multiple follicles in a
reproductive ovary.
FURTHER READING
Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB,
Brewster WR, Coleman B, DePriest P, Doubilet PM, Goldstein
SR, Hamper UM, Hecht JL, Horrow M, Hur HC, Marnach
M, Patel MD, Platt LD, Puscheck E, Smith-Bindman R.
Management of asymptomatic ovarian and other adnexal cysts
imaged at US: Society of Radiologists in Ultrasound consensus
conference statement. Ultrasound Quarterly. 2010; 26:121–131.
Rotterdam E. SHRE/ASRM-Sponsored PCOS Consensus Workshop
Group Revised 2003 consensus on diagnostic criteria and longterm health risks related to polycystic ovary syndrome. Fertil.
Steril. 2004; 81:19–25.
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