L12 - Pelvic Imaging.pdf

FRD40721 - Radiography & Medical Imaging Science ( Ultrasound Imaging ) Lecture 15 Pelvic Imaging (Male & Female) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Readings 1. Rumack, CM Wilson, SR Charboneau, JW 2011, Diagnostic Ult...

FRD40721 - Radiography & Medical Imaging Science ( Ultrasound Imaging ) Lecture 15 Pelvic Imaging (Male & Female) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Readings 1. Rumack, CM Wilson, SR Charboneau, JW 2011, Diagnostic Ultrasound Vol.1, 4th Ed. Mosby, St. Louis, 2. Moore, KL Dalley, AF 2006, Clinically Oriented Anatomy, 5th Ed. Lippincott, Williams & Wilkins Company, Canada. 3. Moore, KL Persaud, TVN 2003, The Developing Human: Clinically Oriented Embryology, 7th Ed. Saunders, USA. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae The Lower Abdomen – (Pelvis) • Male Pelvis - Prostate/ Seminal Vesicles • Female Pelvis – Uterus / Ovaries Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Male Pelvis Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate - Anatomy • Largest accessory gland in the male reproductive system. • Pear-shaped / walnut-sized gland. • Location - midline deep in the pelvis. • The urethra runs through the center of the prostate, from the bladder. • The prostate secretes fluid that nourishes and protects sperm. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate - Anatomy • Bladder is located superiorly to the prostate. • The seminal vesicles are superior and posterior to the prostate gland. • The prostate is comprised of three distinct zones. ZONAL ANATOMY:  Central zone  Transitional zone  Peripheral zone Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate - Anatomy Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Trans-abdominal (TA) Prostate Ultrasound Technique  Primarily done for size assessment  Full bladder  3.5 to 5 MHz probe (deep location)  Place probe superior to pubis and angle caudally  Requires suprapubic pressure  Volume measurement from sagittal and transverse views Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Ultrasound - TA Appearance • Prostate appears as walnut or round shaped • Homogenous mass, benign calcification often present. • Cystic changes also common with BPH (Benign prostatic hyperplasia) • Seminal vesicles are hypoechoic and behind bladder • Size approx: 4cm×3cm×2cm (transverse diameter x sagittal diameter x height). • Volume of less than 30 ml - considered normal Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Ultrasound - TA Appearances Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Ultrasound - TA appearances Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Ultrasound - TA Appearance Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae TA Prostate Benign Prostatic Hypertrophy Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology Benign Prostate Hypertrophy (BPH) – Enlargement of central gland component – Common in elderly with symptoms of : • Poor urinary stream • Frequent urination – Can lead to : o Severe hydronephrosis - renal failure o Bladder diverticuli Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - BPH • Volume exceeding 20ml • May protrude into bladder • (TURP) done to relieve the lower UT symptoms • Radical prostatectomy Ultrasound useful in determining: – Size – Post void residual volume – Any secondary hydronephrosis Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - BPH Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - BPH Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Post TURP Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - Carcinoma • Most common malignancy in males • Predominantly 40 yrs onwards • If detected early — has a better chance of successful treatment • No signs or symptoms in its early stages • Advanced stages may cause signs and symptoms such as: – Trouble urinating – Blood in semen – Pain in the pelvic area Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - Carcinoma Risk factors: – Age – Race / Ethnicity – Family history – Obesity / Eating habits – Genetic changes Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - Carcinoma ULTRASOUND • TA insensitive, useful mainly for outlet obstruction and gross tumour spread • TR confirm clinical suspicion of intra-prostatic mass • Guide biopsy or radiotherapy treatment • Stage peri-prostatic spread Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Pathology - Carcinoma ULTRASOUND • Appearance extensively debated • Could be hypoechoic mass - (61%) • Isoechoic lesion - (35%) • Heterogeneous • Increase in vascularity • Deformed prostate contour = irregular bulge sign Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate - Ultrasound Pitfalls • Incorrect gain ! • Gas in rectum obscuring prostate • Pubic bone preventing view of prostate if low gland or abdominal guarding • Seminal vesicle dilatation may be a normal variant • PZ (Peripheral zone) - calcification may obscure hypoechic malignant mass Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Cancer / Trans-rectal (TR) Ultrasound Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Cancer / Trans-rectal US Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Prostate Cancer / Trans-rectal US Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Anatomy • Female reproductive system located in the pelvis area. • Internal anatomy of the reproductive organs are: vagina, cervix, uterus, fallopian tubes, and ovaries. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Physiology Female reproductive system contains two main parts: • Uterus : – Hosts the developing fetus – Produces vaginal and uterine secretions – Passes the anatomically male sperm through to the fallopian tubes • Ovaries: – Produce the anatomically female egg cells (ova) – Produce and secrete hormones; estrogen and progesterone Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis – Uterus • Pear-shaped muscular organ / located between the bladder and the rectum. • Functions = nourish and house a fertilized egg until the fetus is delivered. • The uterus consists of 3 tissue layers: – Endometrium: the inner lining and consists of the functional endometrium. This layer is shed results in menstrual bleeding. – Myometrium: the muscle layer and is composed of smooth muscle cells. – Serosa: the thin outer layer composed of epithelial cells. • Adenomyosis is a benign condition that occurs when the endometrial layer invades into the myometrial layer. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis – Fertilization • The ovaries release an ovum, which passes through the fallopian tube into the uterus. • It meets with sperm, then the sperm penetrates and merges with the egg, fertilizing it. • The fertilization usually occurs in the fallopian tube, but can happen in the uterus itself. • The zygote then implants itself in the wall of the uterus, where it begins the process of embryogenesis. • The cervix dilates during labour process to deliver the fetus through the birth canal (vagina). • If there is no fertilization, the egg is flushed out of the system through menstruation (every month). Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Clinical Indications  Pelvic Pain  Masses - solid/cystic and site  Bleeding (vaginally)  Abnormal periods; (amenorrhea, irregular, dysmenorrhea, menorrhagia)  Investigation of infertility Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Ultrasound Exam / Trans-abdominal (TA) • Curved probe = 3-5 MHz • Need a full bladder; drink 4 large glasses of water 1 hour prior to exam and hold. • Demonstrates size and location of organs and pathology with some tissue characterization. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Important information to consider !! • Patient History (pain- location, duration and association) • Pelvic Examination / (palpable masses) • Menstrual cycle History • HRT or contraception (OC, IUD) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae TA Ultrasound of Uterus – Sagittal view Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae TA Ultrasound of Uterus – Sagittal view Full Bladder Uterus Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae TA Ultrasound of Uterus – Transverse view Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae TA Ultrasound of Uterus – Transverse view Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Uterus Measurements - Ultrasound Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Uterus Measurements - Ultrasound Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis – TA Ultrasound of LT OVARY Uterus Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis Urinary Bladder LT Ovary fchs.ac.ae Urinary Bladder Female Pelvis – TA Ultrasound of RT OVARY Uterus RT Ovary Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Endometrium Thickness/Phases • A commonly measured parameter in gynecological ultrasound and MRI. • The appearance and thickness of the endometrium will depend on the patient age - (reproductive age or postmenopausal). • The postmenopausal endometrium should be smooth and homogeneous. • In reproductive age, endometrium thickness refers to the menstrual cycle phase. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Endometrium Thickness/Phases • Normal endometrium changes in appearance as well as in thickness throughout the menstrual cycle:  Early proliferative phase: menstrual phase and it appears as thin bright echogenic line.  Late proliferative phase: develops a trilaminar appearance, outer echogenic basal layer, middle hypoechoic functional layer, and an inner echogenic stripe at the central interface.  Secretory phase: it is at its thickest, and becomes uniformly echogenic. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Endometrium Thickness/Phases in US Secretory/post ovulatory Thickened hyperechoic line Early proliferative Thin echogenic line Late proliferative / peri-ovulatory phase Triple layer fchs.ac.ae Uterine variantsPositions • • • • Anteverted Retroverted Anteflexed Retroflexed fchs.ac.ae fchs.ac.ae Congenital Uterine Malformations fchs.ac.ae Bi-Cornuate Uterus Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Bi-Cornuate Uterus – Sagittal view Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Transvaginal Sonography (TVS) • TVS is a technique that uses a specially designed probe, that is inserted into the vagina to obtain images of the pelvis. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Advantages & Strengths of TVS • High resolution - Can see structures not visible on TAS • Earlier diagnosis for some pathologies • Better visualization for obesity, bowel gas, adhesions, retroverted uterus • No need to fill bladder • Less distortion of anatomy • Can be used with biopsy Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Disadvantages & Weaknesses of TVS • Difficult to orient anatomy and landmarks • Specialized equipment - probes, covers, sterilisation etc • Limited FOV – not as in TAS • Some patients prefer TAS because it is less invasive • Many patients do not come prepared for TVS • Sterile procedure - after each patient Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Valid Consent As TVS is an invasive procedure, consent must be obtained.  Explain the procedure, may need an interpreter  Explain why TVS is preferable to TAS  Give the patient time to absorb the information  Don’t pressure patients Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Pathology FIBROIDS  Most common uterine neoplasm  20-30% occurs for females over 30yrs  Solid, hypoechoic masses  Usually multiple  Frequently asymptomatic  Documentation of size and position needed Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Fibroids Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Fibroids Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Pathology Endometrial Polyps: – – – – Masses in the inner lining of the uterus Hyperechoic rounded/oval shape Most polyps are not cancer It can cause problems with fertility Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis -Polyps Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Polyps Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Female Pelvis - Pathology Ovarian Cysts o Follicular cyst o Corpus luteum o Haemorragic Ovarian Masses o Dermoid Cyst o Serous Cystadenoma o Serous Cystadenocarcinoma Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Ovarian Follicles Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Follicle vs follicular cyst Normal follicle (2- 2.5cm), if cysts are enlarged up to (5cm) then it is a functional/follicular cyst. fchs.ac.ae Dermoid cyst A tumor, usually benign, in the ovary that typically contains a diversity of tissues including hair, teeth, bone, etc. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Dermoid cyst Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Questions?? Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae Sample Exam Question Compare the advantages and disadvantages of a trans-abdominal and a trans- vaginal ultrasound examination of the female pelvis. (5 marks) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 6B: Lower Abdomen - Pelvis fchs.ac.ae