CH 12 Pediatric Pelvis: Male and Female Flashcards
normal testicle
homogeneous medium echo texture.
Tunica albuginea is the fibrous capsule surrounding the testicle.
Tunica vaginalis is a saccular extension of the peritoneum into the scrotal chambers.
The inner/visceral layer covers the testis and epididymis. The outer/parietal layer lines the scrotal chamber.
Epididymis
parallel to the testicle and is composed of a head, body and tail. It appears as an echogenic curved structure, posteriorlateral to the testes.
Rete testes
massing together of the seminiferous tubules at the testicular hilum (mediastinum testis)
appears hyperechoic in the testicle
Appendix testes
is a remnant of the mullerian duct. Can only be seen in the presence of a hydrocele.
seen as a small oval structure beneath the epididymal head. this structure can undergo torsion.
Testicular artery
arises from the aorta and supplies the testes and epididymis.
Cremasteric artery
arises from the vesical artery and supplies the scrotal wall and extratesticular structures
Deferential artery
supplies the vas deferens and arises from the inferior epigastric artery
Spermatic cord
vas deferens cremasteric, deferential and testicular arteries pampiniform plexus of veins lymphatics nerves
Cryptorchidism
incomplete descent of the testicles.
associated with urological abnomalities 20% of time (look at kidneys)
usually located in inguinal canal proximal to the internal ring.
increased risk of infertility and malignancy.
sono: smaller testis of increased echogenicity are seen anywhere along the path of descent (similar to lymph node)
Anorchidism
bilateral testicular absence
Monorchidism
unilateral testicular absence.
usually left-sided. thought to be due to a vascular accident or in utero torsion
Polyorchidism
more than 2 testes present
Triorchidism
most common form of polyorchidism; small accessory testis within the scrotum in addition to 2 normal testes
Transverse testicular ectopia
both testes are in the same hemiscrotum.
20% have associated anomalies: seminal vesicle cyst, renal dysplasia, hypospadias, UPJ obstruction and an ipsilateral inguinal hernia.
Smaller than normal testes may result with which anomalies:
cryptorchidism torsion inflammation varicocele primary hypopituitarism inguinal hernia repair radiation treatment trauma Klinefelter's syndrome
True Hermaphroditism
intersex condition where the patient has both ovarian and testicular tissue.
sono: textual difference is seen. Testicular tissue is homogeneous and the ovarian tissue is more heterogeneous with cystic follicles seen.
present prepubertal with ambiguous genitalia or postpubertally with amenorrhea in a female raised paitent or cryptorchidim, gynecomastia and cyclic hematuria in a male raised patient.
Cystic dysplasia of the testis
causes painless scrotal enlargement. *rare congenital condition which causes dilatation of the rete testes and efferent ducts and parenchymal atrophy.
may be associated with: ipsilateral renal agenesis, MCDK or renal dysplasia.
Testicular torsion
most common causes of the acute scrotum in pediatric patients.
when testis and spermatic cord twist one or more times cutting off blood flow.
CFD must be used to determine the absence of flow in the painful testis and flow in the normal asymptomatic testis.
*peaks in infancy and adolescence
Extravaginal torsion
torsion is at the level of the spermatic cord and all scrotal contents are strangulated. Occurs in utero, surgical savage at birth not likely due to necrosis. Necrotic testicle must be surgically removed.
may see thickened skin and hydrocele.
compensatory hypertrophy of the contralateral testis.
Intravaginal torsion
within scrotal sac, more commonly in adolescents and young adults. Secondary to lack of normal fixation of the postero/lateral aspect of the testes to the tunica vaginalis.
bell-clapper deformity- testes free to swing and rotate within the tunica vaginalis of scrotum.
present: sudden onset of scrotal/lower abd pain, nause, vomiting. hemiscrotum is red and swollen and the affected testis is often oriented transversely. (40% bilat)
* true medical emergency
Testicular salvage rates:
*aprox 90-100% if surgery within 6 hours of onset of sypmtoms
20-50% within 12-24 hours
0-10% after 24 hours
Testicle salvage rates:
*aprox 90-100% if surgery within 6 hours of onset of sypmtoms
20-50% within 12-24 hours
0-10% after 24 hours
Testicular torsion sono:
normal = early torsion
4-6 hours = enlarged and hypoechoic secondary to edema
after 6 hours= heterogenous, areas of increased echogenicity secondary to vascular congestion, hemorrhage and ischemia.
with any degree of torsion, see abnormal orientation of the testis within the scrotum, abnormally thickened testicular structures, enlarged hypoechoic epididymis, scrotal wall thickening, reactive hydrocele and enlarged twisted spermatic cord.
determine difference between testicular torsion and epididymitis
CFD!
presence of flow does not exclude the diagnosis of torsion. Incomplete or partial torsion may show arterial flow, but it will be diminished as compared to the asymptomatic side.
Bell-and-clapper
detorsion, where the testicle twists back and forth and acute scrotal pain spontaneously resolves, CFD will show increased flow in the testis and the paratesticular soft tissues due to reactive hyperemia.
Torsion of testicular appendages
can result in the clinical presentation of acute scrotum.
appendix testis and appendix epididymis.
Appendix epididymis
remnant of the meonephric (wolffian) duct.
usually projects from the head of the epididymis, location may vary
Appendix epididymis
remnant of the meonephric (wolffian) duct.
usually projects from the head of the epididymis, location may vary
Epididymitis
swelling/inflammation of the tube (epididymis) that connects the testicle with the vas deferens.
Most common in men ages 19-35 and most often caused by the spread of bacterial infection.
Gonorrhea and chlamydia most common in young men, children and older med commonly caused by E coli and similar bacteria.
**with > than 6 week history of symptoms, classic appearance + increased flow within the edematous epididymis.
Epididymitis
swelling/inflammation of the tube (epididymis) that connects the testicle with the vas deferens.
Most common in men ages 19-35 and most often caused by the spread of bacterial infection.
Gonorrhea and chlamydia most common in young men, children and older med commonly caused by E coli and similar bacteria.
with >
Acute epididymitis
2nd most common cause of acuter scrotal pain in children.
more common in pubertal than prepubertal boys
**< 6 weeks and my be due to infection.
hydrocele is usually present with hypervascularity and enlarged epididymis.
associated with lower UTI symptoms and fever.
Orchitis
inflammation of one or both testicles. (male PID)
may be caused by and infection from many different types of bacteria and viruses.
*common virus causing orchitis is mumps, usually develops 4-6 days after mumps begins, testicles may shrink
may occur with infections of the prostate or epididymis or STI’s such as gonorrhea or chlamydia
Hydrocele
serous collection of fluid that accumulates within the tunica vaginalis or surrounds the testes betweent he 2 layers of the tunica vaginalis.
most are congenital and seen in boys ages 1-2.
represent collections of peritoneal fluid that has entered the scrotal sac via a patent processus vaginalis.
most non-communicating hydroceles disappear within a year.
Varicocele
aquired dilation of the veins of the pampiniform plexus.
usually occur after puberty; few may occur from 13-25 yrs
90% on the left due to the length of the left testicular vein as it drains into the LRV. always use CFD, light up.
Epididymal cysts
result from the dilatation of the epididymal tubules, but are composed of clear fluid
due to prior episode of epididymitis
Spermatocele
cystis mass of the epididymis.
dorm due to dilatation of the epidiymal tubules. filled with a milky fluid containing spermatozoa.
due to prior episode of epididymitis
Spermatocele
cystis mass of the epididymis.
dorm due to dilatation of the epidiymal tubules. filled with a milky fluid containing spermatozoa.
due to prior episode of epididymitis
** testicular tumors appear
either the first 2 years of life or postpubertal
Juvenile granulosa
cell tumors are benign cystic tumors.
appear by the age of 6 months in children with ambiguous genitalia
Leydig cell
tumors are rare benign tumor which presents between 5-10 years.
cause precocious puberty and gynecomastia
Seminoma
most common testicular tumor to develop in patients with cryptorchidism; generally malignant.
aprox 30% with a seminoma have h/o undescended testes.
sono: smaller testis of increased echogenicity are senn anywhere along path of descent (similar to lymph node)
Yolk sac tumors (embrynoal cell tumors)
most common malignant germ cell tumors seen in prepubertal children and within undescended testicles.
Female pelvis
always examin urinary tract and lower instestin for abnormalitis when abnomalities of genital tract seen. (20% will have renal anomalies)
Female pelvis
always examin urinary tract and lower instestin for abnormalitis when abnomalities of genital tract seen. (20% will have renal anomalies)
True pelvis vs False pelvis
True pelvis is delineated from the false pelvis by the LInea Terminalis.
Adnexa:
area posterior to the broad ligaments and adjacent to the uterus
Innominate bones of the pelvis:
Ischium
Ilium
pubic bones
Ovarian ligament
provides support to the ovary and extends from the ovary to the lateral surface of the the uterus.
Piriformis muscles
are posterior and extend from the sacrum to the femoral greater trochanter.
Piriformis and iliopsoas muscles may be confused with the ovary.
Piriformis muscles
are posterior and extend from the sacrum to the femoral greater trochanter.
Levator ani muscles
are located between the coccyx and the pubis. Weakening of this muscle and the coccygeal muscles leads to prolapse of the pelvic organs
Obturator Internus muscles
lateral to the ovaries
Cardinal ligament
houses the vasculature of the uterus.
Arcuate arteries
are the peripheral arteries of the uterus
Spiral arteries
supply blood to the functional layer of the endometrium
Ovarian veins
RT ov vein drains into the IVC
LT ov vein drains into the LRV
Ovarian veins
RT ov vein drains into the IVC
LT ov vein drains into the LRV
Ovarian volume
1 day - 12 months = 1.0 ml
< 6 years = <1.0 ml
size increases after 6 years:
Premenarchal = (6-13 yrs) 1.1 - 4 ml
postmenarchal = 9-10 ml
Ovarian volume
1 day - 12 months = 1.0 ml
< 6 years = <1.0 ml
size increases after 6 years:
Premenarchal = (6-13 yrs) 1.1 - 4 ml
postmenarchal = 9-10 ml
Fallopian tubes
The isthmus is the short narrow segment of the fallopian tube.
The ampulla is the longest most tortuous segment of the tube.
Space of Retzius
anterior to bladder; between bladder and symphysis pubis
Pouch of Douglas
posterior cul-de-sac/ rectouterine pouch. Most dependent recess in the body which is between the rectum and uterus.
Anterior cul-de-sac
Vesicouterine pouch, anterior to the uterus and posterior to bladder.
Newborn female genitourinary (GU)
cervix is 2x the length of the uterine body. (cx 2/3; body 1/3)
hyperechoic endometrium is evident due to the maternal hormone influence in utero.
uterus 3cm L x .5-1 cm AP
2-3 months female genitourinary (GU)
Uterus regresses and cx and body become equal in length. ( 4cm L x 2.5 cm x 1 cm)
no endo stripe seen. Uterus maintains an infantile appearance until age 7.
small cyst may be seen in the ovaries (usually < 9mm but up to 12mm)
*Indications for female genitourinary (GU) sono:
r/o ov cyst r/o PCO Neoplasms congenital uterine anomalies hydro-/hematocolpos evaluate precocious puberty
*determine presence/absence of uterus and vagina in newborns with ambiguous genitalia
*Indications for female genitourinary (GU) sono:
r/o ov cyst r/o PCO Neoplasms congenital uterine anomalies hydro-/hematocolpos evaluate precocious puberty
*determine presence/absence of uterus and vagina in newborns with ambiguous genitalia
Ovarian cysts
follicular cysts in children are of no concern. Rarely secrete estrogens.
Neonatal ovarian cysts
may be seen as a large abdominal mass and may contain a fluid-debris level.
Only ov masses in neonates have this sono appearance. may take up to a year to involute and can be aspirated if causing respiratory difficulty.
*Gartner duct cysts
occur in vagina
*Nabolthian cysts
occur in the cervix
Polycystic ovaries
Ov have an increased ovarian vol. and there is a “string of pearls” appearnace of the follicles (at least 8-10 peripheral)
Increase in echodense stroma of ov.
can occur as early as 6; peaks at puberty
Polycystic ovaries (PCO) associated
seen with bulimia which may be due to swings in insulin levels.
NOT associated with PCOS( includes hirsutism, obesity, oligo-amenorrhea and infertility)
Polycystic ovarian disease (Stein-Leventhal)
Clinical: hirsutism, obesity, oligo-amenorrhea(excess ov adrogens and chronic anovulation) and infertility.
Obese or insulin resistant patiens have more severe cases.
ov are bilat rounded and enlarged (mean ov vol of 14mL)
** FSH is decreased and LH are elevated
sono: increased number of developing follicles seen, maturing follicles are rare.
* increased occurrence of endo cancer due to long-term opposed estrogen.
Polycystic ovarian disease (Stein-Leventhal)
Clinical: hirsutism, obesity, oligo-amenorrhea(excess ov adrogens and chronic anovulation) and infertility.
Obese or insulin resistant patiens have more severe cases.
ov are bilat rounded and enlarged (mean ov vol of 14mL)
** FSH is decreased and LH are elevated
sono: increased number of developing follicles seen, maturing follicles are rare.
* increased occurrence of endo cancer due to long-term opposed estrogen.
Germ cell tumors
make up most of pediatric ov tumors.
*most common is a teratoma/dermoid
Germ cell tumors
make up most of pediatric ov tumors
Dermoids/Teratomas
*most common benign cystic ov neoplasm, comprise nearly 1/2 of all ov tumors. appear from late childhood to early adolescence.
arise from all 3 germ layers and may contain fat, teeth, hair, bone.
increased AFP and HCG levels.
sono: highly echogenic, cystic areas, calcifications, fat-fluid level “tip of iceberg”
Malignant ov tumors
mostly occur in post-pubertal girls.
characteristics: ill-defined margins fluid in pouch of douglas ascites lymphadenopathy liver secondaries more solid
*Lactate dehydrogenase
used to monitor renal function is also used as a tumor marker for ovarian dysgerminoma
*Ovarian Krukenberg tumor
associated with a primary GI tumor
Embryonal (botryoid) rhabdomyosarcoma of vagina
occurs in very young girls.
clinically: present with hemorrhagic discharge, extrusion of the mass from the vagina and/or abdominal mass.
Pseudomyxoma Peritonei
occurs when a mucinous ovarian malignancy ruptures
*Meig’s syndrome
presence of ascites/ pleural effusion in presence of some benign ovarian tumors (fibroma)
Failure of fusion of Mullerian ducts:
Bicorunate uterus (bicornis unicollis most common) Uterus didelphys arcuate uterus
Failure of fusion of Mullerian ducts:
Bicorunate uterus (bicornis unicollis most common) Uterus didelphys arcuate uterus
Genital tract obstructions
may cause a abdominal mass in the neonate or amenorrhea and cyclical pain during puberty.
*most common cause is an imperforated hymen
other causes:
vaginal stenosis/atresia
cloacal abnormalities
urogeneital sinus abnomalities
these may extend up to the vagina to include cx and uterine cavity
Genital tract obstructions
may cause a abdominal mass in the neonate or amenorrhea and cyclical pain during puberty.
*most common cause is an imperforated hymen
other causes:
vaginal stenosis/atresia
cloacal abnormalities
urogeneital sinus abnomalities
these may extend up to the vagina to include cx and uterine cavity
Hematocolpos:
collection of blood is trapped in the vagina and/or uterus, which leads to abdominal pain and causes a mass effect.
sono: distended vagina with low-level echoes is seen.
more common in a teenager due to imperforate hymen, frequently goes undected until after menarche.
Hydrocolpos
collection of fluid within the vagina.
sono: hypoechoic distension of the vagina. endometrium, and posterior acoustic enhancement. Internal echoes may be present due to debris and clot.
Hematometrocolpos:
dilated uterus and vagina
Hematometra:
uterus dilated by blood
Mayer-Rokitansky-Kuster-Hauser syndrome
2nd most common cause of primary amenorrhea.
vaginal atresia, rudimentary bicornuate uterus, normal tubes, ov, and broad and round ligaments.
increased incidence of renal agenesis or ectopia and skeletal anomalies.
sono: didelphys uterus will be seen with ipsilateral renal agenesis and unilateral hydrometrocolpos.
Mayer-Rokitansky-Kuster-Hauser syndrome
2nd most common cause of primary amenorrhea.
vaginal atresia, rudimentary bicornuate uterus, normal tubes, ov, and broad and round ligaments.
increased incidence of renal agenesis or ectopia and skeletal anomalies.
sono: didelphys uterus will be seen with ipsilateral renal agenesis and unilateral hydrometrocolpos.
Primary amenorrhea
never had a menstrual period
Menometrorrhagia
heavy, prolonged bleeding between periods
Metrorrhagia
irregular menstrual bleeding between periods
Precocious puberty
onset of secondary sexual characteristics prior to age 8
True precocious puberty:
results from an early, but normal pattern of gonadotropin secretion from the pituitary gland.
can be secondary to hypothalamic disease or congenital adrenal hyperplasia.
idiopathic in >80%
Precocious pseudopuberty
occurs due to abdnomal exposure to estrogens. (fast foods) Results in the development of secondary sexual characteristics without gametogenesis (production of male/female germ cells)
may secondary to an ovarian tumor, specifically granulosa cell tumor.
Isolated premature thelarche
isolated breast enlargement without progression through puberty. occurs in females between 6mo-2yrs
Asymmetrical breast enlargement is present with absence of axillary and pubic hair.
Pubertal delay
absence of puberty by age 14 in females and 15 in males. more common in males
in girls: check for Turner’s syndrome.
causes: constitutional delay (temporary delay in skeletal growth of a normal child) and low gonadotropin secretion (due to CF, asthma, anorexia, chron’s pituitary disorders, Turner’s Klinefelter’s, chemo, radiation)
Pubertal delay
absence of puberty by age 14 in females and 15 in males. more common in males
in girls: check for Turner’s syndrome.
Ovarian torsion
occurs secondary to the abnormal twisting of the involved ovary on it’s ligamentous support.
can occur due to fallopian tube being long and ovary more mobile.
*Right ovary more frequently affected than the left
Ovarian torsion clinical:
acute onset of lower abdominal pain, nausea, vomiting, and leukocytosis.
OV torsion at mesosalpinx
(portion of broad ligament that stretches from the ov to the level of the fallopian tube)
occurs due to changes in intra-abdominal pressure and body position.
Torsion of OV and fallopian tube
occurs due to partial/complete twisting of the ovary on its vascular pedicle. venous congestion, hemorrhage and ischemia occurs. Prolonged ischemia can lead to necrosis, loss of ovarian function, infection and peritonitis.
OV torsion sono:
ov enlargement due to edema along with a midline ovary is seen, in addition to fluid in the cul-de-sac, an adnexal mass (hemorrhage/infarction), cystic or complex mass with fluid-debris levels and septaions and peripheral multiple (8-12 mm) follicles.
Ambiguous genitalia
when a child is born with a micropenis and no palpable gonads or hypospadias without a palpable gonad or only one palpable gonad.
Ambiguous genitalia sono:
determine the presence/absence of a uterus, identify gonads, examine renals and adrenals (enlarged adrenals may occur)
Gonads which are in the scrotum or lower inguinal canal have testicular tissue and are either testes(homogenous) or ovoteses (heterogenous) in children with ambiguous genitalia.
**ovaries should never be seen this low, unless they are in a hernia.
