Lecture 11: Imaging of the Female and Male Pelvis

Question 1

Common method of imaging female pelvis

Answer 1

Almost exclusively examined via US so can try avoid radiation

Question 2

Modes of Scanning pelvis

Answer 2

1. Transabdominal: bladder must be full as cant scan through air. Full bladder isnt comfortable. “tilted uterus” due to full bladder pushing uterus retroverted
2. Transvaginal: insert tampon sized probe. Closer to uterus.

Question 3

Transabdominal pelvis scanning: Anteverted yterys

Answer 3

Uterus doesnt come to anterior wall

1. cannot feel during bi manual (cervix still in normal position, whole uterus tilts back to sacrum, 10% of woman experience problems)
2. insertion of IUCD –> risk of perforation
3. Keep making patient fill bladder but due to uterus being tilted away cannot see it no matter how full the bladder is –> uncomfortable patient (filled and pressing)

Question 4

Endometrial changes

Answer 4

Dynamic endometrium (cyclical monthly change)
Thin --> flattens --> Day 12 ovulation (glycogen changes) HALO --> disappears --> menstruation
- Halo: woman's uterus has just ovulated (relevant to fertility)

Question 5

Fluid in pouch of douglas

Answer 5

Potential space b/w uterus and rectum
Follicle with egg inside bursts during ovulation and can release fluid which can drain into the pouch
Due to
1. polycystic kidneys creating leaky cysts in kidney
2. ectopic pregnancy –> FREE FLUID also created, in fallopian tube (ruptured and blood released)

Question 6

Polycystic ovaries

Answer 6

Almond shaped
Black bubble follicles (5mm and 3-4mm)
1x ripens per month –> becomes <25mm –> bursts –> tweaky and uncomfortable pain –> fluid drains into pouch of Douglas

Question 7

Ovulation

Answer 7

Broad ligament –> ovaries –> fimbral action sucks egg coming out of ovary (hence egg is briefly intra-abdominal)
Ovaries have small scars where follicles have burst (fluid and egg are being pushed out) –> fertilisation –> fallopian tube –> uterus
Ripened follicles: still functional. growing in a circle

Question 8

Pituitary gland hormonal loop re ovulation

Answer 8

Ripening of follicle requires release of FSH (follicular stimulating hormone) –> therefore follicles remain inside ovaries just sitting there, not being released

• Pearl necklace (stretching follicles but no ovulating)
• associated with infertility and insulin resistance
• Not egg cysts

Question 9

Location of uterus

Answer 9

Uterus is suspended

• ovary is tucked in behind the broad ligament
• cant see broad ligament clearly if there is water in the pelvis

Question 10

Cannulation and Dye injection into uterus

Answer 10

• can inject dye into uterus to see if fallopian tube is blocked (fertility)
  Spillage into abdominal cavity indicates tube is open
  No spillage = tube is blocked = egg cannot come down to be fertilised
  Note: blocked bilateral can occur due to sexually transmitted disease causing pelvic inflammation (PID. chlamydia)

Question 11

Non-examined uterus feastures

Answer 11

Weakened pelvic floor after birth
When the patient strains: bladder and uterus slips down (prolapses)
When the patient stands: prolapses –> leaks. Tilt = cannot empty bladder properly
- take increasing care with these patients
-MRI shows functionally what is happening

Question 12

Imaging of the male pelvis

Answer 12

Prostate, Scrotum, Urinary bladder

• almost always use US and MRI
• Limits radiation to the gonads
  1. Need to know clinical question (Trauma?)
• men shy talking about this area, need to feel safe and not judged.
• without history, scanning can be very unhelpful
• biggest barrier: need to engage with doctor before seeing radiologist for Ultrasound

Question 13

Scrotum ultrasound

Answer 13

Everyone who has it scanned are grateful as are very worries and want to know what is going on
Scan non-sore side first for reassurance
Scan under sheet - more comfortable and private for patient
Keep listening to patient: see f there have more information which they have previously concealed from doctor
Bad stuff/cancers/testis infection: tends to be in Epidiymis

Question 14

Testicular Torsion

Answer 14

Child with acute scrotum (750 children), testicular torsion isnt common
32% epidiymitis (infection)
29% appendix torsion (flap on testes)
19% testicular torsion (whole testes) –> lost blood supply –> can lose testes if not untwisted
- twisted testis = Swollen + NO BLOOD FLOW (see on motion scan)
- main goal is to detect or exclude torsion

Question 15

Epididymitis

Answer 15

Inflammatory process involving the scrotum in adults
typically caused by UTI (urinary tract infections) of sexually transmitted organisms (chlamydia or gonorrhoea)
- infections of epididymitis
In children epididymitis is often caused by 1. streptococcus 2. E.coli
- swollen
- large blood flow (hot and sore)
- potentially same clinical appearance as twist

Question 16

Testicular tumour

Answer 16

Woman seem to be more vocal about breath lumps
Men often dont know about it unless you tell them
Testicular tumours have a much longer survival rate than breast cancer overall –> yet testicular cancer presents later
- testical is hard with cancer inside
Pulmonary mets (cough blood) –> likely that there are also mets in testes

Question 17

Prostate imaging

Answer 17

Controversy over screening/not screening for prostate cancers (diagnosis and treatment of prostate cancer)

1. Transabdominal
2. Transrectal
3. MRI (multi-parametric) - imaging to provide diagnosis (MRI has great precision)

Question 18

Multi-parametric MRI

Answer 18

combines these tests"
- Regular MRI
Spectroscopic MRI
DCE: Dynamic contrast enhanced MRI
DWI: Diffusion weighted imaging MRI

Question 19

Male Bladder scanning

Answer 19

US for bladder emptying

Full bladder = can see prostate (cannot see without)