Pediatrics: Reproductive Flashcards
Hydrometrocolpos
When the uterus and vagina are expanded with blood due to obstruction
Causes of hydrometrocolpos
- Imperforate hymen (most common)
- Vaginal stenosis
- Lower vaginal atresia
- Cervical stenosis
Complications of hydrometrocolpos
Hydronephrosis (due to mass effect from distended uterus)
Hydrometrocolpos is associated with which congenital uterine anomaly?
Uterine didelphys
Note: 75% of cases have a transverse vaginal septum.
RLQ pain in a young female with ultrasound demonstrating an enlarged right ovary with displaced follicles containing fluid-debris levels…
Think ovarian torsion
Is idiopathic ovarian torsion more common in kids or adults?
Kids (due to excessive mobility of the ovary in kids)
Note: Ovarian torsion in adults is usually due to a mass.
When should you consider an ovary to be enlarged enough to be suspicious of ovarian torsion in a kid?
When it is at least 3x larger than the contralateral ovary
Note: There is a lot of variability in ovarian size in the pediatric population.
What are the most common ovarian neoplasms in a child?
- Benign dermoids/teratomas (67%)
- Germ cell cancer (25%)
What imaging characteristics make an ovarian mass suspicious for cancer?
- Mural nodules
- Thick septations
- Peritoneal implants
- Ascites
- Lymphadenopathy
Congenital hydrocele is due to…
A patent processus vaginalis, allowing peritoneal fluid into the scrotal sac
How can you differentiate a hematocele and pyocele?
Clinically
Note: Both hematoceles and pyoceles appear as complicated hydroceles with septations.
Varcicoceles are more common on which side?
Left
Next step if you identify an isolated right-sided varicocele…
Abdominal CT to look for pathology (e.g. extrinsic compression, renal vein thrombosis, portal hypertension with splenorenal shunting)
Note: Isolated right varicoceles are very rare without other pathology.
What is the most common cause of idiopathic scrotal edema?
IgA vasculitis (Henoch-Schonlein purpura)
Common causes of unilateral right-sided varicocele
- Extrinsic compression of the right gonadal vein (e.g. nutcracker syndrome, renal cell carcinoma, retroperitoneal fibrosis)
- Renal vein thrombosis
- Portal hypertension (causing a splenorenal shunt)
Differential for acute scrotal pain in a kid
- Torsion of the appendix testis
- Testicular torsion
- Epididymo-orchitis
Causes of orchitis
- Progression of epididymitis (by far most common)
- Mumps (rare)
10 y/o M with acute onset scrotal pain and a “blue dot sign” on physical exam…
Think torsion of the appendix testis (but exclude testicular torsion with scrotal ultrasound)
What is the most common cause of acute scrotal pain in males age 7-14?
Torsion of the appendix testis
What is the testicular appendage?
A vestigial remnant of a mesonephric duct
Note: Clinically significant because it can torse, causing acute scrotal pain.
Classic imaging appearance of torsion of the appendix testis
Enlargement of the testicular appendage to greater than 5 mm WITHOUT evidence of testicular torsion
Major risk factor for testicular torsion
Bell clapper deformity (failure of the tunica vaginalis to connect with the testis, allowing more testicular mobility than usual)
Note: This is often bilateral, so treatment is a bilateral orchiopexy in the setting of torsion.
5 y/o M with afebrile, painless, scrotal swelling and a heterogeneous extra-testicular scrotal mass with internal vascularity on color doppler…
Think rhabdomyosarcoma
Note: These are usually embryonal from the spermatic cord or epididymis.
Management of testicular microlithiasis
Follow-up screening ultrasounds in 6 months, then annually to look for germ cell tumors
Note: This is controversial.
How can you differentiate different types of intratesticular masses on ultrasound?
You can’t, the best you can do is differentiating intratesticular from extratesticular masses and then guess based on epidemiology (not imaging)
What are the major categories for testicular tumors?
- Germ cell (90%)
- Non germ cell (10%)
What are the most common testicular germ cell tumors?
- Seminoma (40%)
- Non-seminoma (60%):
- Teratoma
- Yolk sac
- Mixed germ cell (choriocarcinoma)
What are the most common testicular non germ cell tumors?
- Sertoli
- Leydig
What are the two most common testicular germ cell tumors seen in the first decade of life?
- Yolk sac tumor
- Teratoma
1 y/o M with a heterogeneous testicular mass…
Think yolk sac tumor to teratoma
How do testicular teratomas differ from ovarian teratomas?
Testicular teratomas tend to demonstrate aggressive biological behavior
14 y/o with a highly vascular testicular mass and elevated b-hCG…
Think choriocarcinoma
Note: Look for hemorrhagic metastases.
Which lab abnormality is classic in testicular choriocarcinoma?
Elevated beta-hCG
Young male with bilateral testicular masses and multiple small, dark macules on their lips…
Bilateral Sertoli cell tumors (in the setting of Peutz-Jeghers syndrome)
Bilateral testicular masses with dense echogenic foci centrally in a pt with Peutz-Jeghers syndrome…
Bilateral Sertoli cell tumors
Note: These tumors tend to “burn out” and form calcified scars.
Bilateral Sertoli cell tumors are associated with…
Peutz-Jeghers syndrome
Risk factors for testicular lymphoma
Immunosuppression
Multiple hypoechoic vascular masses in the bilateral testes of an immunosuppressed child…
Think lymphoma
Which testicular tumors are often bilateral?
- Sertoli cell tumors
- Testicular lymphoma
- Metastases
Why are the testes a common place for lymphoma/leukemia recurrence?
The blood-testes barrier prevents chemotherapy from being as effective in the testes
Testicular mass with microlithiasis…
Think seminoma
Note: Large calcifications are more common in non-sminomatous germ cell tumors.
Classic imaging appearance of testicular lymphoma
Multiple focal or diffuse hypoechoic vascular lesions within the testes with minimal mass effect (lymphomatous tissue “replaces” testicular parenchyma)
What is the most common tumor of the fetus/infant?
Sacrococcygeal teratoma (usually benign)
Large solid and/or cystic mass in the posterior pelvis of a newborn…
Think sacrococcygeal teratoma
Complications of sacrococcygeal teratomas
- GI obstruction
- Hip dislocation
- Nerve compression (possible incontinence)
Treatment for sacrococcygeal teratoma
Surgical resection (with complete resection of the coccyx)
Note: Incomplete resection of the coccyx is associated with a high recurrence rate.
Sacrococcygeal teratomas are more likely to be malignant if they are…
- Totally intraabdominal
- In an older infant
Classification of sacrococcygeal teratomas by location
- Type 1 (extra pelvic)
- Type 2 (pelvis involvement without abdominal involvement)
- Type 3 (abdominal involvement)
- Type 4 (totally intraabdominal; highest risk of malignancy)
