Female Genitourinary

Ovarian Malignancy

• CT A&P is preferred first test for staging

  • MRI is degraded by bowel peristalsis motion and therefore is not preferred

  • PET for follow up but not for initial

General

Junctional zone

• Arrow head = endometrium

• Middle arrow = junctional zone

• Long arrow = Outer myometrium

Mullerian Duct Anomalies

• Can think of these as failure of the septum to resorb or failure of mullerian ducts to fuse

• Agenesis

• Always need to look at kidneys & GU system for additional abnormalities

Agenesis

• Uterus doesn’t form basically because of interruption of mullerian duct early in development

• Complete

  • No uterus, cervix or vagina

• Partial

  • Has any part of the uterus, cervix or vagina present but everything

• Ovaries are fine - can have a surrogate pregnancy

DES Exposure

• Results in a T Shaped uterus

Septate Uterus

• Failure of septum to resorb

• No indentation at top of uterus (normal contour)

• Look at T2 images to see if there is a fibrous or muscular septum - helps surgery

  • T2 dark = fibrous

• Should also measure the septum

• Septate line

  • Drawn line across top of two tips (inter-cornuate line) and another from that line to the fundus

    • Needs to be > 5mm to be a septate uterus

Adenomyosis

• Ectopic endometrial glands in the myometrium

  • Technically myometrial glands 2.5 mm deep to the endometrial-myometrium interface

• Findings

  • Ectopic endometrial glands

  • Echogenic nodules/striations or small cysts (US to R)

    • Small cysts at the endometrial-myometrial junction are most sensitive & specific finding for adenomyosis (green arrow)

  • Hypertrophy of myometrium

  • Junctional zone thickness >12 mm

    • Not required but high specificity

  • Venetian blinds appearance

    • Alternating stripes of increased and decreased echogenicity - looks like light coming through the blinds to me (bottom image)

    • Need to make sure the lines don’t go back to the arcuate arteries within the uterus itself, that’s just artifact

  • Ill defined endometrial-myometrial junction

  • Vascularity

    • Tortuous and increased vascularity

• Specific to MR

  • Thick junctional zone with indistinct margins

  • T2 bright foci in endometrial & myometrium (sometimes T1 bright too)

    • This is how you differentiate it from a fibroid

Adenomyoma

• Basically adenomyosis in mass form

Leiomyosarcoma

• Look for an enlarging uterine mass/uterus with internal areas of hemorrhage/necrosis

• May look largely cystic with blood and shit in there

• Look for mets

  • If none seen, should include degenerative/degenerating fibroid in ddx

Uterine AV malformation

• Basically AV fistula in uterus

• Risk factors

  • Trauma (curettage included)

  • Intrauterine contraception use

  • Treatment of prior trophoblastic disease

Pelvic Actinomycosis

• Life threatening infection

• Associated with IUD use (also surgery, trauma)

• Falls under the umbrella of PID

• Looks like really bad loculated abscess

  • Multiseptated fluid containing mass with enhancing walls and septa

OHVIRA Syndrome

• Obstructed Hemivagina

• Ipsilateral renal anomaly

• So

  • Duplicated vagina, cervix, uterus

  • Renal anomly

  • Hematocolpos

Uterus

Rudimentary horn

• Basically a little uterus next to the main uterus

  • May communicate with regular uterus or not

  • Caused by incomplete development of one of the mullerian ducts (the rudimentary horn) while the other duct forms normally (regular uterus)

• Main uterus may be smaller than usual

  • Increased risk of preterm labor

  • Increased risk of IUGR (smaller uterus so smaller area for baby to grow)

• Need to evaluate if the rudimentary horn has its own endometrial lining

  • Increased risk of ectopic if endometrium is present

    • Need to cut it out

• Increased risk of

  • Uterine rupture

  • Miscarriage

• GU anomaly will typically be on same side as the rudimentary horn

Uterine Disease

Endometrium

• Endometrial disease can be divided into the categories as below

• Endometrial disease

  • Diffuse disease

    • Endometritis

    • Iatrogenic hyertrophy (estrogem, tamoxifen use)

    • Cancer

    • Stimulation from obesity, PCOS, etc

  • Focal disease

    • Adhesions/synechiae

• h

• j

Tamoxifen Use

• Causes multiple changes of the endometrium

• Endometrial hypertrophy

  • On tamoxifen endometrium allowed to be 0.9 mm thick

    • But if bleeding —> need scope regardless

• Cystic changes, polyps etc

• Increased risk of endometrial carcinoma

Uterine Synechiae/Adhesions

• Linear and extend from one uterine wall to another

• Enhance

• T2 hypointense (scar tissue so…)

• Asherman syndrome

Endometrial Cancer

• Adenocarcinoma (80%)

• Serous Papillary (5-10%)

  • Old women w/ atrophic endometrium

• Clear Cell Carcinoma

• Mucinous Adenocarcinoma

• Squamous Cell

• Lymph nodes

  • Nodes as small as 4mm or larger in short axis in the pelvis are considered significant

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Fibroids

Endometriosis

• Honestly this just looks like dark fuck shit, sometimes circumscribed, sometimes ill defined or spiculated, abuts other structures, can tether shit

• Superficial endometriosis = Sampson syndrome

  • Plaques along the superficial portion of the peritoneum lining the ovaries, ligaments, basically everything in pelvis

  • These are the gun powder burn lesions

  • Typically cannot see these on imaging unless they cause hemorrhage (look for T1 bright)

• Deep Endometriosis = Cullen syndrome

  • These are subperitoneal implants

  • Ectopic endometrial glands embedded in fibrous stroma and smooth muscle cells

• Increased risk for

  • Endometriod cancers

  • Clear cell carcinoma

• Hematosalpinx

  • If you see this need to look closely for small endometrial deposits outside the uterus because it is almost pathognomonic for endometriosis

• Torus Uterinus

  • This is where the sacrouterine ligament attaches

  • Commonly site for endometrial implant

• Kissing ovary sign

• Unexpected ureter kinking or hydronephrosis

• Endometrioma

  • When endometriosis implants on the ovary invaginate and create a mass

    • Blood made each cycle cannot escape and accumulates

  • Thick walled with low level internal echos on US

  • Low T2 signal (shading sign) - can be high signal or whatever too but low is the classic

  • Us fat sat to differentiate for teratoma

Salpingitis isthmica nodosa

• Basically nodularity/diverticula of the fallopian tubes

• Risk for ectopic pregnancy

Random Uterine Pathology

Uterine Fibroids

• Exist on a spectrum of benign to non-benign (but not necessarily malignant)

• Benign

  • Non-Degenerated

  • Degenerated

    • Degeneration types

      • Mxyoid

      • Cystic

      • Hemorrhagic

      • Fatty

      • Hyaline

• Non-Benign

  • Mitotically active, increased cellularity, Atypical appearance

  • STUMP (small muscle tumor of

  • Malignant sarcoma

• Imaging Findings

  • US

    • Well circumscribed

    • Hypoechoic

    • Calcs which may have shadowing

    • May have increased vascularity

    • Really just looks like a heterogenous crock of shit

  • MRI

    • Classically T1 isointense to myometrium, T2 hypointense

      • T2 hypo-intensity should make you think of fibrous tissue, the most common of which is a fibroid

    • Areas of internal T1 hyperintensity —> consider hemorrhagic component/degen

      • The internal T1 hyperintensity looks slightly T1 hypointense tbh, not actually very T1 dark but bright relative to myometrium I suppose

    • Enhance

    • Some variation though

    • May have increased calcifications after necrosis or with increased (post-menopausal) age

• Location

  • Submucosal

  • Intramural

  • Subserosal

  • Pedunculated (can torse and cause acute pain)

  • Others

• Red fibroid

  • Basically acutely infarcted and hemorrhagic fibroid

  • T1 hyperintense (again not dramatic but kinda brighter than the myometrium)

  • Look at subtracted images because if already T1 bright internally then will be bright on post-contrast too because its already bright on the T1, so look at subtracted images and if looks like black hole (all dark inside) then likely red fibroid

• Lipomyomyoma

  • Basically a fat fibroid

  • Bright mass on US

    • Look for no shadowing, if bright mass and shadows can be air or calcified fibroid

• If fallopian tube fibroid

  • Should be in between the uterus and ovary

  • Need to look for a normal ipsilateral ovary otherwise a fibrous tumor of the ovary (fibroma) is in the ddx

Nabothian Cyst

Cysts

Cervix