Pediatric Gynecologic Ultrasound. Objectives

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1 Pediatric Gynecologic Ultrasound Marilyn J. Siegel, M.D. Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis, MO Objectives Review normal anatomy Discuss causes of acute pain Emphasize ultrasound findings with pathologic correlation Normal Ovarian Morphology: Key Points Presence of cysts is normal in infants & children Represent follicles Do not confuse for pathology Ovarian Maturation: Morphology Prepubertal ovary Homogeneous or heterogeneous due to presence of primordial follicles (< 1cm) Pubertal ovary Usually heterogeneous Reflects presence of primordial follicles & functional follicles (1-3cm) 10 follicles stimulated each cycle 1 becomes functioning follicle Grows to 15 to 30 mm Normal Maturation Functional Follicles 2 classes Follicular or Graafian Corpus luteal Very common finding in normal cycle May cause pain if they bleed 1

2 Normal Ovary: US Doppler US Waveform changes with phase of cycle Primordial follicles < 9mm Graafian follicle mm Corpus luteum cm Early/late cycle: highimpedance waveform Mid cycle: low-impedance waveform Acute Pain: Role of Ultrasound Acute Female Pelvis First line imaging in the evaluation of young girls presenting with abdominal pain Quick Provides good imaging of pelvic organs No radiation May elucidate other diagnoses Acute Female Pelvis Symptomatic Functional Cysts 15% of acute abdomen diagnoses Functional cysts Ovarian torsion Pelvic inflammatory disease (Ectopic pregnancy) May cause pain because of-- Internal hemorrhage or Rupture Into peritoneal cavity with bleeding, peritoneal signs 2

3 Hemorrhagic Cysts Acute Findings More common in luteal cysts > 3 cm (5-8 cm) Imaging findings vary with age Acutely-thin wispy strands» Fish net or lacy pattern Later fluid-debris level Retracting hyperechoic clot thin wispy strands» Fish net or lacy pattern Later Findings retracting clot clot is avascular Later Findings fluid debris level solid component Functional Cysts More Points Most regress within 2 cycles If the cyst remains for > 3 cycles, likely not functional paraovarian cyst or teratoma Cysts > 5 cm should be followed More likely not to involute 6-8 wk follow up Cysts may rupture resulting in hemoperitoneum 3

4 Ovarian (Adnexal) Torsion Partial or complete rotation of the ovarian pedicle Adnexa usually normal in children Underlying mass less common More common in adults Previous self-limiting recurrent pain Torsed ovary & tube Ovarian Torsion: Path Enlarged ovary hemorrhagic peripheral follicles Ovary and fallopian tube are torsed Ovarian Torsion: US Most suggestive: ipsilateral enlarged, hypoechoic ovary, + peripheral follicles Mass e.g. teratoma, functional cyst Associated thickened fallopian tube Torsion of a Normal Ovary US/CT: Enlarged ovary Tiny peripheral cysts Ovarian Torsion Torsion of a Normal Ovary Doppler is extremely useful Absence of arterial and venous flow High resistance arterial flow Twisted vascular pedicle Corkscrew vessels 4

5 But Beware: Doppler US Ovarian Torsion Flow may be preserved due to dual blood supply Compare with opposite ovary*** 2-4 x larger than normal ovary 3.5 cm 7cm Torsed right ovary with preserved arterial flow! Torsed right ovary with preserved arterial flow!! Pelvic Inflammatory Disease Imaging for: Complications Failure to respond to treatment Alternative diagnoses US is initial imaging study of choice CT/MR for severe cases PID: US Pyosalpinx/PID Normal US Indistinct uterus Thick walled tube (pyosalpinx) Tuboovarian abscess 5

6 Pyosalpinx/PID Abscess/PID Uterus: Hematocolpos Hematocolpos in a 13-year-old girl with acute cyclic pain Vaginal obstruction Causes: vaginal or cervical atresia or imperforate membrane Adolescents may present with lower abdominal pain US: tubular, fluid-filled midline mass Acute Gynecologic Lesions Adnexal Disorders Hemorrhagic Cyst Adnexal Torsion PID» Pyosalpinx/TOA Uterine Disorder Hemtocolpos Summary: Acute Female Pelvis Look for the clues Patient age-adolescent patient Clinical features Gray scale and Doppler US There are clues! 6

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