GYN 10

• Imaging Techniques in Gynecology

  • X-ray
  • Ultrasonography
  • Uterine Artery Embolization
  • Computed Tomography
  • Magnetic Resonance Imaging
  • Positron Emission Tomography
• 1. ray


  Essential for investigation in urogynecology and pelvic malignancy, cervical cancer in particular, prior to staging. Helpful to locate an intrauterine contraceptive device (IUCD) or to look for shadows of teeth or bone in benign cystic teratoma.

  
• Special X-ray using contrast media

  • Hysterosalpingography (HSG)
  • Lymphangiography
  • Intravenous urography
• Intravenous Urography (IVU)

  Excretion radiography is an important investigation in urogynecology. It is useful to detect any tumor, calculi, obstruction, stricture or fistula communication within the urinary tract. Normal peristaltic waves of the ureters could be seen during the procedure.

  
• Presently, computed tomography (CT) based urography imaging is done as a part of cervical cancer staging. CT allows imaging of the cervix, parametrial lymph nodes, uterus, adnexa, retroperitoneal lymph nodes, kidney, ureters and bladder simultaneously.
• Disadvantages of IVU


  Hypersensitivity reaction may occur (rarely). Ultrasonography or CT can provide more information compared to IVU.
• Ultrasonography


  A noninvasive imaging procedure that utilizes high frequency sound waves. It was first introduced by Ian Donald (Glasgow—1950) in the field of medicine.
• Types of ultrasonography


  • Transabdominal sonography (TAS)
  • Transvaginal sonography (TVS)
  • Transvaginal color Doppler sonography (TV–CDS)
  • Three-dimensional sonography (3D sonography)
  • Harmonic imaging
• Transabdominal sonography (TAS)


  Done with a linear or curvilinear array transducer operating at 3–5 MHz. TAS requires full bladder to displace the bowel out of pelvis. Ultrasound is very accurate (>90%) in recognizing a pelvic mass but cannot stabilize a tissue diagnosis.

  
• Transvaginal sonography (TVS)


  Done with a probe, which is placed close to the target organ. There is no need of a full bladder. It operates at a high frequency (5–10 MHz) allowing detailed evaluation of the pelvic organs (within 10 cm of the field).

  
• Transvaginal color Doppler sonography (TV–CDS)


  Provides additional information of blood flow to, from or within an organ (uterus or adnexae). This flow can be measured by analysis of the waveform using the pulsatility index.
• Three-dimensional sonography (3D sonography)

  More accurate. Can provide details of information as regard to the ovarian volumes, follicular dimensions, complex ovarian masses and uterine malformations.
• Harmonic imaging


  Improves tissue visualization and quality by using several frequencies instead of just a single frequency. Visual artifacts are reduced. Post processing features improve image resolution.
• Compression sonography


  Combined with color Doppler sonography. Used to detect deep vein thrombosis (DVT).
• Normal sonographic findings


  • Uterine stroma: Low level uniform echoes
  • Endometrium: Linear echogenic stripe
  • Ovary: Solid and ellipsoid structures
  • Small amount of fluid is normal finding in POD following ovulation
  • Normal tubes are not visible (c.f. hydrosalpinx)
  • Blood is echogenic

  
• Use of ultrasound in gynecology

  • Assessment of ovarian reserve by counting antral follicles (AF)
  • Infertility workup: Folliculometry, assessment of ovulation, oocyte retrieval in IVF
  • Detection of ectopic pregnancy
  • Evaluation of pelvic masses
  • Assessment of endometrial disease
  • Locating missing IUD
  • Transrectal sonography
  • Endoanal USG
  • Endorectal USG

  
• Saline infusion sonography (SIS)


  Infusion of normal saline into the uterine cavity and performing transvaginal (high resolution) sonography is helpful for the diagnosis of many focal intracavity pathology.
• Benefits of SIS


  • Evaluation of uterine cavity anatomy
  • Detection of polyp, submucous fibroids
  • Tubes evaluation—tubal patency

  
• Indications of SIS


  • Postmenopausal bleeding
  • Abnormal uterine bleeding (endometrial polyps)
  • Recurrent miscarriage
  • Release of intrauterine adhesions
  • Infertility

  
• Contraindications of SIS


  • Pelvic infection
  • Hematometra
  • Presence of uterine bleeding
  • Pregnancy
• Complications of SIS


  • Infection (<1%)
  • Pain
• Selective Salpingography (SS)


  Procedure of transcervical tubal catheterization under fluoroscopic guidance. Useful in cases with proximal tubal blockage when seen by hysterosalpingogram (HSG).
• Uterine Artery Embolization (UAE)


  Angiographic interventional procedure. Treatment of uterine myomas. Stops the blood flow through uterine arteries, resulting in ischemic necrosis of fibroids.
• Benefits of UAE


  • Reduction in size of fibroid
  • Reduced bleeding and pain
  • Reduced need of hysterectomy or myomectomy
  • Less hospital stay
  • Early return to daily activities
  • Relief of pressure symptoms
• Contraindications of UAE


  • Pregnancy
  • Pelvic infection
  • Suspected genital tract malignancy
  • Desire for future pregnancy
  • Coagulopathy
  • Renal impairment
  • Large uterus (>20 weeks)
  • Prior use of GnRH agonist
• Complications of UAE


  • Pain
  • Pelvic infection (<1%)
  • Fever
  • Nausea
  • Vomiting
  • Amenorrhea
  • Necrosis of the pelvic tissues
  • Ovarian failure, Post embolization syndrome
• Computed Tomography (CT Scan)

  Provides high resolution two-dimensional images. Cross-sectional images of the body are taken at very close intervals (few millimeters thick) in the form of multiple slices. Can differentiate tissue densities.
• Uterine artery embolization


  Procedure to reduce size of fibroids, bleeding, pain, and need for hysterectomy/myomectomy
• Benefits of uterine artery embolization


  • Reduction in size of fibroid
  • Reduced bleeding and pain
  • Reduced need of hysterectomy or myomectomy
  • Less hospital stay
  • Early return to daily activities
  • Relief of pressure symptoms
• Contraindications of uterine artery embolization

  • Pregnancy
  • Pelvic infection
  • Suspected genital tract malignancy
  • Desire for future pregnancy
  • Coagulopathy
  • Renal impairment
  • Large uterus (>20 weeks)
  • Prior use of GnRH agonist
• Complications of uterine artery embolization

  • Pain
  • Pelvic infection (<1%)
  • Fever
  • Nausea
  • Vomiting
  • Amenorrhea
  • Necrosis of the pelvic tissues
  • Ovarian failure, Post embolization syndrome
• CT scan

  Provides high resolution two-dimensional images of the body in the form of multiple slices, can differentiate tissue densities
• CT scan

  • Useful in diagnosis of lymph node metastases, depth of myometrial invasion in endometrial cancer, ovarian mass and uterine myomas
  • Unlike USG or MRI, endometrium is poorly delineated by CT
  • Can detect enlarged lymph nodes but cannot differentiate between benign hyperplasia and metastatic carcinoma
  • Ideal alternative to sonar in obese or distended stomach/gut
  • Useful in assessing tumor extent and detecting metastases
  • Enhances the lateral margins of the cervix and the parametria
  • Useful in staging of ovarian cancer
• Lower limit of detectable intraperitoneal implants by CT is between 1 and 5 mm
• Helical CT


  Current modification of CT with many advantages, has replaced pulmonary angiography and ventilation-perfusion scans for diagnosis of pulmonary embolism
• Surface radiation dose of CT scan of the abdomen and pelvis is between 2 and 10 cGY
• Value of CT in the assessment of pelvic organ malignancy is limited, MRI is preferred where available
• Use of CT should be avoided in pregnancy
• MRI


  Creates images using a combination of radiowaves and magnetic fields, based on the radiofrequency signal emitted by hydrogen nuclei
• MRI


  • Able to achieve superior soft tissue contrast
  • Used safely in pregnancy regardless of trimester
  • Can differentiate the different zones of the uterus and cervix, measure depth of myometrial penetration
  • Superior to CT or ultrasound in diagnosing adenomyosis, myomas and endometrial cancer
  • Provides detailed soft tissue imaging of female urethra, levator ani muscles, useful for pelvic organ prolapse
  • Useful for detection of peritoneal, lymph node metastasis and tumor extension in ovarian cancer
  • Superior in diagnosis of deep infiltrating endometriosis