Radiography 20 (2014) 178e182

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Radiography
journal homepage: www.elsevier.com/locate/radi

Gonad shielding in paediatric pelvic radiography: Effectiveness

and practice
Thomas Warlow a, Peter Walker-Birch b, Philip Cosson b, *
a
Radiology Department, King’s Mill Hospital, Mansfield Road, Sutton in Ashfield, Nottinghamshire NG17 4JL, UK
b
Medical Imaging, Teesside University, Middlesbrough TS1 3BA, UK

a r t i c l e i n f o a b s t r a c t

Article history: The use of Gonad Shields (GS) has been advocated during pelvic radiography since the 1950’s, particu-
Received 30 September 2013 larly in children where the risks from radiation are higher. Previous literature reports that GS are often
Received in revised form omitted and rarely used correctly.
6 January 2014
Objectives: Presentation of findings concerning use of GS in the context of previous data in the literature,
Accepted 16 January 2014
Available online 8 February 2014
and recommend any appropriate actions.
Method: A retrospective analysis of images from an existing DICOM Digital Teaching Library (DTL) was
conducted. Images of the pelvis from paediatric patients were reviewed and scored on whether a GS was
Keywords:
Pelvis
present and (if present) whether the shield was considered to adequately protect the gonads.
Ovary Results: 130 images were reviewed. 70 male and 60 female. The gonads were deemed to be protected by
Gonads a shield in 22 images (17%), inadequately protected when a shield was used in 44 images (34%) with the
Protective devices remaining 64 images (49%) having no shield at all. A lack of adequate protection for the gonads was
Radiation protection found, with females more likely to be inadequately protected than males (c2 ¼ 19.009, df ¼ 1, p < 0.001).
Radiography These findings become more clinically significant when reports of ovaries lying outside of the pelvic
basin (in paediatric patients) are considered.
Conclusions: The current practice of gonad shielding is neither effective nor beneficial for female pae-
diatric patients, incorrect shield placement can often require repeat exposures. This finding is
commensurate with previous literature. Therefore, gonad shielding is no longer an appropriate opti-
mization tool for female paediatric patients during conventional radiography of the pelvis, and should be
abandoned.
Ó 2014 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction
Projection Radiography of the pelvis is a currently indicated
investigation in assessing hip pathologies in paediatrics.1,2 The
treatment of childhood diseases such as developmental hip
dysplasia, slipped upper femoral epiphysis (SUFE) and Perthes’
disease can often require long term investigation and numerous
radiographs.
The European Directive on health protection identifies children
as a special practice that merit particular attention from the radi-
ation protection point of view.3 Radiation induced cancer risks to
children are higher than the average for the whole population, the
* Corresponding author. Tel.: þ44 01642 384175.
E-mail addresses: Thomas.Warlow@SFH-TR.NHS.UK (T. Warlow), P.Walker-
Birch@tees.ac.uk (P. Walker-Birch), p.cosson@tees.ac.uk, philip.cosson@
shaderware.com (P. Cosson).
risk for children aged 0e9 is twice that compared with an adult in
their thirties.4
Radiation protection during radiography of the pelvis has always
been portrayed as challenging due to the location of reproductive
organs (the gonads). Irradiating the germ cells within the gonads is
reported to cause genetic mutation which has the potential to
develop into hereditary disease passed down and expressed in
future generations, making the risks during pelvic radiography
therefore two-fold, with the potential for both somatic and genetic
mutations.5,6,2
The International Commission on Radiological Protection (ICRP)
has traditionally seen the gonads as a radiosensitive organ with the
highest tissue weighting factor of any organ.7 However, this was
recently revised down from a tissue weighting factor of 0.2 to 0.088
(below that given to Bone-marrow, Colon, Lung, Stomach, and
Breast; all of which have a tissue weighting of 0.12). This revision
was based largely on the lack of direct evidence supporting the link
between gonad irradiation and heritable disease in future

1078-8174/$ e see front matter Ó 2014 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.radi.2014.01.002
 T. Warlow et al. / Radiography 20 (2014) 178e182
generations.5,8 The high tissue weighting of the colon is certainly
notable in this scenario as lower sections of the colon are irradiated
during a pelvis radiograph.
The professional responsibility of the radiographer as operator
or practitioner should ensure that they optimise the examination
for each individual patient. Existing optimisation guidelines for
radiological investigations where the gonads lie within or close to
the primary beam (i.e. during pelvic radiography) from the ICRP
and National Radiological Protection Board (NRPB) state that good
radiographic technique includes standard use of a gonad shield
(GS) without obscuring essential diagnostic information.5,9 Many
radiographic technique books also advocate this practice. However,
optimisation has the aim of reducing the patient risk to as low as
reasonably practicable (ALARP). The radiographer must consider
the practicality of accurately positioning gonad shielding against
the potential reduction in risk to the patient.
A systematic literature search10 was conducted to identify pre-
vious work in which GS placement was assessed. The results are
presented in Table 1. All the studies conducted a retrospective
analysis of radiographic images of the pelvis archived, usually in
Picture Archiving and Communication System (PACS). No data
pertaining to images that had been rejected or repeated by the
radiographer were included. All the studies (excluding the repeat
audits of McCarty et al.11) reviewed the images after they were
taken, protecting them from the Audience-effect.
While the studies vary in size and credibility, they all demon-
strate relatively low rates of adherence to gonad protection advice.
Moreover, a United Kingdom (UK) wide audit on GS use has been
suggested.10 Kenny and Hill12 were first to recognise that adequate
placement of a GS was less common in females than in males. They
identified this as statistically noteworthy finding (choosing p  0.05
as the level of significance, a). Their finding has been replicated by
two other studies10,2 Additionally, the complete omission of a GS
has been found to be more common in females.14,10
Compounding the low rates of adherence is the problem of
inadequately placed shields obstructing bony landmarks.2,15,16
These obstructions can lead to repeat radiographs. The extra radi-
ation dose from these repeats negates any initial benefit to the
patient and is more hazardous than a single unshielded exposure.
Several studies describe the practice of omitting a GS in the very
first instance to limit this problem,2,10,14,15 with the use of a GS in all
subsequent imaging being advised.
Aims and objective
This study aimed to contribute to the evidence on whether GS
use can be a practical optimisation tool in paediatric patients
referred for pelvic radiography. Difference between GS use in males
Table 1
Summary of audit findings from literature search.
Number Adequately
of images protected
reviewed
Kenny and Hill (1992)14 346 29%
Wainwright (2000)2 200 36%
Liakos et al. (2001)1 61 2%
McCarty et al. (2001)13 218 27%
Sikand et al. (2003)6 267 23%
Doolan et al. (2004)15 198 0%
Gul et al. (2005)18 948 49%
Masud et al. (2008)22 100 22%
Fawcett and Barter (2009)19 2405 18%
Frantzen et al. (2011)16 500 9% Female
34% Male
179
and females was investigated; it was predicted that GS use would
be both more frequent and more accurate in males than females,
allowing the following directional hypothesises to be postulated:
H1 e Application frequency of gonad shielding is significantly
higher in males than females.
H0 e There is no significant difference in the frequency of
application of gonad shielding between males and females and.
H2 e Accuracy of gonad shield placement is significantly higher
in males than females.
H0 e There is no significant difference in the placement accuracy
of gonad shields between males and females.
The objective was to present findings in the context of previous
data in the literature, and recommend any appropriate actions.
Methods
The study adopted a non-experimental design, and was con-
ducted as a retrospective survey on radiographic images that were
stored in an existing DICOM digital teaching library (DTL). The DTL
comprises 886,000 anonymised radiographic DICOM images ob-
tained as a result of exposures conducted over a period of six
months. These were then collected from a number of UK NHS
Health Care providers.17
The project collected quantitative nominal data, allowing the
use of the Chi2 test to determine statistically significant differences
between groups and testing hypotheses. It was determined that 87
images need to be analysed for statistical power in a Chi2 test with 1
degree of freedom. A standard alpha level of 0.05 is assumed, and
the population effect size is medium.
The target population and inclusion criterion for images used
was all storage phosphor radiography projections of the pelvis in
paediatric patients (aged under 16 years). Images from theatre
cases were excluded. 130 images were available from the 259 ac-
cessions meeting the inclusion criteria, 70 from male patients and
60 from female patients. All 130 images were included in the study.
Each of the images were reviewed using a pro-forma adapted
from existing published literature.2,6,10,14,15,18 The patient’s gender
was noted, the presence or absence of a GS, and whether this was
on the first or second image in a series. If present, the adequacy of
the shield placement in protecting the reproductive organs was
reviewed. The age of each patient was not recorded.
The shield should not obscure any bony anatomy. If it did, this
was recorded. Shielding of gonads was considered adequate if the
area covered by the shield protects the traditionally expected
location of the reproductive organs (gonad area). In males, this was
defined as covering the soft tissue margins of the scrotum inferiorly
to the symphysis pubis. In females, the pelvic basin was used as
popular gonad shield designs presume the ovaries to lie within the
Shield absent Shield present Comments
but inadequate
40% 31%
42% 22%
* * Only provided data on % of ovaries covered
17% 56%
67% 10%
98% 2%
29% 22%
* * No data to differentiate inadequacy
through omission or placement
52% 30%
* * Results were defined into specific
groups and no summative findings
were presented
180 T. Warlow et al. / Radiography 20 (2014) 178e182

pelvic basin (true pelvis).19 Shielding 100% of the pelvic basin

without obstructing any bony anatomy would require unrealisti-
cally tight precision of shield placement. Consequently, a subjective
estimate was made and coverage was deemed adequate if 90% of
the pelvic basin was protected. Inadequate protection may be a
result of poor positioning or inadequate choice of shield size; this
information was recorded.
Descriptive statistics in the form of percentages were produced
to discuss the distribution of the three possible groups: (1) no
shield present; (2) shield present with inadequate protection of the
gonad area; and (3) shield present with adequate protection of the
gonad area.

Ethical considerations

In accordance with Section 33 of the UK Data Protection Act

(1998)20 written consent was not required from participants in this
investigation as data was obtained from the pre-existing DTL. The
DTL is a historical collection of radiology data entirely anonymized
with all staff and patient identifiable data removed. This anonym-
ization process was carried out with guidance from the National Figure 2. Pie chart showing percentage distribution and difference in shield adequacy
Information Governance Board for Health and Social Care inde- in male patients.

pendently of this study.17

The anonymous DTL ensures complete participant confidenti-
ality, to the point that not even the image assessor gathering data
had access to participant, staff or hospital details. Ethical approval
was granted to conduct the study, including the use of the database
and its comprising images in the manner described.

Results

According to this study’s criteria, the gonads were likely pro-

tected in 22 (17%) images, two female and 20 male. Shields were
present but inadequately protected the gonad area in 44 images
(34%), while the remaining 64 images (49%) had no shield at all,
these results are displayed in Fig. 1, while the difference between
male and female patients are displayed in Fig. 2 and Fig. 3.
No significant difference in frequency of GS application between
gender was found (c2 ¼ 0.293, df ¼ 1, p ¼ 0.588). The adequacy of
GS placement in protecting the gonad area was found to be higher
in males than females (c2 ¼ 19.009, df ¼ 1, p < 0.001). For all

Figure 3. Pie chart showing percentage distribution and difference in shield adequacy
in female patients.

patients the frequency of GS application was higher in the second

image of an accession than the 1st (c2 ¼ 18.692, df ¼ 1, p < 0.001).
Gonad shields (GSs) were present in a total of 51% of images
assessed. Due to the difference between frequency of GS applica-
tion in the first and second images in an accession, it is likely
protocols from the originating departments stated that gonad
shielding should be omitted in the patient’s first image.
Where a gonad shield was placed, three distinct errors were
identified: (1) the shield was too small to offer protection; (2) it was
badly positioned or; (3) it was obscuring bony anatomy (Table 2).

Table 2
Errors in shield use identified.

Male n (%) Female n (%)

Bony obstruction 26 (77) 28 (88)

Incorrect positioning 11 (32) 24 (75)
Figure 1. Pie chart showing percentage distribution of shield adequacy in both male
Too small 8 (24) 26 (81)
and female patients.
 T. Warlow et al. / Radiography 20 (2014) 178e182
Figure 4. Analysis of Gonad Shield errors in Females.
Fig. 4 is an area proportional Venn diagram21 that demonstrates
there was often more than one error in gonad shield use, with 19
(63%) of images from female data exhibiting all three errors. The
male data showed that all the images had more than one error, but
with only 8 (24%) exhibiting all three.
Discussion
In contrast to Fawcett and Barter10 and Kenny and Hill,14 no
significant difference between the application frequency of shield
use in male and female patients was found in this instance.
Therefore the findings of this study do not support the theory that
radiographers intentionally omit shielding more often in female
patients for fear of obscuring bony anatomy.
For the 32 images where a GS was applied for female patients,
only two images (6%) were likely to provide adequate protection to
the gonad area. In comparison, 20 out of 34 images (59%) showing
application of GS for male patients provided adequate protection to
the gonad area. This means that inadequate GS placement in this
study was found to be 94% in female patients and 41% in male
patients. A comparison of this finding with previous work can be
seen in Table 3. (Sikand et al.,6 Gul et al.18 and Masud et al.22 were
omitted, as they did not present enough data to determine the
individual inadequacy rates for each gender.) The inadequate
shielding rate for females is always higher than that of the
males.6,18 This finding points to a cause other than radiographer
ability.
Of the 20 images of male patients with adequate gonad pro-
tection, all had some level of bony anatomy obscured. One of the
two adequately protected female images had bony anatomy
obscured by the shield. While this is less important with patients
who have a first image unshielded, this was not the case with the
Table 3
Inadequate GS placement (when a GS is used, % of those GSs used inadequately) in
this and previous studies.
Male
Kenny and Hill (1992)14 44%
Wainwright (2000)2 38%
McCarty et al. (2001)13 63%
Doolan et al. (2000)15 100%
This study 41%
181
majority of patients in this sample, thus shielding poses the risk of
obscuring pathological information. Winfeld et al.23 reviewed
gonad shielding on abdominal images taken in neonatal intensive
care, and concluded that their results did not support the concern
that a shield may obscure relevant radiographic findings in this
context. However, the clinical indications for pelvic imaging are
different and similarly placed shielding may generate different
conclusions in this scenario.
Adequacy of protection has been defined in this study as
coverage of the gonad area. However, the variable position of the
ovaries has been demonstrated by Counsell et al.24 and Feather-
stone et al.25 (Fig. 5). While the majority of adult ovaries lay within
the pelvic basin,19 some were found outside the pelvic basin, such
as over the sacro-iliac joints, and these could not be protected
without obscuring bony anatomy. Indeed, Fawcett et al.19 found
approximately 13% of the ovaries in adult patients lay outside the
true pelvis.
Patient age is a particular factor affecting ovary location. In a
newborn, the ovaries are located above the true pelvis, descending
down by puberty.19,26,27 Fawcett et al.19 found in 51.4% of patients
under 7 years old this migration was yet to complete, and they did
not have both ovaries within the true pelvis. Thus, the variable
location of the ovaries raises real concerns about assuming gonad
shielding even when assessed as adequate.
Even when a GS is correctly placed, it is not likely to be effective
in protecting paediatric female patients. Frantzen et al.16 conducted
a thorough audit and dose risk evaluation of the efficacy of gonad
shielding. They concluded that even with appropriate shielding, the
reduction in hereditary disease was very small. Risk calculation
should reference all radiosensitive organs. During a pelvic exami-
nation sections of the colon are irradiated. Practitioners rigidly
abiding by the recently revised ICRP tissue weighting factors may
be unsure how to adapt their practice. Female gonad shielding may
become an anachronism.
Limitations of the study
Employing a retrospective analysis for assessment is a limita-
tion,2,15 as it does not account for images that may have been
rejected and repeated by the radiographer due to mal-positioning
of the GS (and obscuring bony anatomy) in the initial image.
Reviewing in this fashion only allows review of images sent to PACS
and which were then subsequently imported into the DTL.
Female
57%
57%
72%
100%
Figure 5. Schematic diagram of pelvis with positions of 128 ovaries plotted, located
94%
using ultrasound; reproduced with permission from Featherstone et al. (1999).24
182 T. Warlow et al. / Radiography 20 (2014) 178e182
Including images rejected and repeated by the radiographer would
provide more depth to the investigation.
Current guidelines on GS placement, and the pro forma used in
the image assessment and data collection for this study was based
upon studies that located the ovaries in adult females.24,25 There-
fore, it is likely that the figures for adequate protection are over-
estimated given the increased variability in the paediatric patient.
Future research would be enhanced by analysing the outcome with
respect to patient age; lack of this data makes it more difficult to
confirm the generalizability of these findings. However, the nature
of the database ensures a representative sample of UK practice.
Conclusion
While radiography has progressed significantly in the last few
decades, the method for gonad protection has remained almost
entirely unchanged. Technical advances in imaging and protocol
optimisation have resulted in potentially significant dose re-
ductions for a pelvic examination while the risk burden has been
diminished per Sievert by the lowered tissue weighting factor for
gonads. This study and review concludes that female gonad pro-
tection is not a practical tool for optimization and should be
abandoned as it has the potential to generate repeat exposures. For
males, the significant dose reduction and ease of locating and
protecting the testes still justifies the use of a gonad shield. Slovis
and Strauss28 believe that a greater reduction in radiation dose can
be achieved through less focus on teaching (successfully or un-
successfully) the positioning of a gonad shield, and more on good
radiographic practice. Female gonad shielding has been a distrac-
tion. Radiographers should take up the challenge of focussing on
reducing overall dose by employing tighter collimation, appro-
priate radiographic technique to prevent repeat images, and pro-
tocol optimisation.
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