Male reproductive radiology:

Imaging of the scrotum:

• Best evaluated by ultrasound

• Mostly performed for acute scrotal pain or palpable mass
• Common scrotal abnorm alties;
o Epididymitis and orchitis
o Hydrocele
o Varicocele
o Torsion
o Less common: testicular mass

Normal ultrasound of testes: Homogenous echotexture with no focal lesions or surrounding fluid

Normal Doppler ultrasound & waveform: Used to evaluate the blood flow

• Venous wave – Approximately same amplitude

• Arterial wave – Symmetric peak followed by down fall pattern

Epididymitis and orchitis: Inflammation of the epididymis and/or testis

Imaging findings of epididymitis:

• Enlarged epididymis
• Increased blood flow to the epididymis
• Decreased echogenicity of the epididymis
• May be focal or diNuse
• Orchitis often secondary due to spread of infection

Epididymo-orchitis:

• Enlarged heterogenous epididymal head with increased blood flow

• Doppler ultrasound of the testicle also demonstrates increasing flow
Hydrocele: Scrotal fluid surrounding the testicle

• Can be congenital
• May be a result of;
o Epididymitis
o Torsion
o Tumor
o Trauma
• Presents with enlarged scrotum

Varicocele: Retrograde flow in the gonadal vein results in veins of the pampiniform plexus dilating to
greater than 2-3mm.

• It is the best seen with resting and Valsalva images of the scrotum
o Valsalva demonstrates increased distention of the vessels due to the retrograde flow
*It is most common cause of male infertility as there resultant increase in heat which destroys

Testicular torsion: DO NOT MISS – timely detorsion can salvage the testicle

• Imaging findings of testicular torsion

o Overall decreased or absent blood flow to the testicle
o First absence of venous flow, then loss of arterial flow
o Enlarged, heterogenous hypoechoic testicle
o DiNusely hypoechoic or small testicle indicates infarction

Torsion and testicular carcinoma:

• The image demonstrates a slightly heterogenous,

hypoechoic testicle with no color or spectral on doppler
evaluation
• Next steps:
o Call urology immediately for detorsion
o There is a 80-100% chance of salvage if it is
detorsed within 6 hours
o There is no chanve of salvage if it has already been 24 hours
o Normal ultrasound does not exclude early or partial torsion

Testicular carcinoma:

• Any solid mass within the testicle should raise suspicion for carcinoma
• First line of imaging in patient presenting with a palpable mass is ultrasound
• It presents itself as a heterogenous solid mass within the testicle with increased blood flow
• Often metastasize to the paraaortic lymph nodes -> CT should always be next step for staging
• Lung metastases are most common
Female reproductive radiology:
Uterine anatomy –

Pelvic ultrasound:

• Transabdominal
o Performed with a full
bladder which helps
push the loops of bowel
away
o Provides a better
window to evaluate the
pelvis
• Transvaginal
o Provides better details of the endometrium and ovaries

Uses of pelvic ultrasound:

• Diagnostic tool in women presenting with pelvic symptoms such as vaginal bleeding or lower
abdominal or pelvic pain
• Routine surveillance and diagnostic tool in pregnant women

Normal ultrasound anatomy of the uterus:

Sonohysterogram – Procedure in which saline is injected into the uterus cavity which provides better
visualization of the endometrium

Uterine position:

• Flexion – the position of the uterine body with respect to the cervix
o Anteflexion or retroflexion
• Version – The position of the cervix with respect to the vagina
o Anteversion or retroversion

Normal endometrium:

• Premenopausal female
o Thickness can vary based on her cycle
o Can be as thick as 18-20 mm
• Asymptomatic post-menopausal female
o Thickness should be approximately 4mm or less
 o If thicker than 4mm, it is a concern for endometrial carcinoma due to no hormonal influx
increasing the thickenss

Normal ovaries – Best viewed under

transvaginal exam

• The uterus and ovaries are not well

evaluated on CT therefore
ultrasound is used as first line
imaging

Pelvic MRI:

• Pelvic anatomy is seen very well on MRI

• MRI is used as a problem solving tool for the pelvis

Ovarian abnormalities:

• Most common:
o Cysts
§ Simple

§ Complex
• Corpus luteal cyst
o Functional ovarian cyst that forms after an egg expulsed from a
follicle
o Measures up to 3cm in size
o Has thick rim with prominent peripheral flow on color doppler -
“Ring of fire” appearance
o Benign finding – no further follow up required
• Hemorrhagic cyst
o Echogenic cyst
which resolves
on follow-up
imaging
o Has reticular or
lacy internal
pattern
o Ruptured
hemorrhagic cyst can cause hemorrhagic free fluid to
accumalte in the pelvis and abdomen
• Dermoid cyst
o Benign ovarian germ-cell tumor
o Hyperechoic mass on ultrasound
o May be heterogenous
o Found to have fat on CT and or MRI
o MRI: Bright on T1 and loses signal on T1 fat saturated images

• Endometrioma
o Endometrial tissue implants that repeatedly hemorrhage from
hormonal stimulation
o Named “Chocolate cyst” due to its appearance
o Contains homogenous low-level internal echoes on ultrasound
similar to that of hemorrhagic cyst
o Classic MRI appearance
§ Bright on T1 and remains bright on T1 fat-saturated
images with T2 shading
§ Loss of signal on T2 weighted images in a cyst that is
bright on T1
 o Torsion
§ Twisting of the ovary and fallopian tube results in lack of blood flow to the ovary
§ Most commonly occurs with an associated ovarian mass acts as a “lead point”
§ Most commonly presents as severe unrelenting pelvic pain

§ Treatment of ovarian torsion

• Open or laparoscopic surgery to untwist the adnexa is performed prior
to infarction
• If the ovary is infracted, then the treatment salpingo-oopheroectomy

Ovarian tumors

• Serous and mucinous cystadenoma and cystadenocarcinoma

• Primarily cystic but contain irregular solid components
• Best evaluated with CT or MRI

Uterine abnormalities:

Common uterine abnormalities include

• Uterine fibroids (Leiomyoma)

o Benign tumors of the smooth muscle cells of the uterus
o Very common during reproductive years
o Mostly asymptomatic but can cause pain, menorrhagia and infertility
o Size determines symptomology
o Imaging findings:
§ Hyperechoic mass
§ Possible calcifications
§ May have cystic
components or fat
o Location
*Common not to discreetly identify multiple fibroids as they have the same echogenicity as the
surrounding tissue. So a distorted heterogenous uterus indicates multiple fibroids

o A fibroid that progressively enlarges in size or is greater than 8cm should be considered
suspicious for a sarcoma and MRI should be performed to help diNerenciate – have
potential to metastasize
• Adenomyosis
o Presence of heterotopic endometrial stroma within the myometrium
o Clinical presentation often: dysmenorrhea (painful menstrual cycle) or menorrhagia
(menstrual cycle lasting more than 7 days)
o Image findings:
§ Enlarged uterus
§ Myometrial cystic spaces
§ Widened posterior uterine wall on ultrasound
§ Best visualized on ultrasound and MRI
o Sagittal sonographic image shows a thickened myometrium
with cystic space
• Endometrial thickening

o DiNicult to distinguish based on imaging alone

o Sonohysterogram is helpful in diNerentiating focal from diNuse and in localizing a focal
lesion
o In post-menopausal women
§ Endometrial carcinoma until proven otherwise
§ Patient needs a hysterectomy with biopsy
o Endometrial atrophy –
§ Occurs in postmenopausal women due to lack of hormonal stimulation
§ Endometrium is found to be less than 4mm
§ The most common cause of postmenopausal bleeding