Genitourinary Imaging Pictorial Essay

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rown et al. MRI of the Female Pelvis Genitourinary Imaging Pictorial Essay Downloaded from www.ajronline.org by 37.44.202.41 on 12/17/17 from IP address 37.44.202.41. Copyright RRS.

1660 Received October 25, 2004; accepted after revision November 23, 2004. 1 ll authors: Department of Radiology, University of California, San Diego, Medical Center, 200 W rbor Dr.

1 rown et al. MRI of the Female Pelvis Genitourinary Imaging Pictorial Essay Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved Michèle. rown 1 Robert F. Mattrey Stephan Stamato Claude. Sirlin rown M, Mattrey RF, Stamato S, Sirlin C DOI: /JR Received October 25, 2004; accepted after revision November 23, ll authors: Department of Radiology, University of California, San Diego, Medical Center, 200 W rbor Dr., San Diego, C ddress correspondence to M.. rown. JR 2005; 185: X/05/ merican Roentgen Ray Society MRI of the Female Pelvis Using Vaginal Gel OJECTIVE. Vaginal distention with aqueous gel optimizes MRI evaluation of the vaginal walls and outer contours of the cervix. The objective of this pictorial essay is to illustrate the use of vaginal gel for MRI of the female pelvis. CONCLUSION. Distention of the vagina with gel is an inexpensive, well-tolerated procedure that may improve MRI evaluation of a variety of gynecologic conditions. RI is the imaging test of choice for M many benign and malignant gynecologic conditions. MRI has been shown to have superior tissue resolution in the female pelvis and reliably shows abnormalities of the uterus and ovaries. However, because the vagina is normally collapsed, distinguishing between anterior and posterior vaginal walls and between cervix and vaginal fornix can be difficult. Such distinction is important in forming differential diagnoses of pelvic masses and staging gynecologic malignancy. Using gel, the vagina can be distended and easily evaluated on T1- and T2-weighted images. The use of vaginal gel has been described for functional imaging of the pelvic floor [1]; however, we have found it useful for a wide variety of diseases in the female pelvis. This study will show that the use of vaginal gel can aid MRI evaluation of a number of benign and malignant gynecologic conditions. Technique Several different types of aqueous gels and administration techniques may be used. We use approximately 60 ml of bacteriostatic surgical lubricant (Surgilube, Fougera). The lubricant is a sterile, nonstaining, water-soluble jelly that is nonirritating to the skin or mucous membranes. The gel is placed in a 60-mL nonlocking syringe, and a standard Yankauer suction catheter is cut approximately 4 cm from its proximal end and placed snugly over the catheter tip. To minimize the introduction of air, the syringes are prepared in advance and stored upright with the catheter facing upward, which Fig year-old woman imaged with and without vaginal gel., Sagittal T2-weighted image without vaginal gel. Note small cystic lesion (arrow) and endometrial irregularity from prior cesarean section (arrowhead)., Sagittal T2-weighted image with vaginal gel allows visualization of exocervical contour, now surrounded by distended vaginal fornices (black arrows), and allows localization of artholin s gland cyst (white arrow) to the posterior wall. Note tiny air bubbles (arrowheads) causing irregular appearance of anterior vaginal wall. JR:185, November

rown et al. Downloaded from www.ajronline.org by 37.44.202.41 on 12/17/17 from IP address 37.44.202.41. Copyright RRS. For personal use only; all rights reserved Fig.

Fat plane separates mass from rectum. Mass is also clearly distinct from urethra (white arrow) and did not enhance with gadolinium (not shown).

5 Cervical fibroid in 48-year-old woman with suspicious pelvic mass on sonography.

Note anterior displacement of external os (arrowhead). Fig. 3 Diffuse vaginal thickening in 69-year-old woman with indurated vagina on physical examination.

Vaginal biopsy revealed no evidence of malignancy; these unusual changes potentially reflect chronic inflammation. Fig.

Sagittal T2- weighted image with vaginal gel allows better visualization of external cervical contour (arrowheads) to help exclude mass. Fig.

2 rown et al. Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved Fig. 2 Gartner s duct cyst in 50-year-old woman with suspicious mass on CT. xial T2-weighted image shows mass (black arrow) in contact with left posterolateral vaginal wall. Fat plane separates mass from rectum. Mass is also clearly distinct from urethra (white arrow) and did not enhance with gadolinium (not shown). Most commonly located anterolaterally in upper vagina, wolffian duct remnants occur along course of mesonephric (wolffian) duct. Fig. 5 Cervical fibroid in 48-year-old woman with suspicious pelvic mass on sonography. Sagittal T2- weighted image with vaginal gel shows large, smooth mass (M) with heterogeneous signal intensity in posterior cervix, outlined by gel in posterior vaginal fornix. Note anterior displacement of external os (arrowhead). Fig. 3 Diffuse vaginal thickening in 69-year-old woman with indurated vagina on physical examination. Sagittal T2-weighted image shows diffuse thickening of vagina (arrowheads), which contains only small amount of gel within narrowed lumen. Vaginal biopsy revealed no evidence of malignancy; these unusual changes potentially reflect chronic inflammation. Fig. 4 Nabothian cysts in 47-year-old woman with CT suspicious for mass in region of cervix. Sagittal T2- weighted image with vaginal gel allows better visualization of external cervical contour (arrowheads) to help exclude mass. Fig. 6 Fibroid uterus in 55-year-old woman with history of breast cancer and pelvic mass on CT. and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show grossly enlarged and distorted uterus (U). Identification of cervix (arrow) is aided by vaginal gel. Note susceptibility artifact from tiny air bubbles (arrowheads, ) that interrupt normal enhancement of vaginal wall. allows gas to escape. Within 3 4 hr, the gel is free of nearly all visible gas bubbles. ccidentally introduced air is easy to identify; however, a large amount may produce sufficient susceptibility artifact to degrade images. The Yankauer tip is placed into the vagina by the patient after she is positioned on the MR table. The MR technologist injects the gel and the catheter is removed. The patient is instructed to avoid moving, coughing, or valsalva during the examination. The cost is 1222 JR:185, November 2005

MRI of the Female Pelvis Fig. 7 Cervical endometriosis in 47-year-old woman with pelvic pain.

ajronline.org by 37.44.202.41 on 12/17/17 from IP address 37.44.202.41. Copyright RRS. For personal use only; all rights reserved approximately $2.00 per examination.

On MR images, the gel is of slightly higher signal intensity than water on fast spin-echo T1-weighted and T2-weighted images, presumably because of T1 shortening effects of gel contents.

and, Sagittal () and oblique axial () T2-weighted images show small low-signal mass (arrow) in posterior vaginal fornix.

3 MRI of the Female Pelvis Fig. 7 Cervical endometriosis in 47-year-old woman with pelvic pain. Sagittal T2-weighted turbo spin-echo image reveals cervical endometrioma (black arrow) in patient with endometriosis and adenomyosis, seen in posterior uterine wall (white arrow). Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved approximately $2.00 per examination. The procedure takes less than 3 min and is well tolerated by patients. We use gel routinely in all patients except minors who are not sexually active. On MR images, the gel is of slightly higher signal intensity than water on fast spin-echo T1-weighted and T2-weighted images, presumably because of T1 shortening effects of gel contents. Vaginal gel may be used with any sequence protocol for imaging the female pelvis. C Fig. 8 Vaginal endometriosis in 40-year-old woman with pelvic pain. and, Sagittal () and oblique axial () T2-weighted images show small low-signal mass (arrow) in posterior vaginal fornix. C, Oblique axial out-of-phase T1-weighted image fails to show india ink artifact between bright deposit and vaginal gel, confirming presence of blood products rather than fat in small mass (arrow). enign Disease Normally, the vaginal walls are directly opposed and the vaginal fornices are collapsed around the cervix (Fig. 1). dministration of gel separates the vaginal walls, demonstrating the exocervical contour (Fig. 1). Vaginal gel may help localize vaginal cysts (Figs. 1 and 2) and allow differentiation from urethral diverticula and other cystic pelvic masses. artholin s gland cysts are typically located posterolaterally in the lower third of the vagina while Gartner s duct cysts are typically in the anterolateral aspect of the upper vagina [2], although mesonephric cysts may form anywhere along the course of the mesonephric (wolffian) duct. In addition to localizing small masses, administration of gel may also aid identification of the vagina in cases of severe vaginal disease (Fig. 3). Vaginal gel facilitates MRI evaluation of the cervix, particularly in the setting of disease that alters the appearance of the cervix and JR:185, November

rown et al. Fig. 9 Cervical stenosis in 54-year-old woman with dyspareunia.

excluded. Downloaded from www.ajronline.org by 37.44.202.

For personal use only; all rights reserved C Fig.

, Sagittal T2-weighted image shows heterogeneous mass (arrow) in region of

and C, xial T2-weighted () and postgadolinium fat-suppressed T1-weighted (C)

through anterior vaginal wall. Note smooth surface of vaginal mucosa (arrowheads).

4 rown et al. Fig. 9 Cervical stenosis in 54-year-old woman with dyspareunia. and, Sagittal T1-weighted () and T2-weighted () images show hematometra with distention of cervix by blood. Vaginal gel outlines thin exocervix (arrowheads), and an obstructing mass can be excluded. Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved C Fig. 10 Urethral cancer in 40-year-old woman., Sagittal T2-weighted image shows heterogeneous mass (arrow) in region of urethra, compressing vaginal canal, which contains gel (asterisk). and C, xial T2-weighted () and postgadolinium fat-suppressed T1-weighted (C) images show mass surrounding urethra (arrow, ) without evidence of invasion through anterior vaginal wall. Note smooth surface of vaginal mucosa (arrowheads). Fig. 11 Cervical carcinoma in 27-year-old woman. and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show large cervical mass (M) causing hematometra with fluid level (arrowheads). Vaginal distention with gel shows no vaginal invasion JR:185, November 2005

MRI of the Female Pelvis Downloaded from www.ajronline.org by 37.44.202.41 on 12/17/17 from IP address 37.44.202.41. Copyright RRS.

and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show large cervical mass (M)

Without vaginal gel, upper and lower vagina would be in contact with mass, potentially leading to overstaging. Fig.

and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show cervical mass (M) that

Without vaginal gel, vagina would be collapsed and extension into lower vagina might be difficult to detect. Fig.

and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show an

5 MRI of the Female Pelvis Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved Fig. 12 Cervical carcinoma invading upper vagina in 44-year-old woman. and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show large cervical mass (M) with invasion of posterior vaginal fornix (arrow). Invasion can be seen to be limited to upper vagina. Without vaginal gel, upper and lower vagina would be in contact with mass, potentially leading to overstaging. Fig. 13 Cervical carcinoma invading lower vagina in 38-year-old woman. and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show cervical mass (M) that extends down anterior vaginal wall (arrowheads). Without vaginal gel, vagina would be collapsed and extension into lower vagina might be difficult to detect. Fig. 14 Cervical carcinoma in 37-year-old woman 30 weeks pregnant. and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show an intermediate-signal-intensity, hypoenhancing mass in posterior cervix and vaginal fornix (arrows). lthough only small amount of gel could be administered in this pregnant patient, it is sufficient to distend posterior fornix and show vaginal invasion limited to upper vagina. JR:185, November

5 and 6), and adenomyosis. Nabothian cysts may be confused with cystic cervical malignancy [3], and clear delineation of the outer cervical contour by vaginal gel may be helpful in some cases.

16 Recurrence of endometrial cancer at the vaginal cuff in 51-year-old woman.

cause of hematometra in patients with benign cervical stenoses (Fig. 9). Fig. 17 Recurrence of ovarian cancer in 62-year-old woman.

Malignant Disease Distention of the vagina can often aid diagnosis and staging of pelvic cancers. In urethral cancer (Fig.

6 rown et al. Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved Fig. 15 Normal vaginal cuff in 41-year-old woman. Sagittal T2-weighted image with gel clearly shows vaginal cuff (arrowheads). uterus such as nabothian cysts (Fig. 4), fibroids (Figs. 5 and 6), and adenomyosis. Nabothian cysts may be confused with cystic cervical malignancy [3], and clear delineation of the outer cervical contour by vaginal gel may be helpful in some cases. In patients with endometriosis, vaginal gel helps detect and localize cervical or vaginal endometrial implants (Figs. 7 and 8), and it can also help exclude an obstructing cervical mass as the Fig. 16 Recurrence of endometrial cancer at the vaginal cuff in 51-year-old woman. and, Sagittal T2-weighted () and postgadolinium fat-suppressed T1-weighted () images show recurrence in superior vaginal cuff (arrows). cause of hematometra in patients with benign cervical stenoses (Fig. 9). Fig. 17 Recurrence of ovarian cancer in 62-year-old woman. and, Sagittal T1-weighted () and T2-weighted () images show large pelvic mass (M) involving vaginal cuff. Portion protrudes into vaginal canal (arrow). Malignant Disease Distention of the vagina can often aid diagnosis and staging of pelvic cancers. In urethral cancer (Fig. 10), visualization of invasion of the vagina is important for staging because it indicates T3 disease, which typically requires radiation and chemotherapy, whereas T2 disease or less may be treated with surgery alone [4]. Vaginal involvement is also important in the staging of cervical cancer (Figs ). In cervical cancer, vaginal gel not only shows the presence or absence of vaginal involvement, but it can also improve detection of small lesions limited to the cervix. MRI has been reported to be far more accurate than CT or clinical examination for staging cervical cancer, with an overall accuracy of 86% according to 1226 JR:185, November 2005

7 MRI of the Female Pelvis Downloaded from by on 12/17/17 from IP address Copyright RRS. For personal use only; all rights reserved one recent study [5]. It is possible that accuracy could be further improved with routine use of vaginal gel. MRI is often used for surveillance after treatment of patients with gynecologic malignancies. fter hysterectomy, the vagina is typically well delineated when gel is used (Fig. 15). Vaginal distention improves detection of recurrence and its relationship with the vaginal cuff (Figs. 16 and 17), and the use of gel can increase confidence in excluding recurrence. fter radiation, however, the vagina may not be distensible because of radiation-induced adhesions. Summary dministration of vaginal gel before pelvic MRI is inexpensive, well tolerated, and can improve the diagnostic usefulness of MRI for a number of benign and malignant gynecologic conditions. References 1. Lienemann, Fischer T. Functional imaging of the pelvic floor. Eur J Radiol 2003; 47: Hahn WY, Israel GM, Lee VS. MRI of female urethral and periurethral disorders. JR 2004; 182: Okamoto Y, Tanaka YO, Nishida M, Tsunoda H, Yoshikawa H. Pelvic imaging: multicystic uterine cervical lesions can magnetic resonance imaging differentiate benignancy from malignancy? cta Radiol 2004; 45: Eng TY, Naguib M, Galang T, Fuller CD. Retrospective study of the treatment of urethral cancer. m J Clin Oncol 2003; 26: Ozsarlak O, Tjalma W, Schepens E, et al. The correlation of preoperative CT, MR imaging, and clinical staging (FIGO) with histopathology findings in primary cervical carcinoma. Eur Radiol 2003; 13: JR:185, November

JMSCR Vol 05 Issue 06 Page June 2017

JMSCR Vol 05 Issue 06 Page June 2017 www.jmscr.igmpublication.org Impact Factor 5.84 Index Copernicus Value: 83.27 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v5i6.29 MRI in Clinically Suspected Uterine and