Imaging evaluation of gynaecological devices

Transcription

1 Imaging evaluation of gynaecological devices Poster No.: C-0850 Congress: ECR 2013 Type: Educational Exhibit Authors: R. M. Lorente Ramos, J. Azpeitia Arman, P. Aparicio Rodríguez Miñón, F. Salazar Arquero, A. Munoz Hernandez, J. C. Albillos Merino ; Madrid/ES, San Sebastián de los Reyes/ES Keywords: Foreign bodies, Hysterosalpingography, Ultrasound, Plain radiographic studies, Genital / Reproductive system female DOI: /ecr2013/C-0850 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 35

2 Learning objectives To review different gynaecological devices commonly used To describe the appearance of gynaecological devices on different imaging techniques (plain radiographs, US, hysterosalpingography, CT, MR) To analyse normal position and signs indicating abnormal positioning, as well as complications To emphasize pitalls, diagnostic difficulties and differential diagnosis Background The number of medical devices keeps increasing. So, since they appear superimposed on plain radiographs and they may also be depicted on other imaging techniques, the radiologist should recognize them in order to describe them in reports. Imaging is also important to determine adequate position of gynaecological devices and may be useful to detect the presence of complications. We analyse the most frequently employed devices, describing their morphology, placement method, clinical and imaging criteria for proper positioning and complications. Imaging findings OR Procedure details TABLE OF CONTENTS ( Fig. 1 on page 19 ). Page 2 of 35

3 Fig. 1: Table of contents References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES 1. IMAGING MODALITIES. The aim of imaging examinations is to determine whether a device is properly positioned and to identify complications. Devices may also be incidentally found on imaging studies. - Abdominal anteroposterior and lateral radiography depict radiopaque devices. Page 3 of 35

4 - Hysterosalpingography, is the preferred method for tubal devices, to confirm absence of tubal patency. - US depicts the uterus, the devices and their location. - CT is the best modality for the evaluation of complications. - MR may also depict the devices, usually incidentally. 2. CONTRACEPTIVE DEVICES INTRAUTERINE DEVICE (IUD) -Device. Two types of IUDs are available: Copper containing IUD. Mirena, a hormone (levonorgestrel) releasing IUD. Both are a T-shaped polyethylene frame with a copper wire or a levonorgestrelcontaining collar around the stem, and a polyethylene monofilament string attached to the base of the stem useful for retrieval. Less frequently IUD of different shapes may be found, such as round IUD (more frequent in Asia) (Fig 2). -Location. The IUD is inserted through the cervix using a sheath and placed within the endometrial cavity at the uterine fundus with no portion of the device within the endocervical canal. The retrieval string is seen protruding through the external cervical os. - Imaging. Proper positioning. Radiographs. A pelvic T-shaped radiopaque device is depicted, usually vertically located ( Fig. 2 on page 21 ). In cases of patients with uterine retroversion the IUD may present in a dfferent position, but then US is mandatory to exclude complications. Page 4 of 35

5 Fig. 2: IUD. Normal position References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES US. The technique of choice depicting the relationship between the device and the uterine cavity. IUDs are hyperechoic, enterely the copper type and proximal and distal ends of the hormone-releasing device, usually with acoustic shadowing between both tips. The stem should be completely within the endometrial cavity, and lateral extensions at the uterine fundus with a distance of less than 3 mm from the top of the uterine cavity to the IUD. The string is usually not depicted. CT. Metal density T-shaped structure within the uterine cavity. MR. IUD appear as signal voids. - Complications. Migration. Displacement and expulsion. Page 5 of 35

6 The IUD may move downwards, decreasing effectivity or even being expelled to the vagina. The complication is usually asymptomatic, but bleeding or spotting and cramping may appear. On US the tip of the device appears in these cases in the mid or lower uterus or in the cervix ( Fig. 3 on page 20 ). Fig. 3: IUD. Abnormal position References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Perforation. The IUD embeds into the endometrium or myometrium or causes uterine wall perforation and migration into the peritoneal cavity. It may be floating within the peritoneum or within adherences, and perforation of other organs may appear. Pain or bleeding are usually present, but it may be asymptomatic. US allows diagnosis of embeded devices demonstrating its position within the miometrium. Page 6 of 35

7 When an IUD is not visualized within the uterus on US, a plain radiograph of the abdomen should be performed to determine if non-visualization is caused by perforation or expulsion. The device is present in perforation, usually in an abnormal position ( Fig. 4 on page 22 ). Fig. 4: IUD. Perforation References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Pregnancy. Intrauterine or more frequently ectopic pregnancies may appear. In cases of intrauterine pregnancy, the IUD should be removed to avoid complications such as premature delivery or infection. Infection. Pelvic inflammatory disease is a rare complication which can manifest as endometritis, pyosalpinx, or a tubo-ovarian abscess. Page 7 of 35

8 US is useful in diagnosis, but CT better depicts abscesses ESSURE. -Device. Microinserts consisting of two coils: a stainless steel inner coil, with polyethylene fibers wound in and around it stimulating tissue growth and scar formation, and a nickel-titanium outer coil, which expands when released and anchors the microinsert in the fallopian tube. -Location. Hysteroscopical insertion of essures through the cervix requires placement of the device within each fallopian tube with several (3-8) spiras remaining in the uterine cavity. - Imaging. Proper positioning. Radiographs. Plain radiographs may be misleading due to uterine and tubal position, and they cannot provide confirmation regarding tubal occlusion. Two pelvic radiopaque devices are depicted in the pelvic area ( Fig. 5 on page 23 ). Page 8 of 35

9 Fig. 5: Essure. Plain radiograph References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Each microinsert has four radiodense markers, indicating the proximal and distal portions of the outer and inner coils, and the distance between the medial aspects in properly located Essures is usually less than 4 cm. Hysterosalpingography. It is the most important method in diagnosis, as it can depict both positioning and function. It should be performed about 3 months after the procedure to confirm tubal occlusion. * Criteria of proper positioning are: a microinsert that crosses the uterotubal junction with less than 50% of the length of the inner coil into the uterine cavity or a device with the proximal end of the inner coil within 3 mm of the proximal fallopian tube measured from the uterine cornua ( Fig. 6 on page 24, Fig. 7 on page 25 ). Page 9 of 35

10 Fig. 6: Essure. Hysterosalpingography References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Page 10 of 35

11 Fig. 7: Essure. Abnormal position References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES On the other hand criteria of inadequate positioning are: more than 50% of the length of the inner coil trailing into the uterine cavity or a device that is too distal in the tube, with the proximal end of the inner coil more than 3 mm from the cornua. A non-satisfactorily located Essure may cause satisfactory occlusion. * Criteria of satisfactory occlusion are: complete non-filling of the tubes or filling of the proximal portion of the tubes but not beyond the distal aspect of the outer coil. The presence of contrast beyond the outer coil or spill into the peritoneal cavity are signs indicating tubal patency. US. Hyperechoic linear images at both sides of the uterine cavity in the uterotubal junction are depicted ( Fig. 8 on page 26 ). Page 11 of 35

12 Fig. 8: Essure. US References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES If the device cannot be identified on US within the proximal region of the fallopian tubes, position is not correct, it may have been expelled into the uterine cavity or migration along the tube may have happened, sometimes reaching the peritoneal cavity. CT. Metal density structures within the tubes. Images are similar to those on plain radiographs ( Fig. 9 on page 27 ). Page 12 of 35

13 Fig. 9: Essure. CT References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES MR. Signal voids appear on all sequences. - Complications. Tubal perforation is the most frequent complication. US is usually normal, but hysterosalpingography depicts Essure location outside the tube ( Fig. 10 on page 28 ). Page 13 of 35

14 Fig. 10: Essure. Perforation References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Occlusion failure. Hysterosalpingographic demonstration of occlusion previously to discontinuing an aditional contraception method is important to avoid undesired pregnancy ( Fig. 11 on page 29 ). Page 14 of 35

15 Fig. 11: Essure. Oclusion failure References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES 2.3. TUBAL LIGATION - Device. Two circular clips. -Location. Tubal occlusion is carried out through laparotomy, laparoscopy or hysteroscopy. The mechanical ligation clips are placed across the isthmic portion of the fallopian tube. -Imaging ( Fig. 12 on page 30 ). Page 15 of 35

16 Fig. 12: Tubal ligation References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Radiographs. Two hyperdense small images in the pelvis. CT. Hyperdense circular structures close to the body of the uterus. US. Usually not depicted. - Complications. Migration within the peritoneal cavity CONTRACEPTIVE VAGINAL RINGS -Device. Page 16 of 35

17 Hormonal contraceptive vaginal rings made of transparent polymer which release hormone for 21 days. -Placement. Into the vaginal canal, usually in the proximal vagina. -Imaging. Imaging is similar to pessaries in all techniques (Fig 13). Plain radiographs. Medium density ring in the pelvic area. CT. Water atenuation ring in the vagina. MR. Signal void in all sequences. 3. OTHER STRUCTURES. 3.1.PESSARIES AND VAGINAL RINGS. -Device. Pessaries are ring-shaped structures of rubber or silicone placed in the vagina to prevent pelvic organ prolapse. Vaginal rings are flexible, silicone elastomer or thermoplastic polymer devices which may be useful in postmenopauseal women by releasing hormones at the same time that they help with pelvic floor laxity. They may also be employed in the delivery of pharmaceutical substances to the vagina for either local or systemic effect, such as microbicides in HIV treatment. -Location. Page 17 of 35

18 The pessary should be localized in the posterior region of the vagina preferably around the cervix. -Imaging ( Fig. 13 on page 31 ). Fig. 13: Pessarium and rings References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Plain radiographs. Rings of uniform high density in the pelvis. CT. Water atenuation ring perpendicular to the plane of the vagina. MR. Signal void in all sequences TAMPONS. Page 18 of 35

19 Tampons are found sometimes incidentally on imaging occupying the vaginal canal. -Imaging ( Fig. 14 on page 32 ). Fig. 14: Tampon References: Radiology, UCR de la CAM. Hospital Infanta Leonor - Madrid/ES Plain radiographs and CT. An air attenuation appears in the vaginal canal due to the gas between the soft fibers of the tampon, and the string may also be depicted. US. Hyperechoic linear image within the vagina. Images for this section: Page 19 of 35

20 Fig. 1: Table of contents Page 20 of 35

21 Fig. 3: IUD. Abnormal position Page 21 of 35

22 Fig. 2: IUD. Normal position Page 22 of 35

23 Fig. 4: IUD. Perforation Page 23 of 35

24 Fig. 5: Essure. Plain radiograph Page 24 of 35

25 Fig. 6: Essure. Hysterosalpingography Page 25 of 35

26 Fig. 7: Essure. Abnormal position Page 26 of 35

27 Fig. 8: Essure. US Page 27 of 35

28 Fig. 9: Essure. CT Page 28 of 35

29 Fig. 10: Essure. Perforation Page 29 of 35

30 Fig. 11: Essure. Oclusion failure Page 30 of 35

31 Fig. 12: Tubal ligation Page 31 of 35

32 Fig. 13: Pessarium and rings Page 32 of 35

33 Fig. 14: Tampon Page 33 of 35

34 Conclusion The major teaching point of this exhibit is to learn the appearance of gynaecolological devices, both clinically and on different imaging techniques in order to understand its proper positioning and the main complications that may appear. The radiologist should familiarize with those images, in order to be able to recognize them. References 1. Peri N, Graham D, Levine D. Imaging of intrauterine contraceptive devices. J Ultrasound Med 2007;26: Boortz HE, Margolis DJ, Ragavendra N, Patel MK, Kadell BM. Migration of intrauterine devices: radiologic findings and implications for patient care. Radiographics 2012;32: Guelfguat M, Gruenberg TR, Dipoce J, Hochsztein JG. Imaging of mechanical tubal occlusion devices and potential complications. Radiographics 2012;32: Panel P, Grosdemouge I. Predictive factors of Essure implants placement failure: prospective, multicenter study of 495 patients. Fertil Steril 2010;93: Malcolm RK, Fetherston SM, McCoy CF, Boyd P, Major I. Vaginal rings for delivery of HIV microbicides. Int J Womens Health 2012;4: Mausner EV, Yitta S, Slywotzky CM, Bennett GL. Commonly encountered foreign bodies and devices in the female pelvis: MDCT appearances. Am J Roentgenol 2011;196: Reiner JS, Brindle KA, Khati NJ. Multimodality imaging of intrauterine devices with an emphasis on the emerging role of 3-dimensional ultrasound. Ultrasound Q 2012;28(4): Shah V, Panay N, Williamson R, Hemingway A. Hysterosalpingogram: an essential examination following Essure hysteroscopic sterilisation. Br J Radiol 2011;84: Khati NJ, Parghi CR, Brindle KA. Multimodality imaging of the essure permanent birth control device: emphasis on commonly overlooked abnormalities. AJR 2011;196(5):W Page 34 of 35

35 Personal Information R. M. Lorente Ramos. Radiology Department. UCR de la CAM Hospital Infanta Leonor. J. Azpeitia Armán. Radiology Department. UCR de la CAM Hospital Infanta Leonor. P. Aparicio Rodríguez-Miñón. Gynecology Department. Hospital Infanta Leonor. F. Salazar Arquero. Gynecology Department. Hospital Infanta Leonor. A. Muñoz Hernández. Radiology Department. UCR de la CAM Hospital Infanta Leonor. J. C. Albillos Merino. Radiology Department. UCR de la CAM Hospital Infanta Sofia. Page 35 of 35