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CONTEMPORARY DIAGNOSTIC RADIOLOGY, Volume 35, Number 13, Answer Sheet Robert E. Campbell, MD, Editor

Lesson 13: Genitourinary Diverticulosis: Multimodality Imaging Findings and Treatment—Part II Sonja I. Parisek, MD, Susan Carbognin, MD, Jason Allen, DO, and Robert A. Jesinger, MD, MSE

Question 13-1. This question concerns several important statements about diverticula of the female reproductive system. Uterine tends to spare the (A), and diffuse uterine adenomyosis can lead to marked uterine enlargement (B). So (A) and (B) are true. Salpingitis isthmica nodosa of the fallopian tubes is a cause of both (C) and (D). Thus (C) is false, and (D) is true. Infertility caused by salpingitis nodosa often can be treated successfully by surgical resection of the abnormal section of and tubocornual anastomosis. Vaginal childbirth (E), pelvic irradiation, and are causes of vaginal fistulas. So (E) is true. Since (C) is false, (C) is the correct answer.

Question 13-2. This question speaks to the most common location of salpingitis isthmica nodosa, which is within the proximal two-thirds of the fallopian tubes, particularly in their isthmic por- tions (B). The diverticula of salpingitis isthmica nodosa may be either single or multiple. So (B) is the correct answer.

Question 13-3. This question alludes to the most frequently found malignancy within a female urethral diverticulum, which is adenocarcinoma (D). So (D) is the correct answer.

Question 13-4. This question is illustrated by a fluoroscopic image from a hysterosalpingogram (Figure 12) on a 26-year-old woman. Opaque medium is not present in the vagina, so a (E) is unlikely. A uterine diverticulum from the uterine cavity into the is not identified, thus focal uterine adenomyosis (C) is unlikely. Because the proximal portions of the fallopian tubes do not reveal any contrast-filled outpouchings, then salpingitis isthmica nodosa (D) is unlikely. The location of a thin tubular structure immediately above the superior aspect of the uterine cavity suggests that it lies outside the but contains opaque medium. The tubular structure does not have the appearance of a foreign body from previous pelvic surgery (B) but does have the appearance of an opaque outlined portion of ureter, most likely related to a fistula or multiple fistulas to a ureter resulting from pelvic inflammatory disease (PID) (A). The displaced ureter is the result of multiple adhesions from previous PID. So (B) is unlikely; but (A) is the most likely diagnosis, and (A) is the correct answer.

Question 13-5. This question deals with the suggested initial treatment of uterine adenomyosis, which should be conservative beginning with a hormonal regimen (specifically gonadotropin-releasing hormone [GnRH] agonists) (B). If this regimen is unsuccessful, then more aggressive treatment with endometrial ablation (A) and hysterectomy (E) may be considered. Uterine artery embolization (D) and fallopian tube recanalization (C) would not be considered. So (B) is the correct answer.

351 West Camden Street, Baltimore, MD 21201-2436 • Tel: 410-528-4000 • Website: Lww.com Question 13-6. This question highlights a clinical situation in which a hysterosalpingogram on an infertile 32-year-old woman reveals multiple, small, contrast-filled outpouchings along the course of the proximal fallopian tubes. The contrast-filled outpouchings suggest fallopian tube diverticula or salpingitis isthmica nodosa. Although the etiology of salpingitis isthmica nodosa of the fallopian tubes is uncertain, it is thought to be most likely caused by previous PID (C). Salpingitis isthmica nodosa is present in approximately 4% of women undergoing evaluation of infertility. So (C) is the most likely diagnosis, and (C) is the correct answer.

Question 13-7. This question calls attention to the most likely cause of multiple uterine cavity outpouchings identified on hysterosalpingography. Salpingitis isthmica nodosa (B) and (D) involve the fallopian tubes, not the uterus. So (B) and (D) are false. Both a degenerating uterine leiomyoma (A) and uterine leiomyosarcoma (E) produce a mass effect and are relatively large, and the latter may have infiltrative margins. Thus (A) and (E) are unlikely. However, uterine adenomyosis (C) with contrast-filled diverticula produces multiple, small uterine cavity outpouchings in the myometrium without mass effect identified on hysterosalpingography. So (C) is the correct answer.

Question 13-8. This question draws attention to the best imaging modality to identify salpingitis isthmica nodosa of the fallopian tubes, which is hysterosalpingography (D). The diverticula of salpingitis isthmica nodosa appear as contrast-filled outpouchings along the fallopian tubes on hysterosalpingography. So (D) is the correct answer.

Question 13-9. This question refers to the pathophysiologic process that underlies uterine cystic adenomyosis, which is hemorrhage (D). So (D) is the correct answer.

Question 13-10. This question emphasizes entities that should be included in the differential diagnosis of salpingitis isthmica nodosa of the fallopian tubes. The entities include tuberculous salpingitis (A), tubal (B), focal uterine adenomyosis (C) with the associated diverticulum near the origin of a fallopian tube, and tubal spasm (D) with secondary pulsion diverticula. Since (A), (B), (C), and (D) are true; (E), all of the above, is the correct answer.

Answer Key for Volume 35 #13: 1. C 2. B 3. D 4. A 5. B 6. C 7. C 8. D 9. D 10. E