and Frequently seen and ????? Dr Anne Marie Coady Consultant Radiologist Head of Obstetric and Gynaecological

HEY WACH

Vagina and Cervix

Common pathologies

Vaginal

Cervical

Vaginal • Gartners • Skene duct • Bartholins • Hydro/haematocolpos • Foreign body • Prolapse

Vagina

The vagina can easily be overlooked

A routine US protocol for the examination of the vagina includes transabdominal, trans labial and transvaginal US.

Trans labial imaging is not part of a routine examination and is limited to cases in which • transvaginal US cannot be performed (e.g. due to obstruction or pain) • there is a specific request for directed vaginal imaging.

The major limitation of imaging the vagina with routine transvaginal US is that the transducer is typically inserted into the anterior or posterior fornix prior to imaging, which bypasses the and vagina.

Examination of the Vagina Transabdominal US images are best obtained with the bladder partially decompressed.

The vagina is a fibro muscular tube extending from the vulvar vestibule to the .

It is located in the middle compartment of the pelvis and is intimately related to

(a) the and -trigone area of the bladder anteriorly, and

(b) the anal canal and lower posteriorly.

US appearance of the normal vagina

The vaginal wall is composed of three layers: (a) the mucosa, (b) the muscularis, (c) the adventitia In females of reproductive age, the normal vagina is seen as a collapsed, hypo echoic tubular structure with a central high-amplitude linear echo representing the apposed surfaces of the vaginal mucosa.

The vagina is more difficult to identify in postmenopausal women, in whom the vaginal mucosa is less echogenic due to the loss of oestrogen stimulation

Vaginal cysts Location location location

Gartner duct cysts result from incomplete regression of the wolffian ducts. They develop in the anterolateral wall of the upper vagina. When Gartner duct cysts are located at the level of the urethra, they can cause mass effect on the urethra, giving rise to urinary tract symptoms

The Bartholin glands are -secreting glands that derive from the and are located at the posterolateral vaginal introitus, medial to the minora. Bartholin gland cysts develop as a result of an obstruction of the gland's duct by a stone or a stenosis related to prior or trauma.

RSNA Radiographics The Skene glands are paired structures located near the external urethral meatus, with ducts draining directly into the urethral These glands may be differentiated from urethral diverticula, which tend to be mid urethral in location and, due to their position, may cause recurrent urinary tract or urethral obstruction

Vaginal cysts Location location location

Gartner

RED

Bartholin

BLUE

Skene

GREEN RSNA Radiographics Vaginal lesions: location location location Vaginal lesions: location location location

• The answer is ???? Bartholin’s cyst Vaginal lesions: location location location Vaginal lesions: location location location

The answer is ??????

Gartners Duct cyst Vaginal lesions location location location Vaginal lesions location location location

The answer is ?????

Skene duct cyst Vaginal lesions location location location Vaginal lesions location location location

The answer is??????

Urethral diverticulum Vaginal lesions location location location Vaginal lesions: in utero

Normal cervix

Cervical pathologies

Nabothian retention cysts

Polyps

Cervical fibroids

Cervical carcinoma

Cervical stenosis

The cervix The cervix is homogeneous in echotexture and similar in echogenicity to the uterine body, with a hypoechoic central canal.

Normal cervix very variable Normal appearance of the cervix

2 !!!!! Nabothian cysts

ANY SIZE Complex Fluid within variable Benign Tumours

Polyps

These are the most common benign of the cervix (found in 4% of the gynaecological population). Endocervical polyps are most usually found in the fourth to sixth decade of life. Cervical polyps are equally benign and tend to occur as single, smooth grey- white lesions that bleed easily if touched. All patients with suspicious lesions or who are symptomatic should be referred to a specialist clinic and the lesions sent to histology. Cervical ? cause Benign Tumours

Fibroids

When found in the cervix, fibroids are smooth, firm masses which are often solitary and tend to be small (5-10 mm in diameter).

They account for about 3-9% of uterine myomata.

A fibroid growing down into the cervix from higher up in the uterus is a more common situation.

Symptoms relate to its size and exact location: dysuria, urgency, obstruction of the cervix and .

Cervical lesions that do not originate in the cervix Benign pathologies

Cervical Endometriosis in the cervix is not uncommon

It can cause and it may present as a mass.

RV septum

Benign pathologies

Stenosis

This problem may be congenital or acquired and tends to occur at the level of the internal os. There are a number of causes and associations:

Diathermy excision of cervical lesions is the most common cause of stenosis (it occurs in 1.3% of cases).

Other acquired causes include radiotherapy, infection, neoplasia and atrophy following a cone .

It may also be associated with endometriosis. Cervical

The sonographic detection rate for is 93–94% and ultrasound is a highly accurate method in classifying early-stage tumour

Role of US

1) Detecting the presence of a tumour and 2) Detecting its location and growth pattern 3) Extent of stromal invasion

Cervical cancer

The vast majority are squamous cell carcinomas but other histologies include • , • small cell carcinoma, • adenoid cystic carcinoma, • sarcoma and • lymphoma.

Squamous and Adenocarcinoma

• SCC tends to be a hypo echoic tumour in approximately 73% of cases • AC tends to be an isoechoic tumour in approximately 68% of cases. Major concern with this tumour type as they may not be seen on vaginal inspection and may well be missed at cytological examination. • Colour Doppler is a very valuable sonographic technique in the assessment of cervical tumours, because the vast majority (95%) of such tumours are vascularized, which will make it easier to detect them and to determine their borders. • Another sonographic tool that may be used to assess isoechoic cervical tumours is a dynamic examination technique when on pushing the probe against the cervix the appreciation is of a rigid, undeformable lesion.

Cervical cancer

Cervical hypo echoic lesions

Sequence of steps

Normal examination technique

• Urethra

• Bladder base

• Anterior fornix

• Cervix Cervical cancer

Dedication not inconsiderable

Serendipitous

Lazy ?????

Normal cervix reported every time Cervical cancer

Hypo echoic SCC Cervical cancer

Colour doppler ULTRASOUND APPEARANCES

Cervical tumour is identified as an area with echogenicity different from that of the surrounding cervical tissue according to real-time gray scale ultrasound examination

Adenoma Malignum

• Adenoma malignum of the cervix, (minimal deviation carcinoma / minimal deviation adenocarcinoma) is considered a rare variant of cervical carcinoma, thought to represent 1- 3% of all cervical . • It can present in a wide age group (25-70 years) peaking at around 42 years • Common presenting symptoms are menorrhagia, vaginal (often watery) discharge, postmenopausal bleeding and abdominal swelling. • It is considered a rare variant of well-differentiated mucinous adenocarcinoma of the uterine cervix. • Associations – Peutz-Jeghers syndrome – mucinous tumours of the • Ultrasound • Lesions can be multilocular cystic, multilocular cystic with solid components or predominantly solid on ultrasound. The solid lesions are usually heterogeneous in echogenicity. Colour Doppler interrogation usually show moderate or abundant colour content 10. Adenoma Malignum

Subtype mucinous adenocarcinoma Rare WATERY DISCHARGE Solid and heterogenous Multilocular tiny locules

Intra lesional vascularity Tunnel cluster Tunnel cluster (TC) is a type of characterised by complex multicystic dilatation of the endocervical glands.

Tunnel cluster is found in 8% of adult women, 40% of whom are pregnant, almost exclusively multigravid older than 30 years. A tunnel cluster is the result of a stimulatory phenomenon occurring during that can persist for a variable period. It is a benign pseudoneoplastic glandular lesion of the cervix, they are involutional in nature and are usually of no clinicalsignificance

?????Adenoma malignum

Cervical problems in pregnancy

Cervical incompetence

Ectopic pregnancy in the cervix

Pad involving the cervix

The crucial concept of the endocervical canal

Cervical problems in pregnancy

Not cervical imcompetence !!! Cervical problems in pregnancy

Ectopic pregnancy in the cervix

Cervical problems in pregnancy

Pad involving the cervix

BUT……..

• Before you become too fraught with pathologies

• Start to examine the cervix properly

And

• Unleash the potential of the endo !!!!

The endocervical canal This is one of the most fundamentally important and useful anatomical structures

Finding the endocervical canal will allow you to understand anatomy and then assess pathology correctly

The endocervical canal is your best friend!!!!!!!! The endocervical canal Small but screamingly important!!!!!!! Endocervical canal The importance of the endocervical canal

•

The importance of the endocervical canal The importance of the endocervical canal US of the cervix and vagina

• Huge potential to pick up pathology and then direct further appropriate imaging

• Needs to be considered every time you scan

• “People only see what they are prepared to see”

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