US of the pediatric female pelvis

The radiologist's role in assessing differences of sex development

When infants are identified with a difference of sex development (DSD), a thoughtful approach to imaging is essential to appropriate clinical management. This review provides a comprehensive guide for radiologists who are tasked with performing this critical assignment. We review the embryologic basis of DSDs, with attention to the imaging findings that can indicate specific diagnoses. We also discuss techniques for optimal imaging, including strategies for identifying the gonads by US, tactics for performing genitograms with fluoroscopy and contrast-enhanced US, and the appropriate utilization of MRI. Finally, we review the clinical data and imaging findings that characterize some of the most common DSDs, including congenital adrenal hyperplasia, complete androgen insensitivity syndrome and gonadal dysgenesis.

Gynecological Examination in Children and Adolescents

Pediatric gynecological examination is one of the gynecological examinations that are quite simple, but many doctors are unable to do it properly because of the infrequentness of doing this examination. Consulting a child with gynecological complaints, endocrine problems, or sexual abuse often takes a long time and is thorough. However, evidence-based data on the problem of gynecological examinations in children and adolescents are inadequate because of the high bias in many studies. The purpose of this review is to seek from the literature regarding the correct procedures for gynecological examinations in children and adolescents, the order of examinations, and how to carry out a good examination so as not to leave a traumatic experience for children.

Homozygous SHBG Variant (rs6258) Linked to Gonadotropin-Independent Precocious Puberty in a Young Girl

Sex hormone-binding globulin (SHBG) in the blood is a major determinant of bioactivity for key sex steroids such as testosterone and estradiol. Low serum levels of SHBG have been associated with obesity, polycystic ovaries, and metabolic syndrome, and other states associated with hyperandrogenemia. A 9-year, 6-month-old girl presented with a history of peripheral precocious puberty and aggressive behavior. The patient's SHBG level was remarkably low for her age, at less than 5 nmol/L (reference range for a girl with a bone age of 10 years, 73 nmol/L [SEM = 10]) [1]. On genetic and protein analysis, the patient was found to have a homozygous missense potentially pathogenic variant in the SHBG gene (c.554C>T, p.P185L); her parents were asymptomatic heterozygote carriers. Laboratory investigations supported the possible involvement of this genetic alteration in the patient's phenotype. Various analyses of this variant support its pathogenicity, although the exact mechanism remains unclear. In conclusion, we present a genetic SHBG variant in the homozygote state that may have been associated with gonadotropin-independent precocious puberty in a young girl.

Time Tracking of Standard Ultrasound Examinations in Pediatric Hospitals and Pediatric Medical Practices - A Multicenter Study by the Pediatric Section of the German Society of Ultrasound in Medicine (DEGUM)

PURPOSE

 Ultrasonography is the primary imaging modality in pediatrics but still lacks sufficient reimbursement in Germany. In this multicenter study, national data for the duration of standard ultrasound in pediatrics were systematically documented in order to specify the actual time required.

MATERIALS AND METHODS

 N = 10 hospitals (N = 5 university hospitals, N = 5 non-university hospitals) and N = 3 medical practices in Germany recorded the entire process of an ultrasound examination in a special protocol developed by the Pediatric Section of the DEGUM. The duration of each of seven single steps during ultrasonography (from data input to final discussion of the results) of different organ systems was logged.

RESULTS

 In total, N = 2118 examinations from different organ systems were recorded. N = 10 organ systems were examined frequently (> 30 times). The total duration of an ultrasound examination was statistically significantly longer in hospitals compared to medical practices (median (IQR) 27 min. (18-38) vs. 12 min. (9-17), p < 0.001). The "hands-on" patient time was approximately one half of the total required time in both settings (49.9 % vs. 48.9 %). Ultrasonography of the abdomen and brain lasted longer in university hospitals than in non-university hospitals (p < 0.001, and p = 0.04, respectively). Cooperation and age did not uniformly correlate with the total duration.

CONCLUSION

 This study provides novel comprehensive national data for the duration of standardized ultrasound examinations of children and adolescents in Germany. These data are essential for a further evaluation of the economic costs and should support better remuneration in the future.

Surveillance recommendations for DICER1 pathogenic variant carriers: a report from the SIOPE Host Genome Working Group and CanGene-CanVar Clinical Guideline Working Group

DICER1 syndrome is a rare genetic disorder that predisposes to a wide spectrum of tumors. Developing surveillance protocols for this syndrome is challenging because uncertainty exists about the clinical efficacy of surveillance, and appraisal of potential benefits and harms vary. In addition, there is increasing evidence that germline DICER1 pathogenic variants are associated with lower penetrance for cancer than previously assumed. To address these issues and to harmonize DICER1 syndrome surveillance programs within Europe, the Host Genome Working Group of the European branch of the International Society of Pediatric Oncology (SIOPE HGWG) and Clinical Guideline Working Group of the CanGene-CanVar project in the United Kingdom reviewed current surveillance strategies and evaluated additional relevant literature. Consensus was achieved for a new surveillance protocol and information leaflet that informs patients about potential symptoms of DICER1-associated tumors. The surveillance protocol comprises a minimum program and an extended version for consideration. The key recommendations of the minimum program are: annual clinical examination from birth to age 20 years, six-monthly chest X-ray and renal ultrasound from birth to age 6 years, and thyroid ultrasound every 3 years from age 8 to age 40 years. The surveillance program for consideration comprises additional surveillance procedures, and recommendations for DICER1 pathogenic variant carriers outside the ages of the surveillance interval. Patients have to be supported in choosing the surveillance program that best meets their needs. Prospective evaluation of the efficacy and patient perspectives of proposed surveillance recommendations is required to expand the evidence base for DICER1 surveillance protocols.

Role of Transperineal Ultrasound (TPUS) in Children with Ambiguous Genitalia

Objectives  Accurate delineation of anatomy in children with ambiguous genitalia early in life is important. This commonly involves conventional fluoroscopic genitogram (traumatic to the child) and magnetic resonance imaging (MRI) examination (involves sedation). In this study, our objectives were twofold: (1) to describe the findings on transperineal ultrasound (TPUS) in normal children and (2) to describe the findings on TPUS in children with ambiguous genitalia and correlate them with conventional genitogram. Materials and Methods  TPUS was prospectively performed in 10 children without genital ambiguity (5 girls and 5 boys). Subsequently, 15 consecutive children having disorders of sex differentiation (DSDs) with genital ambiguity underwent TPUS. The presence or absence of müllerian structures was documented. Of these patients, 14 also underwent conventional genitogram as a part of routine evaluation. The gold standard was established either by comparison with surgical findings (in patients who underwent surgery) or by comparison with a combination of findings on genitogram and transabdominal ultrasound in patients who did not undergo surgery. Results  In all normal children, lower urogenital tracts could be clearly delineated on TPUS. Out of the 15 children with ambiguous genitalia, TPUS could establish the presence/absence of müllerian structures in 14. This was concordant with findings on conventional genitogram/surgery. In one patient, müllerian structure was missed on TPUS but demonstrated on genitogram. In two children, TPUS showed the müllerian structure, which was not seen on genitogram. When both the controls and the cases were combined, TPUS had an accuracy of 95% and specificity of 100% in the detection of müllerian structures. Conclusion  TPUS is feasible and accurate in demonstration of lower urogenital tract anatomy in children with DSDs having ambiguous genitalia. It can be performed without sedation, and is suitable for use as a screening modality in children with ambiguous genitalia.

Ultrasonographic and multimodal imaging of pediatric genital female diseases

Ultrasonography is the first-line imaging modality in the evaluation of the female pelvis in childhood and adolescence, because it is easy to perform, non-invasive and it does not require sedation. The transabdominal approach is preferred in children and adolescents, after filling the bladder to move away the bowel loops from the pelvis. The probe frequency must be adapted to age, thickness of tissues and depth of the structures under examination. High-frequency (4-12 MHz) linear or convex probes are used in newborns; high-frequency linear probes (4-12 MHz) in toddler, convex 5-7.5 MHz probes in girls and convex 3.5-5 MHz probes in teenagers. In this article, the main pathological conditions of the genital female tract in pediatric age are examined, such as congenital anomalies, disorders of sex development, ovarian cysts, ovarian tumors, adnexal torsion, primary amenorrhea, precocious puberty and pelvic inflammatory disease.

Plea for a standardized imaging approach to disorders of sex development in neonates: consensus proposal from European Society of Paediatric Radiology task force

This consensus article elaborated by the European Society for Paediatric Radiology task force on gastrointestinal and genitourinary imaging is intended to standardize the imaging approach in newborns with disorders of sex development. These newborns represent a difficult and stressful situation necessitating a multidisciplinary team approach. Imaging plays an important role in the work-up but needs to be optimized and customized to the patient. Ultrasound plays the central role in assessing the genital anatomy. The examination must be conducted in a detailed and systematic way. It must include transabdominal and transperineal approaches with adapted high-resolution transducers. The pelvic cavity, the genital folds, the inguinal areas and the adrenals must be evaluated as well as the rest of the abdominal cavity. A reporting template is proposed. The indications of magnetic resonance imaging and cysto- and genitography are discussed as well as they may provide additional information. Imaging findings must be reported cautiously using neutral wording as much as possible.

Normative values for ultrasound measurements of the female pelvic organs throughout childhood and adolescence

BACKGROUND

Normative data from pelvic ultrasonography (US) of the pediatric female reproductive organs are outdated and limited by sample size.

OBJECTIVE

The purpose of this study was to report normal uterine and ovarian volumes and endometrial stripe thickness in children and young adults and throughout the menstrual cycle in post-menarchal adolescents.

MATERIALS AND METHODS

Females ages 0 through 20 years who underwent pelvic US between January 2010 and May 2014 were identified. After excluding patients with pelvic and/or endocrine pathology, nomograms of uterine and ovarian volumes and endometrial thickness by age year were created. Data for patients ages 12 years and older with a recorded day of last menstrual period were used to create additional nomograms of volumes/thickness throughout the menstrual cycle. Student's t-tests and linear regression were performed to assess differences in measurements between groups and association of volumes/thickness with age.

RESULTS

During our study period, 5,647 patients underwent 6,953 pelvic US examinations. After further review, 907 examinations from 889 patients were included (mean age: 11.3±6.0 years). Mean pelvic US volumes (cm³) per organ were 25.5±27.0 (uterus), 4.5±4.7 (right ovary) and 4.0±4.1 (left ovary). Mean endometrial thickness was 4.5±3.7 mm. Right ovarian volume was significantly larger than the left (P=0.0126). Uterine volume, ovarian volume and endometrial thickness were significantly associated with age (P-values<0.0001). Plots of mean organ measurements with respect to week of menses are provided.

CONCLUSION

We report normal volumes of the uterus and ovaries and endometrial stripe thickness measured by pelvic US throughout childhood and adolescence with reference to the menstrual cycle. These values are significantly associated with age and vary visually by menstrual cycle week.

Imaging of diseases of the vagina and external genitalia in children

A wide range of congenital or acquired conditions, some pretty rare, may affect the vulva and vagina in children. Swelling, visible or palpable masses and abnormal discharges are common symptoms of conditions affecting the vulva and/or the lower genital tract. The majority of these diseases are benign. Ultrasonography is pivotal to elucidate the anatomical origin of these conditions and make the diagnosis. Magnetic resonance imaging can be relevant to improve diagnostic confidence and, if needed, to plan more accurate surgical treatment. The aim of this pictorial essay is to review the related imaging findings to help make radiologists familiar with these conditions.

Incidental findings during ultrasound of thyroid, breast, testis, uterus and ovary in healthy term neonates

Incidental sonographic findings in thyroid and estrogen-responsive organs have been described in children and adults, but no publications describe incidental findings of these organs in infancy. We describe ultrasound features in thyroid, breast buds, testes, uterus, and ovaries in infants up to 32 weeks old that vary from the expected tissue architecture. Infants described in this paper were enrolled as healthy term neonates in a longitudinal study of normal feeding practices. Radiology reports for ultrasound exams in these infants described a range of findings that are similar to those reported in older populations. Knowledge of these asymptomatic variants occurring in infancy may guide radiologists in interpretation of these findings during clinical exams.

Emergent ultrasound evaluation of the pediatric female pelvis

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examples, conditions encountered when performing emergent pelvic US for common and uncommon clinical scenarios.

Pelvic pain in the middle of the night: use of MRI for evaluation of pediatric female pathology in the emergent setting

Acute pelvic pain in pediatric female patients is a common cause of emergency room visits. Imaging plays a crucial role in the clinical evaluation of these patients. Pelvic pain in female children can result from various pathologies. Ultrasound is the preferred first line imaging study; however, magnetic resonance imaging (MRI) is a helpful adjunct after hours, as it is available 24/7 in many institutions. Advantages of MRI include superior delineation of anatomy and higher tissue contrast resolution, particularly of the small pelvic structures. Given the lack of ionizing radiation, there is increasing use of MRI in children and adolescents, specifically in an emergent setting. In this pictorial review, we discuss pelvic MRI techniques and illustrate imaging findings of common etiologies of pelvic pain, emphasizing the advantages of MRI as an adjunct imaging modality.

Transperineal Ultrasound as a Tool to Plan Surgical Strategies in Pediatric Urology: Back to the Future?

OBJECTIVE

To demonstrate the usefulness and advantages of transperineal ultrasound (TPUS) on planning the surgical tactics to treat childhood pelviperineal disease (CPPD).

METHODS

A cohort of CPPD is reviewed to provide a pictorial review of TPUS as imaging method variety of CPPD. Other imaging methods are compared with TPUS.

RESULTS

TPUS studies of patients showing different conditions on the spectrum of pelviperineal malformation are shown in detail (pictorial review, graphically shown-see figures in the article and as supplementary material), highlighting the advantages of the method and comparing TPUS findings with other imaging techniques.

CONCLUSION

Magnetic resonance imaging, contrast genitograms, voiding cystourethrography, and genital or urologic endoscopy have some important disadvantages, especially radiation exposure, high cost, not easily available equipment, and the need of general anesthesia or deep sedation in children. TPUS is easily available, including in impoverished environments, portable, painless, reproducible, inexpensive, and capable of providing detailed and specific information about pelviperineal malformation with accuracy. Data provided by TPUS are comparable with other imaging techniques (Table 1). Its main disadvantage is the dependency on the expertise of the operator to obtain high-quality, well-interpreted images.

Combined Application of Ultrasound and CT Increased Diagnostic Value in Female Patients with Pelvic Masses

Purpose. The current study aimed to evaluate whether combined application of ultrasound and CT had increased Diagnostic Value in Female Patients with Pelvic Masses over either method alone. Patients and Methods. 240 female patients with pelvic masses were detected preoperatively with ultrasound and CT prior to surgery. The sensitivity, specificity, and accuracy of ultrasound, CT, and combined ultrasound/CT application were evaluated, respectively. Results. The sensitivity, specificity, and accuracy of ultrasound were 52.8%, 86.7%, and 68.75%, respectively. The sensitivity, specificity, and accuracy of CT were 80.3%, 90.3%, and 85%, respectively. The sensitivity, specificity, and accuracy of combined application of ultrasound and CT were 89%, 94.7%, and 91.7%. The sensitivity, specificity, and accuracy of combined application of ultrasound and CT were higher than those of either ultrasound or CT. Conclusions. The combined application of ultrasound and CT had higher Diagnostic Value in Female Patients with Pelvic Masses than either method alone.

Laparoscopic ovarian surgery in children and adolescents

Background and Objectives:

Although laparoscopy is widely used in gynecologic surgery in adults, few studies have been undertaken to examine its use in young and adolescent patients. This study was conducted to investigate the safety and feasibility of laparoscopic surgery for the treatment of benign ovarian disease in children and adolescents.

Methods:

A retrospective chart review was conducted on 106 patients (age, <20 years) who underwent laparoscopic surgery at Kangnam Sacred Heart Hospital from 2006 through 2012.

Results:

The mean patient age was 17.1 years, and the youngest one was 8. Pathologic analyses revealed that 32 (30.2%) patients had dermoid cyst, 30 (28.3%) had simple cyst, and 15 (14.2%) had endometrioma. Conservative procedures, such as cystectomy (48.1%), aspiration (5.7%), fulguration (4.7%), and detorsion (3.8%), were performed in 65.1% of all cases. A subanalysis revealed that the surgical outcomes of children (age, ≤15 years), including operative time, estimated blood loss, postoperative hemoglobin decrease, and postoperative length of hospital stay, were comparable to those of adolescents (age, 16–19 years), despite significant differences in mean height between the 2 groups (156.1 ± 10.71 cm in children vs. 162.1 ± 5.14 cm in adolescents; P < .0001). (The age break between the study groups was set at 15 years, because most girls reach their adult height between the ages of 15 and 16 years.) No intra- or perioperative complications were noted. In a comparison study of surgical outcomes in 433 women (age, 20–50 years) and the 106 young and adolescent girls in our sample (age, <20 years), those in our patients were not inferior.

Conclusion:

In children and adolescents, laparoscopic surgery can be successfully performed with conventional instruments designed for use in adults.