Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Varicocele TERMINOLOGY Definitions • Dilatation and tortuosity of pampiniform plexus > 2-3 mm due to congestion and retrograde flow in internal spermatic vein IMAGING General Features • Best diagnostic clue ○ Dilated serpiginous veins adjacent to superior pole testis ○ "Flash" of color Doppler with Valsalva • Location ○ Left (78%), right (6%), bilateral (16%) ○ Can extend along spermatic cord to inferior scrotal sac or rarely may have intratesticular varicocele • Size ○ Varicose veins are > 2-3 mm diameter, increase in size with Valsalva Ultrasonographic Findings • Grayscale ultrasound ○ US should be performed in supine and standing positions – Hypoechoic, tubular structures superior and lateral to testis ○ ± low-level internal echoes due to slow flow and formation of red cell rouleaux ○ Scan retroperitoneum for mass • Color Doppler ○ Detection approaches 100% with color Doppler US ○ Slow flow may be visible only with Valsalva Other Modality Findings • Catheter venography demonstrates dilated venous channels • Enhancing tubular structures may be seen on CECT or MR Imaging Recommendations • Best imaging tool ○ US with color Doppler • Protocol advice ○ Resting and Valsalva color Doppler DIFFERENTIAL DIAGNOSIS Tubular Ectasia/Rete Testis • Normal variant: Dilated tubules of mediastinum &/or testis • No flow on color Doppler Testicular Torsion • Absent or decreased flow to testis on color Doppler • Enlarged, hypoechoic testis Epididymitis • Enlarged epididymis with increased flow on color Doppler • Flow does not show change with Valsalva PATHOLOGY General Features • Etiology ○ Primary: Incompetent venous valve near junction of left renal vein (LRV) and IVC – Left testicular vein is longer than right, enters LRV at right angle, sometimes arches over LRV ○ Secondary: Obstruction of LRV by renal or adrenal tumor, nodes, or rarely SMA compression • Pathophysiology: Engorged veins have 3 distinct mechanisms of potential testicular damage ○ Increased heat: Warms blood heats testes ○ Oxidative stress: Reactive oxygen species (ROS) ○ Hemodynamics: ↑ venous pressure ↓ arterial inflow Staging, Grading, & Classification • Grading of varicoceles ○ Small varicocele: Palpable only with Valsalva maneuver ○ Moderate varicocele: Palpable with patient standing ○ Large varicocele: Visible through scrotal skin, and palpable with patient standing CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Most frequent cause of male infertility ○ Vague scrotal discomfort or pressure, primarily when standing Demographics • Age ○ Primary: Idiopathic > 15 years ○ Secondary: < 40 years or elderly • Epidemiology ○ 10-15% of men in USA have varicoceles ○ Subclinical varicocele in 40-75% of infertile men Natural History & Prognosis • Excellent prognosis in treated cases Treatment • Catheter embolization, surgical treatment, or sclerotherapy if symptomatic • Emerging research suggests even subclinical varicoceles should be treated DIAGNOSTIC CHECKLIST Consider • Left renal vein occlusion by tumor in elderly male patient presenting with recent onset varicocele Image Interpretation Pearls • Valsalva essential for diagnosis of small varicoceles • Varicocele diagnosed when vessel > 2 mm during quiet respiration in supine position SELECTED REFERENCES 1. Cantoro U et al: Reassessing the role of subclinical varicocele in infertile men with impaired semen quality: a prospective study. Urology. 85(4):826-30, 2015 2. Kim YS et al: Efficacy of scrotal Doppler ultrasonography with the Valsalva maneuver, standing position, and resting-Valsalva ratio for varicocele diagnosis. Korean J Urol. 56(2):144-9, 2015 3. Karami M et al: Determination of the best position and site for color Doppler ultrasonographic evaluation of the testicular vein to define the clinical grades of varicocele ultrasonographically. Adv Biomed Res. 3:17, 2014 Diagnoses: Scrotum 721

PART II SECTION 11 Female Pelvis Introduction and Overview Approach to Sonography of the Female Pelvis 724 Cervical and Myometrial Pathology Nabothian Cyst 726 Cervical Carcinoma 730 Adenomyosis 736 Leiomyoma 740 Uterine Anomalies 746 Endometrial Disorders Hematometrocolpos 752 Endometrial Polyp 756 Endometrial Carcinoma 762 Endometritis 766 Intrauterine Device 770 Pregnancy-Related Disorders Tubal Ectopic Pregnancy 774 Unusual Ectopic Pregnancies 780 Failed First Trimester Pregnancy 786 Retained Products of Conception 792 Gestational Trophoblastic Disease 796 Ovarian Cysts and Cystic Neoplasms Functional Ovarian Cyst 800 Hemorrhagic Cyst 804 Ovarian Hyperstimulation Syndrome 808 Serous Ovarian Cystadenoma/Carcinoma 812 Mucinous Ovarian Cystadenoma/Carcinoma 816 Ovarian Teratoma 820 Polycystic Ovarian Syndrome 824 Endometrioma 826

PART II<br />

SECTION 11<br />

Female <strong>Pelvis</strong><br />

Introduction <strong>and</strong> Overview<br />

Approach to Sonography of the Female <strong>Pelvis</strong> 724<br />

Cervical <strong>and</strong> Myometrial Pathology<br />

Nabothian Cyst 726<br />

Cervical Carcinoma 730<br />

Adenomyosis 736<br />

Leiomyoma 740<br />

Uterine Anomalies 746<br />

Endometrial Disorders<br />

Hematometrocolpos 752<br />

Endometrial Polyp 756<br />

Endometrial Carcinoma 762<br />

Endometritis 766<br />

Intrauterine Device 770<br />

Pregnancy-Related Disorders<br />

Tubal Ectopic Pregnancy 774<br />

Unusual Ectopic Pregnancies 780<br />

Failed First Trimester Pregnancy 786<br />

Retained Products of Conception 792<br />

Gestational Trophoblastic Disease 796<br />

Ovarian Cysts <strong>and</strong> Cystic Neoplasms<br />

Functional Ovarian Cyst 800<br />

Hemorrhagic Cyst 804<br />

Ovarian Hyperstimulation Syndrome 808<br />

Serous Ovarian Cystadenoma/Carcinoma 812<br />

Mucinous Ovarian Cystadenoma/Carcinoma 816<br />

Ovarian Teratoma 820<br />

Polycystic Ovarian Syndrome 824<br />

Endometrioma 826

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