Quiz 4

neonatal & pediatric female pelvis; cervical & vaginal pathology

Normal characteristics of pediatric bladder

smooth,thin walled

• distended - < 3mm

• Empty/partially full - appear thicker, no > 5mm

why are post-void scans utilized in pediatric bladders

change in size can demonstrate in bladder to differentiate cystic structures in pelvis

normal characteristics of newborn uterus

• prominent uterus with echogenic endometrial lining (from maternal hormones)

• Pear-shaped

• Length is approx. 3.5 cm

• Fundal:cervix ratio is 1:2 (fundus is smaller than the cervix)

normal characteristics of pediatric uterus after birth

• uterus size decreases from newborn (hormone levels dropped)

• Teardrop-shape

• Fundal:cervix ratio 2:1 

normal characteristics of 2-3 months old uterus

• regresses to prepubertal size and configuration

• Length approx. 2.5-3cm

• Fundal:cervix ratio is 1:1

• Endometrial stripe disappears

normal characteristics of uterus - 7 yrs old

uterus increases in size

Normal characteristics of uterus - post-puberty

• greatest increase in size after puberty

• Fundus is much larger than the cervix

• Length approx. 5-7cm

• Fundal:cervix ratio is 3:1

• Endometrial echogenicity and thickness changes on menstrual cycle

what vasculature supplies the uterus?

bilateral uterine arteries that branched off the internal iliac arteries

what is the best way to visualize the pediatric vagina?

Sagittarius plane with bladder distended

sonographic appearance of pediatric vagina?

Tubular in structure continued with the cervix

mucosal walls appear echogenic with central echogenic structure within tubular structure

where could neonatal ovaries be found?

Anywhere between the lower pole of the kidneys and true pelvis

characteristics of pediatric ovaries

• mean ovarian volume of 0-5 yrs old: 0.75-0.86cm³

  • Menstrual = 9.8cm³

• Neonatal- heterogenous secondary to tiny cysts

• >1 yr old- homogenous with small follicles

Vasculature of ovaries?

ovarian artery coming from aorta, which is an adnexal branch of the uterine artery

what are some of the mullerian abnormalities?

• uterine agensis

• Vaginal atresia

• Bicornuate uterus

• Uterine didelphys

• Septate uterus

• Unicornuate uterus

• Arcuate uterus

What is ambiguous genitalia?

errors in sexual development results in ambiguous genitalia

True and pseudo hermaphrodites

What is true hermaphroditism?

• have both ovarian and testicular tissue

• Internal and external genitalia is variable

• 46XX- phenotypically appear female (most common)

• Gonadal dysgenesis - no production of the gonads

  • Most common 45X0 - turner syndrome

what is pseudohermaphroditism?

• masculine external genitalia (enlarged clitoris, abnormalities of urogenital sinus and partial fusion of the labia majors)

What is the most common cause of pseudohermaphroditism?

congenital virilizing adrenal hyperplasia

• increased production of androgens, which cross placenta when mom has PCOS, drug intake, ovarian tumors

  • Produces excess testosterone in mom’s bloodstream which crosses the BBB of placenta into the fetus which increases levels of testosterone in female fetus

What are the two classifications of precocious puberty?

true precocious puberty and pseudo precocious puberty

what is true precocious puberty?

• activation of the hypothalamus cycle early (before age 8)

• Always isosexual and involves development of secondary sex characteristics

What is pseudoprecocious puberty?

• no activation of hypothalamus cycle

• Maturation of secondary sex characteristics but not the gonads

• Most common cause: excessive exogenous synthesis of gonadal steroids

what is an abnormal pediatric ovary size?

> 20mm (normal is < 9mm)

what is ovarian torsion?

• partial or complete rotation of the ovary on its vascular pedicure compromising both arterial and venous blood supply

• Most common cause: enlarged ovarian cysts or tumors present

• Seen in first two decades of life because mobility of annexation at mesosalpinx

• Clinical presentation: severe onset of abdominal/pelvic pain

• Sonography: enlargement of the ovary, no evidence of Doppler flow, free fluid in cul-de-sac

What are ovarian teratomas?

• Uncommon in neonate and adolescents

• Germ cell tumors are most common (60%) in females under 20

• There are benign and malignant 

• Sonography: variable with ovarian neoplasms (solid, cystic, or complex)

What is the most common vaginal lesion?

gartner’s duct cyst

What is vaginal cuff?

• remaining portion of the vagina after a hysterectomy

• Upper size limit: 2.1cm

  • Larger is sus for malignancy

• Can also be seen from post radiation fibrosis

what is the normal measurement of the cervical canal?

2-4cm

what are nabothian cysts?

• benign condition

• Result from chronic cervicitis in middle-age women or obstructed dilated transcervical glands

• Normal size: < 2cm

• Sonography: discrete, round, fluid-filled anechoic structures along the cervical canal

What is another name for nabothian cysts?

epithelial inclusion cyst

what are cervical polyps?

• hyperplastic protrusion of the epithelium of the endocervix

• Caused by chronic inflammation of cervix

• Develop in late middle-age women

• Benign condition

• Clinical presentations: irregular bleeding

• Sonography: pedunculated, projecting out of cervix or broad based

what is leiomyoma?

• fibroid, estrogen dependent, benign condition

• Small leiomyomas are usually asymptomatic

  • Large leiomyomas = bleeding

• Sonography: best seen with sonohystography, appear pedunculated and prolapse into the vaginal canal. Can help with determining location and thickness of stalk

What is cervical stenosis?

• acquired condition with obstruction of the cervical canal and internal or external os

• Benign condition

• Pts experience: abnormal bleeding, oligomenorrhea/amenorrhea, cramping, dysmenorrhea, infertility

• Sonography: hematometrocolpos or large endometrial fluid collections

what does cervical stenosis usually result from?

• exposure to radiation therapy

• Previous cone biopsy

• PMP cervical atrophy

• Chronic infection

• Cervical carcinomas

• Laser or cyrosurgery

what is cervical carcinoma?

• undifferentiated neoplastic cells - carcinoma in situ

• Squamous cell carcinoma is most common type

• Precursors: cervical dysplasia

• Most early lesions are benign

• Sonography: solid retrovesical mass is present (often indistinguishable from cervical leiomyoma)

what forms the primary sex cords?

coelomic epithelium covering the gonadal ridges

what are the sonographic characteristics of cervical stenosis?

how would you describe the use of doppler to characterize lesions?

which one of the following is most likely the result of an acquired condition of the cervical canal?

cervical stenosis

in which of the following structures would a Garter’s duct cyst be found?

vagina

what is the normal size of a nabothian cyst?

1-2 cm

the premenarcheal fundal to cervial ratio is typically

1:1

which statement is true for an infantile uterus?

during embryologic development what is responsible for creating the vaginal plate?

sinovaginal bulbs

by 2-3 months old, the fundal to cervical ratio should be

1:1

female pseudohermaphroditism is most often caused by

ovarian masculinization

T or F: the most common form of gonadal dysgenesis is Turner Syndrome

true

what most likely causes hematometra in pediatric patients?

imporforate hymen

what is the most common karyotype that causes errors in sexual development resulting in ambigious genitalia?

a 12 year old patient presents with primary amenorrhea and pelvic pressure. the most likely cause of her symptoms is

hematocolpos

which of the following conditions is associated with sexual ambiguity?

what is termed as abnormally little flow during the menstrual cycle?

oligomenorrhea

in a patient after a hysterectomy, the normal vaginal cuff shoudl not exceed _____ cm

2