Ultrasonographic and multimodal imaging of pediatric genital female diseases

Abstract

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.

Keywords: Congenital anomalies; Disorders of sex development; Genital female tract; Pediatric age; Pelvic expansive masses; Ultrasound examination.

Fig. 1

Normal pre-puberal uterus of a 7-year-old girl, transabdominal approach. UT uterus, (++) length, VAG vagina, B bladder. The bladder is an important acoustic window

Fig. 2

Neonatal uterus of a 3-day-old child. The neonatal uterus shows a prevalence of the neck on the body and the endometrial rhyme is thickened. a Longitudinal section. b Axial section. UT uterus, B bladder, (++) length

Fig. 3

Pubertal uterus of a 13-year-old-girl. The uterus has the classic pear appearance with a body:neck ratio of 2:1. UT uterus, B bladder

Fig. 4

Neonatal ovary of a 4-day-old child. There are usually some prominent follicles (x) which will disappear as the child grows. OV ovary, B bladder

Fig. 5

Prepubertal ovary of a 6-year-old child. No prominent follicles are visible even though sometimes they can appear. OV ovary, (++) length

Fig. 6

Pubertal ovary of a 12-year-old girl. Some prominent follicles (++) are visible. OV ovary

Fig. 7

Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still-unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance

Fig. 8

Uterus septum of an 11-year-old girl. In this malformation, there is a normal fund, concavity < 10 mm and endometrial emicavities (EM) separated by a septum (↑)

Fig. 9

Unicornuate uterus of an 11-year-old girl. a Ultrasonography. b MRI. The uterus has a “banana” morphology. UT uterus, B bladder, (xx) longitudinal diameter, O ovary, R rectus

Fig. 10

Hematocolpos in a distal vaginal atresia of a 15-year-old girl. There is no vaginal orifice and this can lead to hematocolpos (HE). UT uterus

Fig. 11

Hematocolpos caused by imperforate hymen in a 14-year-old girl. a Ultrasonography. b MRI. There a massive distension of the entire vaginal lumen with hematocolpos (HE). UT uterus

Fig. 12

Cloacal malformation of a newborn. There is an abdominal mass with a non-homogeneous content caused by the accumulation of urine and meconium in the cloaca. UT uterus, CL cloaca

Fig. 13

Intracystic hemorrhage due to torsion of the appendage in a newborn. It contains echogenic material (↑) with fluid–fluid images

Fig. 14

Right ovarian cyst (x); left multifollicular ovary (↓) of a 7-year-old girl. A cyst is defined when its diameter is more than 3 cm

Fig. 15

“Daughter cyst” sign in a 5-year-old girl. It consists of a small cystic formation seen within an ovarian cyst (CY)

Fig. 16

Luteal cyst (LC) in a 13-year-old girl. It contains fluid, septa, internal trabeculation and it has a heterogeneous aspects (“ground glass”) (←)

Fig. 17

Hemorrhagic cyst (CY) of an 18-year-old girl. It shows a heterogeneous pattern with irregular trabeculation which leads to a “moth-eaten” or “worm-eaten” aspect (←)

Fig. 18

Paraovarian cyst (CY) of a 10-year-old girl. They arise from the mesonephric ducts and the mesothelium and they are separated from the ovary (OV)

Fig. 19

Ovarian torsion in the newborn. a The ovary appears medialized with an inhomogeneous echostructure, a central hyperechogenic stroma (↓), small peripheral distribution of the follicles (→). b The twisted vascular pedicle (“whirl” sign) is a pathognomonic sign of this condition