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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses typical imaging characteristics of the uterus, endometrium, and myometrium based on patient age, reproductive cycle stage, and associated benign pathology. Other topics include the imaging of pelvic floor disorders, and imaging recommendations for the adnexa.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Emagnetic resonance imaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ediagnostic \u0026amp; surgical procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eultrasonography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eurogenital diseases\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Etomography\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EReena C. Jha, MD, Georgetown University Medical Center, Washington, District of Columbia, USA, discussed typical imaging characteristics of the uterus, endometrium, and myometrium based on patient age, reproductive cycle stage, and associated benign pathology.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EPostpartum physiologic changes a few days after vaginal delivery show uterine enlargement and heterogeneous engorgement of the myometrium. Cesarean delivery delays involution. Intracavitary gas has been seen in asymptomatic women as late as 3 weeks after vaginal delivery and has been noted after both vaginal and cesarean deliveries [Kamaya A et al. \u003Cem\u003EUltrasound Q.\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EIn premenopausal women, endometrial thickness and appearance vary with the phases of the menstrual cycle [Langer JE et al. \u003Cem\u003ERadiographics.\u003C\/em\u003E 2012]. There are physiologic changes in the uterus seen using magnetic resonance imaging (MRI), depending on the phase of the cycle. The zonal anatomy of the uterine muscle is often less distinct on MRI during premenarche, pregnancy and up to about 6 weeks postpartum, and postmenopause. The appearance and thickness of the endometrium should be considered abnormal if they do not align with expectations for each phase of the menstrual cycle. Dr Jha noted that in a postmenopausal patient, the upper normal range of the endometrium is \u0026lt; 4 to 5 mm, regardless of whether she is using hormone therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EIf the patient is bleeding and the endometrium measures \u2265 5 mm, the causes could be atrophy, polyps, or fibroids. Dr Jha then explained endometrial pathology, including polyps, tamoxifen, hyperplasia, and cancer. She noted that it is important to distinguish between how polyps and submucosal fibroids appear on the ultrasound (US; \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16485\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16485\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16485\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EDifferences Between Polyps and Submucosal Fibroids Using Ultrasound\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EFinally, Dr Jha noted that the normal thickness measurement of the junctional zone, based on histologic studies, is \u0026lt; 8 mm. If the junctional zone is \u0026gt; 12 mm, a diagnosis of adenomyosis is likely. The results of 1 meta-analysis showed that a correct diagnosis of adenomyosis was obtained more often with MRI than with US [Champaneria R et al. \u003Cem\u003EActa Obstet Gynecol Scand.\u003C\/em\u003E 2010]. Adenomyosis can mimic fibroids, uterine contractions, and invasive endometriosis.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAN UNDERREPORTED QUALITY-OF-LIFE ISSUE: PELVIC FLOOR DISORDER\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EMark Lockhart, MD, MPH, University of Alabama, Birmingham, Alabama, USA, discussed pelvic floor disorders, which are an underreported health problem with a major impact on quality of life.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EBy the year 2050, 43.8 million American women will have at least 1 symptomatic pelvic floor disorder, 28.4 million will have urinary incontinence, 16.8 million will suffer from fecal incontinence, and 4.9 million will live with pelvic organ prolapse [Wu JM et al. \u003Cem\u003EObstet Gynecol.\u003C\/em\u003E 2009]. Risk-based factors for pelvic floor disorder include multiple vaginal deliveries, trauma, and obesity. Older women are particularly hard hit: 37% of those aged 60 to 79 years and 50% of those aged \u2265 80 years had at least 1 pelvic floor disorder based on 2005 to 2006 National Health and Nutrition Examination Survey data [Nygaard I et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThorough preoperative assessment of pelvic floor failure is necessary to reduce the rate of relapse, which is reported to be as high as 30% [Bitti GT et al. \u003Cem\u003ERadiographics.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EImaging options include defecography, cystography, US, and dynamic MRI. Dynamic MRI is a powerful tool that enables radiologists to comprehensively evaluate pelvic anatomic and functional abnormalities, thereby helping surgeons to provide appropriate treatment and avoid repeat surgeries. Magnetic resonance defecography changed surgical plans in 67% of patients who underwent fecal incontinence surgeries [Hetzer FH et al. \u003Cem\u003ERadiology.\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EIndications for MRI include anal incontinence (sphincter evaluation); anal symptomology, pain, or mass; pelvic organ prolapse (difficult physical examination or suspicion or multicompartment damage); and failed prior surgery. According to Dr Lockhart, the MRI technique calls for a collapsed bladder and the insertion of US gel into the rectum. The patient is supine for 20 to 30 minutes, with a center-phased array coil on the low pelvis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ETechnical considerations include the use of an internal vs external anal coil, the volume of rectal contrast, repeated strain vs defecography, static images vs cine clips, filling of the vagina and small bowel, empty vs filled bladder, pubococcygeal vs midpubic line, and 1.5 vs 3.0 T. Defecation phase images can be very useful in identifying additional instances of abnormal bladder, vaginal, and rectal descent [Flusberg M et al. \u003Cem\u003EAJR Am J Roentgenol.\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EDr Lockhart concluded that improvement is needed in the standardization of MRI examinations and interpretation criteria. Future trends will focus on 3D imaging, automation and standardization, postsupport imaging, strain vs evacuation criteria, and reduction of interpretation variability.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIMAGING THE ADNEXA\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EMaitray D. Patel, MD, Mayo Clinic Arizona, Scottsdale\/Phoenix, Arizona, USA, spoke on imaging recommendations for the adnexa. He outlined an algorithm for thinking about an adnexal mass, reviewed the 2009 Society of Radiologists in Ultrasound (SRU) consensus recommendations for managing simple cysts identified by US [Levine D et al. \u003Cem\u003EUltrasound Q.\u003C\/em\u003E 2010], and also discussed the American College of Radiology (ACR) recommendations for managing incidental ovarian findings on computed tomography (CT) images [Patel MD et al. \u003Cem\u003EJ Am Coll Radiol.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EDr Patel first discussed an algorithm that can help analyze and understand adnexa pathology. He used this as the basis of his presentation (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/13\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Suggested Approach to an Adnexal Mass Identified by US\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1634471765\u0022 data-figure-caption=\u0022Suggested Approach to an Adnexal Mass Identified by US\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/13\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/13\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/13\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16484\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-17\u0022 class=\u0022first-child\u0022\u003ESuggested Approach to an Adnexal Mass Identified by US\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003Edx, diagnosis; f\/u, follow-up; tx, treatment; us, ultrasound.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted with permission of Elsevier Inc, from Patel MD. Practical Approach to the Adnexal Mass.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003E\n               \u003Cem\u003EUltrasound Clin.\u003C\/em\u003E 2006;1:335\u2013356. Permission conveyed through Copyright Clearance Center, Inc.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EAccording to Dr Patel, imaging impressions regarding an adnexal mass are paramount in determining case management particularly because the majority of adnexal masses in premenopausal women will be nonneoplastic ovarian cysts that will spontaneously resolve, usually within 2 menstrual cycles. These nonneoplastic adnexal cysts can also be found in postmenopausal women. In postmenopausal women, up to 50% usually resolve within 1 to 2 years, with resolution more common in women who have been postmenopausal \u0026lt; 10 years [Castillo G et al. \u003Cem\u003EGynecol Oncol.\u003C\/em\u003E 2004]. Therefore, imagers must be well versed in recognizing adnexal masses that do not require intervention or further imaging.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EThe risk of malignancy in simple adnexal cysts (unilocular adnexal cysts without internal echoes) measuring \u0026lt; 10 cm in diameter is extremely low [Modesitt SC et al. \u003Cem\u003EObstet Gynecol.\u003C\/em\u003E 2003]. In a study of about 3000 unilocular cysts measuring \u0026lt; 10 cm in \u0026gt; 15 000 in postmenopausal women, \u0026lt; 0.1% had a risk of malignancy. In that study, rare malignancies were all borderline malignancies and always \u0026gt; 5 cm and had identified septations or tiny wall nodules recognized at follow-up.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EThe SRU consensus recommendation for managing incidental simple cyst identified on US are based on the following criteria: a simple cyst does not require further imaging evaluation or follow-up if the patient is asymptomatic and the cyst is either \u2264 5 cm in premenopausal patients or \u0026lt; 1 to 3 cm in postmenopausal women [Levine D et al. \u003Cem\u003EUltrasound Q.\u003C\/em\u003E 2010]. Dr Patel noted that the SRU criteria allow that imagers can choose any cutoff value between 1 and 3 cm as valid for not following a simple cyst in a postmenopausal woman. Asymptomatic simple cysts between 5 and 7 cm in diameter can be safely followed with yearly US. When simple cysts are \u0026gt; 7 cm in diameter, the SRU criteria suggest that magnetic resonance evaluation and\/or surgical consultation can be pursued.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EA CT of the pelvis is commonly performed prior to US when a patient is presenting with acute pain in the emergency room, suspected bowel pathology, and suspected renal calculi. The ACR recommendations should be used when managing incidental findings on abdominal and pelvic CT and MRI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EReimaging with US refers to when the US is performed immediately or within a few days of CT to further characterize a CT finding or suspected clinical entity. Follow-up imaging with US refers to when US is performed after some interval from the CT, to assess the effect of time on a detected finding [Patel MD, Dubinsky TJ. \u003Cem\u003EUltrasound Q.\u003C\/em\u003E 2007]. Dr Patel emphasized that neither reimaging nor follow-up imaging should be necessary when the CT scan shows gynecologic structures to be normal; when an incidental finding is identified in which the differential diagnosis is a nonneoplastic cyst vs a benign neoplasm, reimaging is not helpful, as one needs to understand the evolution of the finding over time (requiring follow-up imaging rather than reimaging).\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EDr Patel summarized by emphasizing the importance of developing a conceptual framework for managing decisions on how to assess the type of cysts in patients.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/53\/13.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlseq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlseq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlseq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}