Adolescents With Labial Enlargement Misdiagnosed as Labial Masses on Imaging

Background: Literature describing radiologic imaging of the adolescent labia is lacking and may lead to misdiagnoses and unnecessary medical care. Cases: Two adolescent patients presented with sudden-onset unilateral labia minora enlargement and underwent multiple imaging modalities which identified a discrete mass. One patient was diagnosed with aphthous ulcers after a prolonged emergency department stay, and the other underwent an exam under anesthesia for mass removal and was found to have an elongated labia minora rolled into itself. Conclusion: Labia minora enlargement in adolescents can be significant and may be mistaken for a discrete mass on radiologic imaging given a lack of literature on expected findings. Clinical correlation and understanding of age-appropriate etiologies of noninfectious labial swelling is crucial to avoid unnecessary medical therapies and procedures.

Imaging the Female Urethra: US and MRI in Cystic and Solid Pathologic Conditions

The female urethra can be affected by numerous pathologic conditions, many of which are infrequent and often underdiagnosed, particularly before the introduction of MRI. Diagnosing urethral pathologic conditions is challenging due to ambiguous signs and symptoms, nonspecific physical examinations, atypical presentations (such as benign conditions mimicking malignant disorders), and large lesions. Various imaging techniques, including transperineal or transvaginal US and MRI, are essential for accurate anatomic and tissue characterization. Female urethral pathologic conditions can be categorized into cystic lesions (with urethral diverticulum as the most common), benign and malignant solid urethral lesions, and iatrogenic lesions. Defining the location of the pathologic finding is the first step in radiologic diagnosis. By analyzing tissue characteristics (cystic versus noncystic), shape, morphology, and location (including urethral dependence and relationship to the pubic symphysis), an accurate diagnosis can often be achieved. Identifying whether a lesion is urethral-dependent helps distinguish between urethral and other conditions, such as Bartholin gland and Gartner duct cysts. Radiologists must recognize these features to determine the most appropriate diagnostic and therapeutic strategies. ©RSNA, 2025 Supplemental material is available for this article.

The role of magnetic resonance imaging in the rare pathologies of the vulva

Pathologies of the vulva encompass a wide range of mesenchymal and epithelial benign and malignant lesions. Suspicion is raised by non-specific symptoms or clinical findings detected during routine gynecological examinations, and histopathology is essential for the diagnosis. The role of imaging has often been limited, but it can be essential in guiding treatment and, in some cases, in helping differential diagnosis. In particular, magnetic resonance imaging (MRI) can play a central role in identifying the extent of disease and planning surgical treatment. To this aim, rigorous image acquisition, correct disease evaluation in the context of vulvar anatomy and understanding of the possible differential diagnosis are essential. The aim of this article is to review the role of MRI in the evaluation of rare vulvar pathologies, focusing on different sites of origin, imaging characteristics, and local extent.

MR imaging of benign vulvar lesions: a pictorial essay

Benign vulvar lesions can be difficult to differentiate with few publications on their imaging appearances. While many vulvar lesions may be clinically diagnosed and treated, more are being detected incidentally with the increasing prevalence of magnetic resonance imaging (MRI) of the pelvis. In addition, clinicians may find imaging of benign vulvar lesions helpful for greater anatomical correlation. After reviewing the important MRI sequences for vulvar imaging and the anatomy of the vulva on MRI, this pictorial essay illustrates variety of cystic and solid benign vulvar lesions to familiarize radiologists with their common MRI appearances. Other miscellaneous pelvic lesions that can affect the vulva are also described.

Current update on the role of endoanal ultrasound: a primer for radiologists

Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.

Endometriosis MR mimickers: T1-hyperintense lesions

Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.Critical relevance statementMRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.Key points• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.

Vulvar glomangioma: A case report and literature review

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Vulvar glomangioma is a rare cause of pelvic pain and can be confused with angiomyxoma or Bartholin gland cyst.

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Vulvar glomangioma are best treated with resection.

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Glomangiomas are associated with GLMN gene mutations.

GLMN is a gene that encodes a critical protein necessary for normal vascular development. Mutations of GLMN predispose individuals to development of glomangiomas, with nearly 100% penetrance by age 30. Glomangiomas are tumors of the glomus body, a thermoregulatory arterial-venous shunt composed of modified smooth muscle cells. Vulvar glomangioma is an exceedingly rare cause of chronic pelvic pain, that may be easily confused for other conditions such as Bartholin’s gland abscess or deep angiomxyomas, thereby delaying diagnosis and treatment. Glomangiomas have characteristic pathologic and imaging findings which may aid diagnosis. We herein describe the case of a 24-year-old female who developed chronic pelvic pain in the setting of a vulvar glomangioma. We further delineate the magnetic resonance imaging and biopsy findings critical to her diagnosis, and the appropriate steps taken for surgical management. She was found to harbor a heterozygous GLMN mutation. To the best of our knowledge, this is the first description of such a case in the medical literature.

Clitoral Anatomy in the Feminist Literature: Vagina Obscura: An Anatomical Voyage (2020) and Clitoral Conventions and Transgressions: Graphical Representations in Anatomy Texts, c1900-1991 (1995)

O'Connell et al. (1998) proposed that the vestibular bulbs be renamed the "clitoral bulbs" because of their consistent relationship to the clitoris and inconsistent relationship to the vestibule. Normally such proposed esoteric changes in anatomical nomenclature would get little notice by anatomists, yet alone the general public; however, many subsequent articles and books placed this change in the context of centuries of male anatomists and physicians downplaying female sexual anatomy and sexuality. Most prominent is a 2022 book by Rachel Gross, Vagina Obscura: An Anatomical Voyage. Here we review this "Anatomical Voyage" and find author bias in omitting/including erroneous facts in this book. We also present a critique of a 1995 article that appeared in Feminist Studies; Graphical Representations in Anatomy Texts, c1900-1991 (Moore and Clarke, 1995). This article, which has been repeatedly cited in the clinical literature, asserts that between circa 1950-1980 anatomy textbooks purposely eliminated depicting/labeling the clitoris in illustrations because the authors of the textbooks were reflecting societal norms that de-emphasized the importance of the clitoris. Unfortunately, the methods used by Moore and Clarke are not replicable; and further, their conclusions were not justified because of clear bias in their description and depiction of the anatomy sources they review.

Vaginal Swelling After Intercourse: A Case Report

Introduction: A vulvar hematoma is a hemorrhagic fluid collection in the female external genitalia. The majority occur as an obstetrical complication, especially during labor. Non-obstetrical vulvar hematomas are usually the result of trauma, with coitus being the most common etiology. Case Report: We present the case of a 25-year-old woman with significant vaginal pain and swelling after vigorous sexual intercourse. She exhibited tenderness and swelling of the left labia majora and minora. The differential diagnosis included bleeding, abscess, and deep venous thrombosis. Laboratory studies were normal and computed tomography of the pelvis indicated the swelling was most likely due to blood. The patient was taken to the operating room, and approximately 150 cubic centimeters of clot was evacuated. The patient had an uneventful recovery and was discharged home the next day. Conclusion: This case illustrates the unique presentation and challenges in making the diagnosis of vulvar hematoma.

3D quantitative analysis of normal clitoral anatomy in nulliparous women by MRI

INTRODUCTION AND HYPOTHESIS

We present a 3D computational approach for automated clitoral measurements. We hypothesized that computationally derived measurements would be comparable and less variable than reported manual measures.

METHODS

In this retrospective study, MRIs of 22 nulliparous women age 20-49 years with normal vaginal and clitoral anatomy were collected. Manual segmentations were performed to reconstruct 3D models of the whole clitoris (glans, body, crura, and bulbs) and vagina. The length, width, and volume of the clitoral structures and the distance between the vagina and clitoral structures were calculated. Computed clitoral morphometrics (length, width) were compared to median [range] values from a previously published cadaver study (N = 22) using the median test and Moses extreme reaction test. Calculated distances were compared to mean (± SD) reported by a 2D MRI study (N = 20) using independent t-test and Levene's test.

RESULTS

Overall, computed clitoral morphometrics were similar to manual cadaver measurements, where the majority of length and width measures had ~1-2 mm difference and had less variability (smaller range). All calculated distances were significantly smaller and had smaller SDs than manual 2D MRI values, with two-fold differences in the means and SDs. Large variation was observed in clitoral volumetric measures in our cohort.

CONCLUSIONS

The proposed 3D computational method improves the standardization and consistency of clitoral measurements compared to traditional manual approaches. The use of this approach in radiographic studies will give better insight into how clitoral anatomy relates to sexual function and how both are impacted by gynecologic surgery, where outcomes can assist treatment planning.

MRI Staging in Locally Advanced Vulvar Cancer: From Anatomy to Clinico-Radiological Findings. A Multidisciplinary VulCan Team Point of View

MR imaging provides excellent spatial and contrast resolution to stage locally advanced vulvar cancer (LAVC) for tumor and nodal evaluation in order to facilitate the planning of treatment. Although there are no standard indications for how to estimate the clinical stage of International Federation of Gynecology and Obstetrics at diagnosis, MR imaging can depict the tumor and its extension to the vulvar region and adjacent organs, such as the vagina, urethra, and anus. Optimizing the MR imaging protocol and technique is fundamental for correct staging. The aim of this overview was to focus on the role of MR imaging in LAVC staging. We define vulvar anatomy and corresponding MR imaging findings, MR imaging protocol, and technique. Moreover, we describe the MR imaging findings of LAVC with example cases stage by stage. Key imaging findings based on signal intensity, diffusion restriction, and enhancement are portrayed to correctly identify and stage vulvar cancer. A structured report for LAVC staging is reported in order to give all necessary information to the clinicians and to facilitate MR imaging comprehension.

Imaging of the Vagina: Spectrum of Disease with Emphasis on MRI Appearance

The vagina is a median fibromuscular structure of the female reproductive system that extends from the vulva inferiorly to the uterine cervix superiorly. As most vaginal lesions are detected at gynecologic examination, imaging performed for nongynecologic indications can frequently cause concomitant vaginal pathologic conditions to be overlooked. The vagina is often underevaluated at routinely performed pelvic transvaginal US because of a narrow scan area and probe positioning. MRI has progressively become the imaging method of choice for vaginal pathologic conditions, as it provides excellent soft-tissue detail with unparalleled delineation of the complex pelvic floor anatomy and helps establish a diagnosis for most vaginal diseases. It is important that radiologists use a focused approach toward understanding and correctly recognizing different vaginal entities that may otherwise go unnoticed. In this case-based review, the authors discuss the key imaging features of wide-ranging vaginal pathologic conditions, with emphasis on appearance at MRI. Knowledge of vaginal anatomy and embryology is helpful in evaluating congenital anomalies at imaging. Often seen incidentally, vaginal inflammation can cause diagnostic confusion. Because of its central location in the pelvis, the vagina can form fistulas to the urinary bladder, colon, rectum, or anus. Vaginal masses can be neoplastic and nonneoplastic and include a myriad of benign and malignant conditions, some of which have characteristic imaging features. Therapeutic and nontherapeutic vaginal foreign bodies include pessaries, vaginal mesh, and packing that can be seen with or without associated complications. Online supplemental material is available for this article. ^©RSNA, 2021.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

Diagnosis and Treatment of Vulvo-Perineal Endometriosis: A Systematic Review

Objective: To describe the available knowledge on vulvo-perineal endometriosis including its diagnosis, clinical management and recurrence rate.

Methods: We followed the PRISMA guidelines for Systematic Reviews and our study was prospectively registered with PROSPERO (CRD42020202441). The terms “Endometriosis” and “Perineum” or “Vulva” were used as keywords. Cochrane Library, Medline/Pubmed, Embase and Clinicaltrials.gov were searched. Papers in English, Spanish, Portuguese, French or Italian from inception to July 30, 2020 were considered. Reference lists of included articles and other literature source such as Google Scholar were also manually scrutinized in order to identify other relevant studies. Two independent reviewers screened potentially eligible studies according to inclusion criteria.

Results: Out of 539 reports, 90 studies were eligible including a total of 283 patients. Their mean age was 32.7 ± 7.6 years. Two hundred sixty-three (95.3%) presenting with vulvo-perineal endometriosis have undergone either episiotomy, perineal trauma or vaginal injury or surgery. Only 13 patients (4.7%) developed vulvo-vaginal endometriosis spontaneously i.e., without any apparent condition favoring it. The reasons that motivated the patients to take medical advice were vulvo-perineal cyclical pain increasing during menstruations (98.2% of the patients, n = 278). Out of the 281 patients for whom a clinical examination was described, 274 patients (97.5%) showed a vulvo-perineal nodule, mass or swelling while six presented with bluish cutaneous lesions (2.1%) and 1 with bilateral polyps of the labia minora (0.4%). All but one patients underwent surgical excision of their lesions but only 88 patients (28.1%) received additional hormonal therapy. The recurrence rate was 10.2% (29 patients) considering a median follow-up period of 10 months (based on 61 studies).

Conclusion: In conclusion, vulvo-perineal endometriosis is a rare entity with approximately 300 cases reported in the literature since 1923. With the available knowledge shown in this systematic review, we encourage all practitioners to think about perineal endometriosis in case of perineal cyclical pain with or without previous perineal damage. Diagnosis should be done with clinical exam, perineal ultrasound and pelvic MRI when available. In case of anal sphincter involvement, perianal ultrasound should be performed. Surgical excision of the lesion should be realized in order to remove the lesion and to confirm the diagnosis histologically. Hormonal treatment could be proposed to attempt to decrease the size of a large lesion before surgery or to avoid recurrence of the lesion. As evidence-based approach to the diagnosis, treatment and recurrence rate of affected patients remains a challenge given its low prevalence, the variations in management found in the articles included and the limited quality of available studies, we suggest that a prospective database on vulvo-perineal endometriosis should be generated to increase knowledge but also awareness among healthcare professionals and optimize patients' care.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202441.

Best Practices in Robotic-assisted Repair of Vesicovaginal Fistula: A Consensus Report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology

CONTEXT

Surgical repair of a vesicovaginal fistula (VVF) has been described extensively in the literature for several decades. Advances in robotic repair have been adopted since 2005.

OBJECTIVE

A consensus review of existing data based on published case series, expert opinion, and a survey monkey.

EVIDENCE ACQUISITION

This document summarizes the consensus group meeting and survey monkey results convened by the European Association of Urology Robotic Urology Section (ERUS) relating to the robotic management of VVF.

EVIDENCE SYNTHESIS

Current data underline the successful robotic repair of supratrigonal nonobstetric VVF. The panel recommends preoperative marking of the fistula by a guidewire or ureteral catheter, and placement of a protective ureteral JJ stent. An extravesical robotic approach usually provides a good anatomic view for adequate and wide dissection of the vesicovaginal space, as well as bladder and vaginal mobilization. Careful sharp dissection of fistula edges should be performed. Tension-free closure of the bladder is of utmost importance. Tissue interposition seems to be beneficial. The success rate of published series often reaches near 100%. An indwelling bladder catheter should be placed for about 10 d postoperatively.

CONCLUSIONS

When considering robotic repair for VVF, it is essential to establish the size, number, location, and etiology of the VVF. Robotic assistance facilitates dissection of the vesicovaginal space, harvesting of a well-vascularized tissue flap, and a tension-free closure of the bladder with low morbidity for the patient being operated in the deep pelvis with delicate anatomical structures.

PATIENT SUMMARY

Robotic repair of a vesicovaginal fistula can be applied safely with an excellent success rate and very low morbidity. This confirms the use of robotic surgery for vesicovaginal fistula repair, which is recommended in a consensus by the European Association of Urology Robotic Section Scientific Working Group for reconstructive urology.

Advances in MR Imaging of the Female Pelvis

This article focuses on advanced MR imaging techniques of the female pelvis and clinical applications for benign and malignant disease. General and abbreviated protocols for female pelvic MR imaging are reviewed. Diffusion-weighted imaging, dynamic contrast-enhanced MR imaging, and susceptibility-weighted imaging are discussed in the context of adnexal mass characterization using the ADNEx-MR scoring system, evaluation of endometriosis, local staging of cervical and endometrial cancers, assessment of nodal and peritoneal metastasis, and potential detection of leiomyosarcoma. MR defecography is also discussed regarding evaluation of multicompartmental pelvic floor disorders.

Elucidating vaginal fistulas on CT and MRI

Vaginal fistulas (VF) represent abnormal communications between the vagina and either the distal portion of the digestive system or the lower urinary tract, but lack an accepted classification and standardised terminology. Regardless of the underlying cause, these uncommon disorders result in profound physical, psychological, sexual and social distress to the patients.Since diagnosis of VF is challenging at gynaecologic examination, ano-proctoscopy and urethro-cystoscopy, imaging is crucial to confirm the fistula, to visualise its site, course and involved organ, and to characterise the underlying disease. The traditional conventional radiographic studies provided limited cross-sectional information and are nowadays largely replaced by CT and MRI studies.Aiming to provide radiologists with an increased familiarity with VF, this pictorial paper summarises their clinical features, pathogenesis and therapeutic approach, and presents the appropriate CT and MRI acquisition and interpretation techniques that vary according to the anatomic site and termination of the fistula. The current role of state-of-the art CT and MRI is presented with examples regarding both entero- (involving the colon, rectum and anus) and urinary (connecting the bladder, distal ureter or urethra) VF. The resulting combined anatomic and functional cross-sectional information is crucial to allow a correct therapeutic choice and surgical planning.

MRI for Radiation Therapy Planning in Human Papillomavirus-associated Gynecologic Cancers

Locally advanced human papillomavirus (HPV)-associated gynecologic cancers, including cervical, vaginal, and vulvar cancers, are treated primarily with radiation therapy (RT). Cervical cancer remains a leading cause of cancer death among women worldwide. The superior soft-tissue resolution of MRI compared with other imaging modalities makes it an ideal modality for RT planning, execution, and follow-up of these malignancies. This superiority has been corroborated in the literature when comparing MRI-based RT planning to radiography-based conventional treatment planning approaches. In 2005, the Groupe Européen de Curiethérapie and the European Society for Radiation Therapy and Oncology guidelines underscored the central role of MRI for successful implementation of three-dimensional image-based cervical cancer brachytherapy. The delineation of both gross tumor volume and clinical tumor volume for brachytherapy is performed at the time of each brachytherapy application, on the basis of the findings depicted on anatomic MR images. Contemporary knowledge concerning the role of MRI for RT planning in HPV-associated gynecologic cancers warrants an understanding of the epidemiology and clinical manifestations of these cancers, as well as knowledge of MRI protocol for cancer staging, selection of RT candidates, brachytherapy implant assessment, posttreatment surveillance, and delineation of treatment-related complications. Technical requirements, patient preparation, and image acquisition protocols are detailed in this review, and imaging-based treatment protocols are summarized. Knowledge of these fundamental concepts enables the radiologist to play an important role in diagnosis, staging, and posttreatment follow-up, helping to guide radiation oncologists and other clinicians in the management of these malignancies.^©RSNA, 2019.

Ischiorectal fossa: benign and malignant neoplasms of this "ignored" radiological anatomical space

PURPOSE

To review the pertinent anatomy and the imaging features of common and uncommon benign and malignant neoplasms and masses of the ischiorectal fossa.

RESULTS

The ischiorectal or ischioanal fossa is the largest space in the anorectal region. The benign neoplasms that develop in the ischiorectal originate from the different components that forms the fossa including vascular tumors such as aggressive angiomyxoma or hemangioma; neural tumors as plexiform neurofibroma or schwannoma; fat tumors as lipoma; skin/skin appendages tumors as hidradenoma papilliferum; smooth or skeletal muscle tumors as solitary fibrous tumor. The malignant neoplasms that develop in the ischiorectal fossa also originate from different components that forms the fossa including vascular tumors such as angiosarcoma, neural tumors as malignant granular cell tumor and malignant peripheral nerve sheath tumor; fat tumors as liposarcoma; smooth or skeletal muscle tumors as leiomyosarcoma, rhabdomyosarcoma, malignant PEComa, or undifferentiated pleomorphic sarcoma. Additionally, the ischiorectal fossa can also harbor secondary hematogenous metastases and be affected by direct invasion from neoplasms of adjacent pelvic organs and structures. Furthermore, other miscellaneous masses can occur in the ischiorectal fossa including congenital and developmental lesions, and inflammatory and infectious processes.

CONCLUSION

Knowledge of the anatomy, and the spectrum of imaging findings of common and uncommon benign and malignant neoplasms of the ischiorectal fossa is crucial for the radiologists during interpretation of images allowing them to make contributions to the diagnosis and better patient management.

Dynamic magnetic resonance imaging of the female pelvic floor-a pictorial review

Pelvic floor dysfunctions represent a range of functional disorders that frequently occur in adult women, carrying a significant burden on the quality of life, and its incidence tends to increase attending to the expected aging of the population. Pelvic floor dysfunctions can manifest as incontinence, constipation, and prolapsed pelvic organs. Since pelvic floor weakness is frequently generalized and clinically underdiagnosed, imaging evaluation is of major importance, especially prior to surgical correction. Given some interobserver variability of soft-tissue measurements, MR defecography allows a noninvasive, radiation-free, multiplanar dynamic evaluation of the three pelvic compartments simultaneously and with high spatial and temporal resolution. Both static/anatomic and dynamic/functional findings are important, since pelvic disorders can manifest as whole pelvic floor weakness/dysfunction or as an isolated or single compartment disorder. Imaging has a preponderant role in accessing pelvic floor disorders, and dynamic MR defecography presents as a reliable option, being able to evaluate the entire pelvic floor for optimal patient management before surgery. The purpose of this article is to address the female pelvic anatomy and explain the appropriate MR Defecography protocol, along with all the anatomic points, lines, angles, and measurements needed for a correct interpretation, to later focus on the different disorders of the female pelvic floor, illustrated with MR defecography images, highlighting the role of this technique in accessing these pathologic conditions.

Colorectal-Vaginal Fistulas: Imaging and Novel Interventional Treatment Modalities

Colovaginal and/or rectovaginal fistulas cause significant and distressing symptoms, including vaginitis, passage of flatus/feces through the vagina, and painful skin excoriation. These fistulas can be a challenging condition to treat. Although most fistulas can be treated with surgical repair, for those patients who are not operative candidates, limited options remain. As minimally-invasive interventional techniques have evolved, the possibility of fistula occlusion has enriched the therapeutic armamentarium for the treatment of these complex patients. In order to offer optimal treatment options to these patients, it is important to understand the imaging and anatomical features which may appropriately guide the surgeon and/or interventional radiologist during pre-procedural planning.

Asymptomatic Bartholin Cyst: Evaluation With Multidetector Row Computed Tomography

OBJECTIVE

The aim of this study was to determine the frequency, morphology, and attenuation characteristics of Bartholin cysts on multidetector computed tomography (MDCT) in asymptomatic women.

METHODS

A total of 3280 consecutive MDCT examinations were assessed for Bartholin cysts. The diagnosis was based on shape, contrast enhancement, and anatomical location. Age, laterality, size, and attenuation patterns were recorded. Scans from patients with paravaginal-related symptoms were excluded, and any available follow-up MDCT scans or magnetic resonance images were evaluated.

RESULTS

Asymptomatic Bartholin cysts were seen in 17 patients (0.52%) (mean age, 56 years). The mean maximum cyst diameter was 21.8 mm. High-attenuation cysts comprised 47% of cases, all in older (≥50 years) patients. Follow-up MDCT scans showed minimal changes over time.

CONCLUSIONS

High-attenuation Bartholin cysts are more common than previously thought and are usually seen in older women. The size and attenuation of Bartholin cysts show only minimal changes over time.

Clear Cell Adenocarcinoma of the Urethra in Women: Distinctive MRI Findings for Differentiation From Nonadenocarcinoma and Non-Clear Cell Adenocarcinoma of the Urethra

OBJECTIVE

The purpose of this study is to evaluate the MRI findings differentiating clear cell adenocarcinoma of the urethra (CCAU) from nonadenocarcinoma of the urethra (NACU) and non-clear cell adenocarcinoma of the urethra (NCCAU) in women.

MATERIALS AND METHODS

Six women with pathologically proven CCAU, six women with pathologically confirmed NACU (two squamous cell carcinomas and four transitional cell carcinomas), and nine women with NCCAU underwent preoperative MRI. The MRI findings for CCAU, NACU, and NCCAU were reviewed by a radiologist who was blinded to the histopathologic findings and were compared using the Mann-Whitney U test and the Fisher exact test.

RESULTS

CCAU was shorter in height than NACU (3.4 cm vs 5.5 cm; p = 0.020) and also had a smaller height-to-width ratio than NACU (0.85 vs 1.51; p < 0.001) and NCCAU (0.85 vs 1.48; p = 0.002). The proportion of preserved urethra in CCAU (67%) was larger than that in either NACU (9%; p < 0.001) or NCCAU (22%; p < 0.001). All cases of CCAU originated within a diverticulum, whereas none of the cases of NACU and only one NCCAU originated in a diverticulum. Intratumoral septation was more frequently observed in CCAU (100%) than in NACU (16.6%; p = 0.015) or NCCAU (11.1%; p = 0.001).

CONCLUSION

MRI findings for CCAU were significantly distinctive, compared with findings for NACU and NCCAU. All cases of CCAU were associated with a urethral diverticulum, and CCAU had a lower height-to-width ratio, more frequent intratumoral septation, and greater preservation of normal urethra than did NACU and NCCAU.

The imaging findings of typical and atypical genital and gynecologic infections

Genital and gynecologic infections are common medical problems, affecting millions of women worldwide. The spectrum of these infections extends from the labia, including processes such as necrotizing fasciitis and anogenital warts, to the upper reproductive tracts in conditions including endometritis and pelvic inflammatory disease. Although often a clinical diagnosis, the radiologist plays an important role in determining the etiology of acute abdominal and pelvic pain as well as facilitating the diagnosis for cases which are not clinically straightforward. Imaging also plays an important role in assessing the complications and sequelae of these conditions, including infertility, chronic abdominal and pelvic pain, and pelvic adhesions. Familiarity with the appearances of these infections, their complications, and their potential mimics on sonography, computed tomography, magnetic resonance imaging, and hysterosalpingography is important for timely diagnosis and optimal clinical outcomes.

Endoluminal contrast for abdomen and pelvis magnetic resonance imaging

Magnetic resonance (MR) imaging of the abdomen and pelvis can be limited for assessment of different conditions when imaging inadequately distended hollow organs. Endoluminal contrast agents may provide improved anatomic definition and detection of subtle pathology in such scenarios. The available routes of administration for endoluminal contrast agents include oral, endorectal, endovaginal, intravesicular, and through non-physiologic accesses. Appropriate use of endoluminal contrast agents requires a thorough understanding of the clinical indications, available contrast agents, patient preparation, and interaction of the contrast agent with the desired MR imaging protocol. For example, biphasic oral enteric contrast agents are preferred in MR enterography as their signal properties on T1- and T2-weighted imaging allow for evaluation of both intraluminal and bowel wall pathology. In specific situations such as with MR enterography, MR defecography, and accurate local staging of certain pelvic tumors, the use of an endoluminal contrast agent is imperative in providing adequate diagnostic imaging. In other clinical scenarios, the use of an endoluminal contrast agent may serve as an indispensable problem-solving tool.

Female perineal diseases: spectrum of imaging findings

The female perineum, which is divided into the anterior urogenital triangle and the posterior anal triangle, is a surface structure often overlooked. Female perineal diseases may present with nonspecific clinical signs due to its close anatomical relationship between the different compartments. Diagnosis of the origin of a perineal disorder may also be a difficult problem encountered in pelvi-perineal imaging. Therefore, a precise knowledge of the female perineal anatomy and the associated disease processes is essential to radiologists, pathologists, and surgeons alike who are involved in the evaluation of the patient who presents with a perineal mass. Cross-sectional imaging plays a crucial role for proper management. Due to the robust contrast resolution of MR, MR imaging is the modality of choice for evaluation of the extent of a complex perineal lesion, its relationship to the adjacent structures. It has a greater sensitivity and specificity for the diagnosis than the other non-invasive imaging techniques and is helpful in guidance for surgical planning. The purpose of this article is to highlight the spectrum of imaging findings of female perineal diseases.

Aggressive Angiomyxoma: Imaging Findings in 3 Cases With Clinicopathological Correlation and Review of the Literature

Aggressive angiomyxoma is a rare mesenchymal tumor with a typical presentation as a slowly growing perineal soft tissue mass in paravulvar and pararectal region in young adult women. We present 3 cases of aggressive angiomyxoma with clinicopathological correlation and describe their main imaging features with emphasis on magnetic resonance imaging, adding useful information about their behavior on dynamic contrast-enhanced sequences and diffusion-weighted imaging and including a comprehensive review of the existing literature.

Sonographic findings of prescrotal superficial angiomyxoma

Sonographic findings of a prescrotal superficial angiomyxoma have never been reported in the English literature. Here, we describe a case of left prescrotal superficial angiomyxoma, which was depicted on ultrasonography as a well-circumscribed, heterogeneously, and mildly echogenic, unilocular complex, posterior acoustic-enhanced, and dermally attached subcutaneous mass without increased vascular flow.

MR imaging of the pelvic floor: defecography

Defecography by magnetic resonance (MR) imaging makes it possible to view the multiple compartments of the pelvic floor at one examination, with high-resolution images at rest and dynamic images, providing accurate evaluation of the morphology and function of the anorectal and pelvic organs and muscles, involved in pelvic floor dynamics. MR imaging of the pelvic floor identifies the diseases affecting the evacuation mechanism, providing information essential for surgical planning and choice of treatment approach. This article focuses on the MR details of the pelvic floor anatomy and the most commonly observed anatomic and functional abnormalities.

Müllerian duct and related anomalies in children and adolescents

Although many Müllerian duct anomalies do not require treatment, surgical intervention is sometimes necessary to enable sexual activity or to preserve fertility. The identification of these anomalies is important for optimal clinical management or surgical treatment. Magnetic resonance (MR) imaging is a robust method for adequately evaluating and characterizing uterine and vaginal anomalies. The information provided by MR imaging allows for a more complete understanding of the malformation, facilitating management decisions and potentially changing the outcome. In this article, the embryology, classification, and MR imaging findings of Müllerian duct and related anomalies in children and adolescents are reviewed.