1. Female and Male Reproductive System & HSG and Prostate Imaging
SPRING 2009

2. Female Reproductive Anatomy

3. Cervical Os

4. Female Reproductive System Imaging and Procedures

5. Infertility

7. HSG

9. Instruments

10. Vaginography

11. Pelvimetry

12. Pelvimetry

13. Localization of Intrauterine Devices (IUD)

14. IUD Imaging

15. Congenital Anomolies (FEMALE)

16. Bicornate Uterus

17. Bicornate Uterus

18. Vaginogram with Fistula to sigmoid

19. Unicornuate Uterus

20. Uterus Didelphys
Uterus didelphys with an obstructed hemivagina. (a) Axial T2-weighted image shows two separate uteri and two cervices (arrows), all of which have normal zonal anatomy. Arrowheads = ovaries. (b) Coronal T2-weighted image shows a hematocele (H) due to obstruction of the right hemivagina. (c) Contrast-enhanced computed tomographic (CT) scan shows agenesis of the right kidney. Uterus didelphys with an obstructed hemivagina is termed Wunderlich syndrome and is usually associated with ipsilateral renal agenesis. (Reprinted, with permission, from reference 50.)

21. Uterus Didelphys

22. Neoplastic Diseases (FEMALE)

23. Ovarian Cancer

25. Uterine Cancer

26. Endometriosis

27. Endometrial Polyp

28. Teratoma Dermoid Cyst

29. Dermoid Cyst

30. Dermoid Cyst

31. Uterine Fibroid
They are benign growths, arising from the muscular wall of the uterus. Their origin is thought to be the muscle in the walls of uterine blood vessels.
Fibroids vary greatly in size, and can remain for years with little change. Others can grow much larger and reach the size of a 5 month pregnancy or more.
In pregnancy, pre-existing fibroids can increase 3-5 times in size. This is thought to be due in part to the very high estrogen level in pregnancy, as well as to other factors stimulating the pregnancy changes. Quite remarkably after pregnancy, these same fibroids can shrink to their pre-pregnancy size.
Menopausal patients who take estrogen show a varying response. Some who start with significant size fibroids may notice a slow increase in size, while others experience very little change at all.
Fibroids are extremely common. They are estimated to reach significant size in 25-30% of all Caucasians, and in 50% of women of African background. If very tiny fibroids are included, some studies suggest that by the menopause virtually every woman has them.
In most cases, there is more than one fibroid present. Sometimes there are many - 50 or more have been counted. A Solitary fibroid can occur, but is much less frequent.
Cancer in a fibroid is very uncommon (perhaps 1:750 to 1000). There is some data that suggests this cancer (called a sarcoma) may not arise from a pre-existing fibroid at all, but develop in an area of the uterus not a fibroid.
Fibroids are also called by other names such as: Myoma, Leiomyoma, Leiomyomata and Fibromyoma
Serosal Fibroids (or those which develop in the outer portion of the uterus and expand giving the uterus a "knobby" appearance.)
A serosal fibroid develops below the capsule of the uterus, and slowly expands outwards. (Observe the animated drawing to the left.)
Probably because they are not trapped below the surface of the uterus, they can expand to large size.
They produce no change in menstrual flow, and no increase in the miscarriage rate. They are compatible with pregnancy (though because of their size they can become uncomfortable by causing increasing pressure).
Serosal fibroids produce a problem in pregnancy only if they are in the lower part of the uterus. There they can block the outlet of the pelvis making a C-Section the only way to deliver the baby. Intra-Mural Fibroids (or those which develop within the wall of the uterus and expand making the uterus feel larger than normal during a pelvic exam.)
An Intra-mural fibroid develops below the capsule of the uterus, and slowly expands, increasing the bulk of the uterus. (Observe the animated drawing to the left.)
When there are many fibroids within the wall, the uterine cavity also expands. This can result in heavier menstrual flows.
Should the combined bulk of the fibroids (all types) be large enough to fill the pelvis tightly, a blockage of flow of urine from the kidneys may result. Though this is uncommon, it can damage the kidneys if left untreated. Hence once this blockage is discovered, these fibroids must be removed

32. LEIOMYOMA (FIBROID TUMOR)
Due to the presence of needles, and possibly also due to her long-term disability, the patient has chronic ileus, causing severe constipation and stool impaction. By the way, the lesion projecting over the right iliac wing is a calcified leiomyoma uteri. The uterus is displaced to the right by the stool-distended sigmoid colon.

33. Uterine Ablation What is an endometrial ablation?
Endometrial ablation is a procedure to permanently remove a thin tissue layer of the lining of the uterus to stop or reduce excessive or abnormal bleeding in women for whom childbearing is complete. The lining of the uterus is called the endometrium. In some cases, endometrial ablation may be an alternative to hysterectomy.
There are several techniques used to perform endometrial ablation including the following:
electrical or electrocautery - electric current travels through a wire loop or rollerball that is applied to the endometrial lining to cauterize the tissue
hydrothermal - heated fluid is pumped into the uterus and destroys the endometrial lining with high temperature
laser - a beam of light radiation is used to destroy the endometrial lining
balloon therapy - a balloon at the end of a catheter is inserted into the uterus and filled with fluid, which is then heated to the point that the endometrial tissues are eroded away
electrode ablation - a triangular mesh electrode is expanded to fill the uterine cavity. A gentle suction brings the tissue into contact with the electrode which delivers electrical current and destroys the endometrial lining.
cryoablation (freezing) - a probe uses extremely low temperatures to freeze and destroy the endometrial tissues
microwave ablation - microwave energy is delivered through a slender probe that has been inserted into the uterus and destroys the endometrial lining.
Some endometrial ablation procedures are performed using a hysteroscope, a lighted viewing device inserted through the vagina for a visual examination of the canal of the cervix and the interior of the uterus. Ablation instruments can be inserted through the opening and a camera or video camera can be used to record findings through the hysteroscope.
A resectoscope may be used instead of the hysteroscope. This device is similar to the hysteroscope but has a built-in wire that uses electrical current for resecting (removing) endometrial tissue.
Other ablation techniques use ultrasound to guide the instrument to the areas for treatment. Ultrasound is a diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs.
Other related procedures used for treating the endometrium include dilation and curettage (D & C), hysteroscopy, endometrial biopsy, and hysterectomy. Please see these procedures for additional information.
click image to enlargeWhat are female pelvic organs?
The organs and structures of the female pelvis are:
endometrium - the lining of the uterus
uterus - also called the womb, the uterus is a hollow, pear-shaped organ located in a woman's lower abdomen, between the bladder and the rectum. The uterus sheds it’s lining each month during menstruation, unless a fertilized egg (ovum) becomes implanted and pregnancy follows.
ovaries - two female reproductive organs located in the pelvis in which egg cells (ova) develop and are stored and where the female sex hormones estrogen and progesterone are produced
cervix - the lower, narrow part of the uterus located between the bladder and the rectum, forming a canal that opens into the vagina, which leads to the outside of the body
vagina - the passageway through which fluid passes out of the body during menstrual periods. Also called the "birth canal," the vagina connects the cervix and the vulva (the external genitalia)
vulva - the external portion of the female genital organs

34. Fibroid Embolization

35. HPV
Cervical Cancer
-Caused by HPV types16 & 18 (high-risk HPV strains)
-The virus enters the body through a cut, abrasion or tear in the outer layer of skin. It invades the cervical tissue cells and transfers genetic material. This leads to abnormal changes in the cells.

36. Cervical Cancer

37. DES

38. Bladder Prolapse

39. Prolapsed Uterus

40. Prolapse Device- Pessary
The illustration above shows how a pessary should fit. The most common types of pessaries are the Gellhorn and the doughnut. A pessary is used to support areas of pelvic organ prolapse.
Your doctor will try to find a pessary that fits you. It should not cause any pain. You may need to try different shapes and sizes of pessaries to find one that fits you just right.
Your doctor will show you how to take out and clean the pessary and how to put it back into place. This should be done on a regular schedule. If it is hard for you to take out your pessary or to put it back into place, you can have it done at your doctor's office.

41. Pessary Imaging

42. Male Reproductive System Imaging and Procedures

43. Male Reproductive Anatomy

44. Function of the Prostate
It makes and stores seminal fluid
This fluid is released to form part of semen
If the prostate grows too large, the flow of urine can be slowed or stopped.
To work properly, the prostate needs male hormone (testoserone)

45. Epididymogram

46. Epididymogram

47. Vesiculogram

48. Congenital Anomolies
(MALES)

49. Cryptorchidism

50. Cryptorchidism

51. TSE

52. Benign Prostatic Hyperplasia

53. Benign Prostatic Hyperplasia

54. PSA Test

55. TURP
About 90% of all surgeries for BPH involve transurethral resection of the prostate (TURP). This procedure requires no external incision and takes about 90 minutes. It is considered the 'golden standard' in BPH treatment and all other therapies are compared to TURP. After giving anesthesia, the urologist inserts an instrument called a resectoscope into the penis through the urethra. It resembles a cystoscope and contains a light, valves for controlling irrigating fluid and an special high-frequency electrical loop to cut tissue and seal blood vessels. This loop is used to remove the enlarged tissue in little pieces, small enough to fit through the resectoscope. The irrigating fluid is used to flush the prostate continuously and thus keep visibility at maximum. At the same time the resected pieces of prostate tissue are temporarely flushed into the bladder and flusehd out again at the end of the operation. Patients usually must remain in the hospital for about 3 days after TURP surgery, during which a catheter must be used to drain their urine and flush out blood clots that may have been left after the surgery. After that, recovery usually is quick. Most men find their BPH symptoms improve rapidly and are able to return to work within a month. Advantages of TURP are the quick recovery compared to the open prostatectomy and the fact that much more tissue can be removed than with the other semi-surgical means (Laser, TUMT). Disadvantages include the need for anaesthesia, possible blood loss during surgery, while recovery may take some time. The endresult in terms of improvement of symptoms is often remarkable, although urination may be too easy in te beginning when a new anatomical situation has to be incorporated into urinary functions. The most common, unavoidable, permanent side effect of prostate surgery is retrograde ejaculation ('dry climax'), which results when the tiny sphincter muscle that usually blocks off the bladder during ejaculation is cut during surgery, which is always the case. Semen then enters the bladder instead of being expelled through the penis, so the patient will be unable to father (any more) children.

56. Prostate Cancer

57. Radium Needle Placement

58. Brachytherapy

59. Diabetes and Impotence
Impotence or erectile dysfunction is a very common problem that affects 20 million (1 out of 5) American Men. Erectile dysfunction is the result of a single, or more commonly a combination of multiple factors. At one time impotence was thought to be the result of psychological problems, but we now know that 90% of the cases are organic in nature. Some of the many causes of impotence include, diabetes, high blood pressure, heart and vascular disease, stress, hormone problems, pelvic surgery, trauma, venous leak, and side effects of frequently prescribed medications. No matter what the cause, most men have a secondary psychological reaction that can worsen the situation. Feelings of performance anxiety, guilt, and low self-esteem are common. The penis contains two chambers called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.
Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed

60. Prostatitis

61. Prostatitis

62. Testicular Torsion

63. Testicular Torsion

64. Scrotal Hernia

65. Male Prosthesis (Implants)
A penile prosthesis (implant) is a fixed or mechanical device surgically implanted within the two corpora cavernosa of the penis, allowing erection as often as desired. Penile prosthetic implantation surgery gives good results and high satisfaction ratios with low complication rates when performed at centers of excellence. The incidence of side effects is low. Penile prostheses are available in semi-rigid, self-contained 2-piece inflatable, and 3-piece inflatable models. Newer advances in implant design have reduced the complication rates and increased satisfaction rates further.

66. Vasectomy
The vasectomy will take about minutes to perform. A local anesthetic is injected into the scrotal skin adjacent to the vas deferens. This affords almost immediate anesthesia. A small incision is made in the scrotum, the vas deferens is exposed, and a small portion is removed. The severed ends are then either clipped, tied with suture or cauterized. The skin incisions are usually closed with one suture, which dissolves in seven to ten days. The patients can take showers the following morning. The patient is advised to be very sedentary for 48 hours after the procedure to reduce the incidence of complications. Ice packs can be applied to the scrotum periodically for the first 24 to 36 hours to ease swelling. After 48 hours, the patient may begin physical activity, including intercourse, as comfort allows.