Faye C. Laing

Sonourethrography in the Evaluation of Urethral Strictures: A Preliminary Report

A total of 17 patients with suspected stricture disease underwent conventional retrograde urethrography and sonourethrography. When the length of the stricture as assessed by each imaging modality was compared to measurements at open urethroplasty in 7 patients, sonourethrography was consistently more accurate. Distension of the urethra with saline during the ultrasound examination enabled classification of the degree of spongiofibrosis, which was confirmed by full depth biopsy in 5 patients. Sonourethrography cannot adequately image the posterior urethra, even when the transcrotal approach is used. However, because it is a dynamic 3-dimensional study and can be repeated without risk of radiation exposure, sonourethrography is preferable to radiographic retrograde urography to evaluate patients with suspected anterior urethral strictures.

Papillary Stenosis and Sclerosing Cholangitis in the Acquired Immunodeficiency Syndrome

Eight homosexual men with the acquired immunodeficiency syndrome (AIDS) presented with clinical, biochemical, and radiologic features of stenosis of the papilla of Vater and sclerosing cholangitis. This newly recognized complication of AIDS produces abdominal pain, nausea, and vomiting and may predispose patients to superimposed bacterial cholangitis. Marked elevation of serum alkaline phosphatase levels and lesser changes in hepatic aminotransferase levels are common. Although abdominal ultrasonography and computed tomography detect ductal abnormalities, endoscopic retrograde cholangiography best shows precise ductal irregularities and provides therapeutic intervention. Prompt relief of symptoms follows endoscopic sphincterotomy, often with resolution of biochemical evidence of cholestasis. Biliary tract infection with cytomegalovirus or cryptosporidia and resultant viral or coccidial cholangitis are the proposed pathophysiologic mechanisms.

MAJOR TRAUMATIC AND SEPTIC GENITAL INJURIES

Major injuries to the testicles, penis, and genital skin from trauma and infection were seen in 62 patients over a 6-year period (1977 to 1983). Urethral injuries were excluded. In the past blunt testicle injuries were infrequently diagnosed and surgically ignored because of large surrounding hematomas. With the use of real-time ultrasound, 17 of 18 cases of testicle rupture were correctly diagnosed preoperatively. Surgical repair resulted in testicle salvage in 16 patients. Penetrating testicle injuries resulted in a high orchiectomy rate secondary to the infrequently described but recognized entity of self-emasculation in transsexuals. Penile rupture from blunt injuries (8) was successfully repaired and complete function was recovered. Penetrating penile injuries (4) were extensive and involved the urethra in two cases; full function returned after reconstruction. Major skin loss of the penis and/or scrotum (19) occurred from necrotizing fasciitis, burns, avulsion and penetrating injuries. Early debridement, bowel and urinary diversion followed by penile skin grafting, thigh pouches to protect testicles, and scrotal reconstruction resulted in acceptable cosmetic and functional results in all cases of major skin loss.

Distinguishing normal from abnormal gestational sac growth in early pregnancy.

In order to evaluate normal and abnormal gestational sac development, serial sonograms were performed in 83 women whose initial sonogram demonstrated a gestational sac lacking a detectable embryo. Of 53 normal gestations, the mean sac growth was 1.13 mm/day (range, 0.71‐1.75). In comparison, of 30 abnormal gestations, 24 demonstrated sac growth, and of these, the mean growth was 0.70 mm/day (range, 0.14‐1.71). Based on these observations, we suggest that gestational sac growth of less than or equal to 0.6 mm/day is evidence for abnormal development. Analysis of the initial and follow‐up scans for the 53 normal gestations showed that a living embryo was always detected when the mean gestational sac was greater than 25 mm in average diameter, and a yolk sac was always seen when the mean sac diameter was greater than 20 mm. In comparison, of 30 abnormal gestations, six were greater than 25 mm without a detectable embryo, and four were greater than 20 mm without a yolk sac. Recommendations for the optimal time of a follow‐up sonogram are presented based on the initial sac size.

The Decidual Cast of Ectopic Pregnancy: A Confusing Ultrasonographic Appearance

The appearance of the central uterine cavity was analyzed in 39 cases of ectopic pregnancy. In nearly 20% of cases, a fluid collection surrounded by an echogenic ring was present which could be mistaken for a normal early intrauterine pregnancy. When ectopic pregnancy is suspected clinically, and there is fluid in the cul-de-sac or an adnexal mass on ultrasound, a fetal pole should be evident within the central fluid collection before a definitive diagnosis of intrauterine pregnancy is made.

Adnexal Masses: US Characterization and Reporting

Pelvic ultrasonography (US) remains the imaging modality most frequently used to detect and characterize adnexal masses. Although evaluation is often aimed at distinguishing benign from malignant masses, the majority of adnexal masses are benign. About 90% of adnexal masses can be adequately characterized with US alone. In this article, the important US features that should allow one to make a reasonably confident diagnosis in most cases will be discussed. The role of follow-up US and alternative imaging modalities, along with the importance of careful reporting of adnexal masses, will also be reviewed.

Ultrasonographic identification of dilated intrahepatic bile ducts and their differentiation from portal venous structures

The appearance of dilated intrahepatic bile ducts was evaluated on ultrasonograms of 50 patients with proven extrahepatic biliary obstruction. Five characteristic changes allowed differentiation between biliary and portal venous systems. These changes included: (1) Alteration in the anatomic pattern adjacent to the main right portal venous segment and the main portal vein bifurcation. (2) Irregular walls of dilated bile ducts. (3) Stellate confluence of dilated bile ducts. (4) Acoustic enhancement by dilated bile ducts. (5) Peripheral location of dilated bile ducts. Many patients exhibited more than one of these findings. Parasagittal scans of the main right portal vein were the most sensitive for detection of intrahepatic ductal dilatation. Recognition of the characteristic changes and knowledge of the portal venous anatomy makes it possible to diagnose extrahepatic biliary obstruction with a high degree of confidence.

Computed tomography of blunt trauma to the gallbladder.

The CT findings are reviewed in two patients with injuries to the gallbladder following blunt abdominal trauma. In one patient with a laceration of the cystic artery a large intraluminal clot was identified within the gallbladder associated with extensive hemoperitoneum. Another patient presented with extensive bile leakage into the peritoneal cavity 72 h after blunt trauma due to laceration of the fundus of the gallbladder. The clinical features of blunt trauma to the gallbladder and the utility of CT in this entity are reviewed.

Ovary-Containing Hernia in a Premature Infant Sonographic Diagnosis

In both male and female fetuses, inguinal canal development entails a complex sequence of anatomic events involving the gubernaculum and processus vaginalis. In the normally developing female fetus, the processus vaginalis is usually obliterated by 8 months of gestation. 1 In premature infants, because this structure is often patent, an inguinal hernia commonly develops. In female infants, it has been reported to contain the ovary with or without portions of the fallopian tube 15% to 20% of the time. 2 Although some hernias regress spontaneously, 3 this is less likely to occur if it contains the ovary, and, in comparison to a bowel-containing hernia, the risk of incarceration is greatly increased. 2,4,5 The pediatric and surgical literature have described ovary-containing inguinal hernias in neonates and infants, 1-6 but reports in the ultrasound and radiology literature are lacking. We describe such a case to alert sonographers to its appearance and presentation and to emphasize the pathophysiologic characteristics of this condition in the premature infant.

Value of Ultrasonography in the Detection of Retroperitoneal Inflammatory Masses

The ultrasonographic and radiologic findings for 7 patients with retroperitoneal inflammatory processes are presented. Ultrasonographic findings were critical to the diagnosis in 6 of the 7 patients and allowed for rapid evaluation and the institution of successful therapy. The relative sensitivity and specificity of ultrasonography is compared with conventional radiologic modalities. The application of diagnostic ultrasound to the problem of retroperitoneal inflammation is advocated.