The role of ultrasound scanning in Genitourinary Medicine
The role of ultrasound scanning in Genitourinary Medicine |
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Summary
Scientific data on the value of genital ultrasound scanning in conditions presenting to Genito-Urinary Medicine department were reviewed. All abstracts under ultrasonography, Genito-Urinary, Gynaecology, Obstetrics and Urology from 1974 to date were reviewed. Articles were selected which specifically addressed ultrasound scanning of the male and female organs. These articles were further analysed for content relevant to conditions seen in Genito-Urinary Medicine. Literature on the psychological benefits of reassuring the patient that the genital tract is normal and articles comparing the accuracy of bimanual pelvic examination with pelvic ultrasound scan were also examined. Critical analysis of all significant data suggest that genital ultrasound is an important tool in the diagnosis of chronic genital conditions seen by the genito-urinary medicine physicians. Analysis of the literature shows that genital ultrasound scan is an important tool in the investigation of the Genital and Pelvic conditions. The provision of scanning facilities on site depends on the interests of clinicians within the clinic as well as the availability of appropriate training. In view of the rising numbers of complex chronic conditions seen within a confidential setting, it seems to be a good idea.
Keywords: Ultrasound, Diagnosis, Genito-Urinary Medicine.
Introduction
Over the last decade there has been a change in the epidemiology and case mix of patients presenting to Genito-Urinary Medicine (GUM), and more patients attend now with complex upper genital tract morbidity as a result of sexually transmitted infections (STIs). One of the statutory regulations of Venereal Diseases (V.D.) Act 1917 is the provision of high quality facilities for immediate diagnosis on site. Ultrasonography is a non-invasive technique that can be used in the diagnosis of various upper genital tract conditions, many of which develop as a result of sexually transmitted infections. In the male patient, transrectal, prostatic, scrotal and penile ultrasonography are of great benefit in the investigation of deeper structural pathogenesis. In the female patient, pelvic ultrasonography (transabdominal/transvaginal) is invaluable in the diagnosis of various upper genital tract conditions presenting to the GUM clinic as well as reassuring some patients with chronic pelvic pain that there is no significant pelvic pathology.
Genito-Urinary Medicine as a speciality deals with infections that affect both the upper and lower genital tract. This is particularly relevant in view of our current understanding of the pathogenesis of sexually transmitted infections and their carnicular spread. Ultrasound scan of the genital tract is a commonly requested investigation by physicians in Genito-Urinary Medicine as a result of the increasing diversity of conditions presenting to Genito-Urinary and sexual health clinics. The presentation of increasing number of patients suffering from chronic upper genital tract morbidity has highlighted the limitations of our current in-house diagnostic facilities. Improvements in ultrasound scanning technology have made it a very useful diagnostic tool in many areas of medical practice, including Genito-Urinary Medicine. It has revolutionised our understanding of upper genital tract pathology in both male and female patients in relation to sexually transmitted infections (STIs) and has improved our understanding of pelvic pain, deep dyspareunia, testicular swelling, prostatitis as well as sexual dysfunction. The advantage of having ultrasound scanning facilities on site in the Genitourinary clinic is that is offers the possibility of having instant access to ultrasonogrpahy whilst ensuring confidentiality for the patient. This in turn allows the GUM clinician to make an instant, accurate diagnosis and institute effective management.
Ultrasound methodology and technique
Male Genital Tract Examination
Different ultrasound probes are now available that optimise the view of different anatomical targets. The scrotum and its contents are examined using a 5-10 mHz transducer applied directly to the scrotal skin. Transrectal ultrasonography (TRUS) using a dedicated transrectal probe that is covered by a sheath is used to examine the prostate and seminal vesicles. The probe can provide images in both longitudinal and transverse sections. Doppler examination is beneficial in assessing blood flow and new vascularisation suggestive of pathological changes.
Female Genital Tract Examination
The female genital tract can be examined using transabdominal approach, the uterus and ovaries being visualised through a distended bladder using a 3.5 mHz transducer. The development of the transvaginal transducers and high frequency probes with better resolution allows better imaging, more accurate diagnosis and is more convenient for the patient as there is no need for a distended bladder. Different real-time transducers may to visual the female genital tract including mechanical rotator, mechanical sector oscillators, electronic linen array, electronic cured array and electronic sector scanner (phased array).
Ultrasound in clinical diagnosis - Women
An increasing number of patient attend GUM clinics with symptoms not only related to the lower genital tract such as vaginal discharge and superficial dyspareunia, but also with symptoms of upper genital tract morbidity such as pelvic pain and deep dyspareunia. In- house microbiological diagnostic facilities are well established which address the diagnosis of lower genital tract symptoms. However, patients with chronic pelvic pain, pelvic inflammatory disease and sexual dysfunction are now frequently referred to Genitourinary Medicine clinics. Pelvic inflammatory disease (PID) causes significant morbidity and in 75% of cases the underlying cause is related to a current or previous sexually transmitted infection. [1] The role of pelvic ultrasonography in the investigation of pelvic pain and other conditions of the female genital tract is well established, [2] and since the introduction of the trans-vaginal approach, the sensitivity and specificity of pelvic ultrasonography has markedly improved. [3] It can also give valuable information on changes in endometrial thickness, which may indicate other underlying pathology. Clinical examination of the pelvis, which is an important part of the clinical assessment of patients with pelvic pain, is subjective and does not provide reliable longitudinal data for monitoring the size of the uterus, ovaries and fallopian tubes.
There are several ultrasound markers [4] of acute and chronic PID that can be assessed in a scoring system similar to the biophysical profile used to assess the wellbeing of the fetus. Markers such as uterine enlargement, thickened endometrium, fluid in the endometrial cavity (fig1) , enlarged adnexa, and free fluid in the Pouch of Douglas often indicate an inflammatory process. When assessed in combination with the clinical and microbiological findings, these markers considerably enhance the accuracy of the diagnosis of PID.
Ultrasound is also useful in the diagnosis of physiological and pathological conditions of the adenexae. The ultrasound appearances of pathological conditions such as ovarian cyst or tumour may help to distinguish them form physiological swelling, but further biochemical and pathological investigation would be required.
Pelvic congestion syndrome (PCS) often manifests ultrasonically as an enlarged uterus and thickened endometrium is seen in 54% of cases, and the pelvic veins are frequently dilated [5]. Cystic changes in the ovaries are present in 56% of cases, all of which can be detected ultrasonically. [6] Ultrasound has its limitations in the diagnosis of other causes of pelvic pain, but the chocolate cysts of complicated endometriosis can often be detected by ultrasound. Laparoscopy remains the gold standard for making the diagnosis and obtaining a biopsy, but such an invasive procedure would not be undertaken at an outpatient clinic and is therefore out of the remit of the GUM clinic.
It is common for patients with complications of early pregnancy to be seen in GUM clinics. Early pregnancy failures such as ectopic pregnancy are more common in patients with previous history of PID. Transvaginal ultrasound is a useful tool in the diagnosis of ectopic pregnancy during the first few weeks’ gestation [7] (Figure 2). Patients presenting with abdominal pain who have a positive pregnancy test and no gestational sac in the intrauterine cavity visible ultrasound must be assumed to have an ectopic pregnancy. Immediate diagnosis, proper counselling and a decisive plan of management can be outlined, allowing continuity of care and preserving confidentiality for the patient. Uterine fibroids may also give rise to symptoms of pelvic pain during pregnancy due to red and other degeneration. Ultrasonography can demonstrate the presence and the signs of fibroids (figure 3). Most antibiotics used to treat STIs are contraindicated in pregnancy. Patients with an irregular menstrual cycle who are unaware that they are pregnant may therefore be given inappropriate antibiotics for their STIs. In-house ultrasound scan would prevent and minimise this problem by early detection of gestational sac in conjunction with pregnancy testing.
Huegerberg [8] noted a high clinic default rate amongst female patients who had been referred for investigation of pelvic pain. One contributing factor may be the lack of availability of tests such as ultrasound scan within a confidential environment.
There are many other causes of pelvic pain such as inflammatory bowel disease, appendicitis and urinary tract infection, but ultrasound is of limited value in the assessment of patients with these conditions.
Ultrasound in clinical diagnosis - Men
Transrectal ultrasonography (TRUS)
Symptoms suggestive of prostatitis are common presenting complaints in patients attending the GUM clinic. Ascending infection secondary to urethritis and cystourethritis give rise to inflammatory pathological conditions, such as acute and chronic prostato-vesiculitis, which may occur as complications of a sexually transmitted infection. The relative inaccessibility of the prostate gland and seminal vesicles has meant that clinical examination of those glands has significant limitations. Traditionally, bacterial culture of ejaculate or prostatic fluid obtained via prostatic massage has been used to establish a diagnosis of prostato-vesiculitis. Unfortunately the result of this is frequently unrewarding as the assessment of leucocyte concentration of these fluids alone is too non-specific and specimens are subject to contamination with normal urethral bacterial flora. The role of TRUS as an aid to diagnosis in these conditions has been established [9]. Ultrasonic markers of prostatic inflammation, which can occur without obvious prostatic symptoms are well described by Doble et al [10].
These are:
· Thicknening and irregularity of the prostatic capsule
· Presence of concretion
· Ejaculatory duct calcification
· Echo-lucent Zones
· Elongation of the seminal vesicles
· Major thickening of the wall of the vesicle
· Signs of fluid retention and the presence of luminal septa
Histopathological confirmation of the underlying pathology of the inflammatory change can be performed via ultrasound guided biopsy. [11]
TRUS can also be used to follow-up patients with chronic disease. Ghaly (1994) has highlighted the link between urethritis and prostatitis [12]. Although the population surveyed was relatively small, the prevalence of prostatic abnormality and inflammatory changes in patients with non-gonococcal urethritis were significantly higher when compared with controls. The consequences of overlooking upper genital tract inflammatory changes and inadequately treating these infections may be a complex untreatable long-term morbidity in terms of sub fertility and prostadynia. [9] The rapidly increasing use of ultrasound for the diagnosis of inflammatory conditions in the male genital tract, especially in patients with urethritis, will probably highlight that significant cases of upper genital tract infections are not diagnosed. It is, however, debatable as to whether or not TRUS should routinely be offered to patients with non-gonococcal urethritis, but it has a place in those patients with symptoms suggestive of prostatitis.
In addition, TRUS has been widely used in assessment of the prostatic gland for conditions such as malignancy [13]. With modem high frequency transducers the sensitivity and the specificity of the technique has been established [14]. Although biopsy of the prostate would usually be outwith the scope of the GU Medicine clinic, suspicion of malignancy on ultrasound would allow immediate referral of the patient to the appropriate specialist for further investigation.
Scrotal Ultrasonography
Patients with testicular pain and swelling often present to GU Medicine. There have been numerous publications describing the ultrasonic appearance of different scrotal pathological conditions since scrotal ultrasound was first described in 1974 [15]. The accuracy of scrotal ultrasound over clinical examination has been demonstrated, particularly for tumour detection [16]. It is, however, debatable as to whether or not routine scrotal ultrasonography should be carried out on all patients who present with scrotal symptoms [17]. In terms of cost-effectiveness, ultrasonography should probably be limited to patients who present with scrotal masses or swelling. In the majority of patients with chronic scrotal pain no organic pathology is found and what these patients require is psychological reassurance and counselling. The demonstration of normal ultrasound findings may have some psychological benefit, hence the advantage of having access to in-house ultrasound facilities.
The investigation of scrotal swellings with high-resolution ultrasound is important to establish the normality of the testicle. Clinically it is difficult to establish the normality of the testicle itself in the presence of a hydrocoele, for example. Early testicular seminoma may be missed clinically but can be detected on ultrasound (figure 4). Furthermore the nature of the pathology of some testicular lesions can be differentiated, for example syphilitic gumma and tuberculosis.
Sudden-onset severe testicular pain requires immediate, accurate diagnosis [18]. In-house ultrasound scanning allows the GUM clinician to offer this to patients with testicular pain without comprising patient confidentiality. If acute torsion of the testis is suspected clinically, the patient should be referred immediately for surgical assessment. Torsion in the early stages and acute orchitis have a similar clinical appearance as the testes is swollen and oedematous. Necrosis and haemorrhagic areas will be visible subsequently. Ultrasound may have a role to play in when the diagnosis of testicular torsion is doubtful and is difficult to distinguish from epididymo-orchitis. Epididymo-orchitis usually produces thickening of the epididymis with either local or diffuse pathological changes of the testes: the main role of ultrasound in this instance is to exclude abscess formation [19]. Testicular torsion and epididymo-orchitis can be further differentiated by Doppler ultrasound (duplex or colour) to assess blood flow [20].
Penile Ultrasonography
Patients with recurrent, inadequately treated urethritis can develop urethral stricture particularly following gonococcal infection. Untrasound investigation of the urethea may be indicated in patients with recurrent urethritis as it may influence treatment. Patients with a stricture on ultrasound should be referred for surgical intervention or urethral dilation. The prognosis is better in those without periurethral scarring, as there is little risk of stricture recurrence following internal urethrotomy. [21]
Penile ultrasonography also plays a major role in the diagnosis and management of Peyroine's disease. Determination of the extent and the position of any blockage or scarring is important for successful medical or surgical treatment.
Penile ultrasound may also be a useful investigation in patients with penile warts as studies have shown that up to 22% of patients with meatal warts also have intra urethral warts (figures 5&6) [22]. Traditionally patients with urethral warts are diagnosed using invasive endoscopic techniques, which may require hospitalisation. The advantage of ultrasonography is that it is non-invasive technique that allows visualisation of the entire urethra with any warty lesion as well as the penile substance. Ultrasound scan of the penis can also be useful in the diagnosis of other conditions such as penile foreign body [23].
The application of pulsed and coloured Doppler in the assessment of erectile failure within the psychosexual clinic in GU medicine may be of great benefit. This is not only in diagnosing arterial insufficiency but also in ensuring the normality of the penile substance. It will also shed light on the possibility of venous leakage [24] [25].
Other benefits of ultrasound
The majority of patients attending GU clinics require reassurance for their symptoms, especially in the absence of organic disease. Counselling and discussion have their limitations. The visual demonstration of normality of the genital tract using ultrasonography offers reassurance to the patient and may help to dispel patient anxiety and apprehension [26]. High-resolution pelvic ultrasound has much to offer prior to surgical assessment of female patients [27]. The use of ultrasound in such as in transvaginal ultrasound-guided aspiration of pelvic abscess in pelvic inflammatory disease is well established. There are significant benefits for the patient if this type of procedure can be carried out, removing the need for surgical intervention [28].
Practical approach and training
A good quality, high-resolution ultrasound scanner can be purchased for around £12,000 to £15,000 (18,000 – 22,000 US dollars). Although the initial purchase of the instrument is costly, the recurring costs are low and are limited to the cost of the annual maintenance contract. The workload figures would vary depending on the criteria chosen for ultrasound investigation and on the special interests of the clinicians involved. In the authors' department where there is a chronic pelvic pain clinic, a genital dysfunction/genital pain clinic and a psychosexual clinic, ultrasound is a common investigation and between 10 and 20 ultrasound scans are performed each week. In clinics without these specialist interests the need for ultrasound examination may be minimal and would not justify having in-house ultrasound facilities.
Although there may be some duplication of resources that are probably already available within the radiology department, the benefits of instant access to ultrasound within the clinic are significant in terms of patients' confidentiality and waiting times for this investigation. The service could therefore be regarded as complementary to the service offered in radiology. It would not be cost effective nor practical to request a radiographer to carry out ultrasonography within the clinic, and so staff working in the GUM clinic must be properly trained in the use of the equipment and in the interpretation of scans. Theoretical and practical training courses are widely available and one such programme is currently run by the Royal College of Radiologists in conjunction with the Royal College of Obstetricians and Gynaecologists (RCOG/RCR). Training in unltrsonography can be incorporated into the medical staff-training programme either during specialist registrar training and post accreditation. It may be possible to arrange ultrasonography-training programmes that are more specifically directed towards GUM conditions and involve both male and female genital tracts. For continuity of service it is important that a least one permanent staff member undertakes ultrasound on a regular basis. Audit and continuing education are important, and these are probably best done in conjunction with the hospital radiology department. Ultrasound examination undertaken by improperly trained staff and not subject to regular audit is not to be recommended.
Conclusion
The speciality of GU Medicine is evolving and it is important that practitioners take advantage of the advances in medical technology to modernise their in-house, diagnostic facilities. In-house ultrasonography is a valuable, non-invasive investigation that is useful in the diagnosis of many Genito Urinary conditions. Although in-house ultrasonography requires clinicians to be specifically trained this can be done as part of the specialist registrar training programme. The availability of in-house ultrasonography together with other diagnostic tools such as the microscope and the colposcope not only help to make an accurate instant diagnosis but also to maintain the confidential, free and readily available service which is unique within the United Kingdom.
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