ARRS Case of the Week

PEDIATRIC RADIOLOGY: Genitourinary Radiology

Case Author: Krista L. Birkemeier, MD

History

15-year-old girl with 4 days of right-sided pelvic pain and a negative pregnancy test result.

Imaging Findings

Longitudinal pelvic ultrasound image (A) shows a heterogeneous right ovarian mass with an echogenic component with a lacelike configuration of crisscrossing linear echogenicity (straight arrows). The angle (curved arrow) between the hyperechoic and anechoic portions of the mass at the periphery is acute, consistent with retracting clot. Transverse Doppler ultrasound image (B) of the right ovary shows lack of flow in the mass, but peripheral flow is present. Longitudinal Doppler ultrasound image (C) shows an area of peripheral ovarian tissue with flow. Spectral Doppler imaging (not shown) depicted normal waveforms.

Diagnosis

Hemorrhagic ovarian cyst

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Teaching Points

Endometrioma is a well-defined mass with low-level echoes. Fibrin strands may be seen, but retracting clot is not typically present.

Hemorrhagic ovarian cyst is a complex cyst, often with retractile clot. There is no internal Doppler flow, and the cyst typically resolves after two menstrual cycles. No follow-up is necessary if the imaging findings are characteristic and the lesion is smaller than 3 cm in diameter.

Normal arterial Doppler waveforms do not exclude torsion, and ovaries with masses are prone to torsion. Ovarian volume less than 20 mL is strong evidence against torsion.

Tuboovarian abscess is a complex adnexal mass, often with other signs of inflammation (echogenic fat, free fluid, hyperemia with Doppler ring of fire appearance) in the presence of clinical signs of infection.

Suggested Readings

Slovis TL, Adler BH, Bloom DA, et al. Caffey’s pediatric diagnostic imaging, 11th ed. Philadelphia, PA: Mosby, 2008

Stranzinger E, Strouse PJ. Ultrasound of the pediatric female pelvis. Semin Ultrasound CT MRI 2008; 29:98–113 

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