YL5: 10.

04 Imaging of the Reproductive System

03/06/2019 Reproductive System
8:00-10:00 Reza Marie Koa-Sales, MD, FPCR

TABLE OF CONTENTS

I. INTRODUCTION.............................................................................. 1
A. RADIOGRAPHIC ANATOMY .................................................. 1
B. REPRODUCTIVE STRUCTURES ........................................... 2
II. PLAIN RADIOGRAPHY (X-RAY) ..................................................... 2
A. STRUCTURES VISUALIZED .................................................. 2
B. STRUCTURES INDIRECTLY SEEN........................................ 2
C. PATHOLOGIES...................................................................... 3
III. FLUOROSCOPIC STUDIES ........................................................... 4
A. HYSTEROSALPINGOGRAPHY (HSG) ................................... 4
B. IMAGED STRUCTURES......................................................... 4
IV. ULTRASONOGRAPHY .................................................................. 4
A. IMAGED STRUCTURES......................................................... 5
B. MODES .................................................................................. 5
V. COMPUTED TOMOGRAPHY (CT) SCAN ....................................... 7
A. OVERVIEW ............................................................................ 7
VI. MAGNETIC RESONANCE IMAGING ............................................. 8
A. OVERVIEW ............................................................................ 8
VII. OBSTETRIC APPLICATIONS ....................................................... 9 Figure 1. Plain radiograph of the pelvis; AP view (left images), Lateral
A. PELVIMETRY......................................................................... 9 view (right images) (Koa-Sales, 2019)
B. PRENATAL ULTRASOUND or SONOGRAM......................... 10
C. 3D IMAGING ........................................................................ 10 Comparison of the Male and Female Pelvis
VII. BREAST IMAGING ..................................................................... 10
• Conjugate vs. Transverse Diameter
A. MAMMOGRAPHY ................................................................ 10
B. GALACTOGRAPHY.............................................................. 11 → Conjugate – anteroposterior (AP) diameter (basic view) from
C. ULTRASONOGRAPHY or SONOMAMMOGRAPHY .............. 11 promontory to symphysis pubis
D. MRI OF THE BREAST .......................................................... 12 → Transverse – right to left diameter 

QUICK REVIEW ............................................................................... 12 • Sacrosciatic notch – better seen and measured in lateral view 

SUMMARY OF TERMS ............................................................ 12
REVIEW QUESTIONS .............................................................. 14
REFERENCES ................................................................................. 15
REQUIRED .............................................................................. 15
APPENDIX ....................................................................................... 15

LEARNING OBJECTIVES
• General Objective:
→ Recognize normal radiologic images of the reproductive
system based on knowledge of gross anatomy and
physiology
• Specific Objectives:
→ Recognize the normal radiographic anatomy of the male
and 
female reproductive system 

→ Select and compare the appropriate imaging tools in
reproductive imaging
→ Discuss the obstetric applications of radiographic
imaging
→ Familiarize with breast imaging techniques 


I. INTRODUCTION
A. RADIOGRAPHIC ANATOMY
• Anatomy based on radiographic images
• From plain radiographs for the reproductive system, the bony pelvis Figure 2. Pelvic diameters (Moore, 2017)
is the most prominent structure seen
Table 1. Comparison of the Male and Female Pelvis
Bony Pelvis
Parameter Male Female
• In the antero-posterior view, the structures that can be identified
Shape of Android (wedge or
are the following: Gynecoid (oval)
Inlet* heart)
→ Bones
▪ Iliac crest Diameter Conjugate > Transverse Transverse > Conjugate
▪ Iliac spine
▪ Ischial spine Sacrosciatic Long, narrow notch Wide notch
▪ Ischial tuberosity notch High rounded apex Blunt apex
▪ Obturator foramen Narrow and long Wide and short
Sacrum
▪ Iliopectineal line – imaginary (cannot be directly seen) Inward Outward
▪ Sacrum Ischial
Sharp Blunt
 Joints spines
▪ Symphysis pubis Pubic angle Narrow Wide
▪ Sacroiliac joint
 Soft tissue • NOTE: Some males can have gynecoid, while some females can
▪ Muscles also have android shaped inlets.
▪ Fat • The characteristics of the female pelvis are such because there is
a need to accommodate the baby during vaginal delivery.

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 • Visualizes only the following structures in a plain radiograph:
→ Bone (pelvis: sacrum, iliac crest, iliac spine, etc.)
→ Joints (Symphysis pubis, sacroiliac joint) 

→ Some of the soft tissues apart from the internal organs (i.e.
gluteus muscles, fat)

Figure 3. Differences in Male (Left) and Female Pelves (Right). Top -

pelvic inlet, Bottom - pubic angle (radiologypics) Figure 5. Male Adult Pelvis-AP View (radiopaedia)

Figure 6. Female Adult Pelvis-AP View (radiopaedia.org)

B. STRUCTURES INDIRECTLY SEEN

• X-ray can indirectly surmise some structures which are not
normally seen in plain radiograph

Females
• Ovaries
• Fallopian tube 

• Uterus: May be visualized in a patient with an IUD (i.e. can tell the
direction to which the uterus is leaning towards) 

→ IUD: Intrauterine device; an inert material usually used for
Figure 4. Comparison of Pelvic Diameters of Female (Left) and Male birth control
(Right). The transverse diameter of the female pelvis is greater than ▪ NOT an abnormality, but a finding
the conjugate diameter. The conjugate diameter of the male pelvis is ▪ Shaped like the letter T
greater than the transverse diameter. (radiopaedia.org)

B. REPRODUCTIVE STRUCTURES

Table 2. Visualized reproductive structures using different imaging

modalities (Koa-Sales, 2019)
Male Female
Testis Uterus
Epididymis Ovaries
Seminal vesicles Fallopian tubes
Prostate Breasts (some journals say this
is NOT part of the reproductive
Penis
organs)

II. PLAIN RADIOGRAPHY (X-RAY)

• Imaging technique that uses radiation to view the internal
structures of the body 

• Patient lies in a supine position on a radiographic bed, with beam
from the source directed towards center of the pelvis (reproductive
structures), and images are converted to digital format 


A. STRUCTURES VISUALIZED
• X-ray has limited use in reproductive system imaging
Figure 7. Uterus with IUD inserted in endometrial cavity.
→ Because there is a limitation on which structures can be seen,
The IUD is leaning towards the right, thus the uterus must also be
radiographs cannot be considered as one of the two best
located towards the right. (radiopaedia.org)
imaging modalities for reproductive structures

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 2. Ovarian teratoma/benign cyst
→ Teratomas: Dermoid tumors composed of tissues and cells
which did NOT develop into their potential
→ Usually benign but have to be taken out because they can
grow to large sizes 


Figure 8. Uterus with IUD in the center of the pelvis (Journal of Family
Medicine and Primary Care, 2019)

Males
• Uses contrast radiography (i.e. intravenous pyelogram/IVP) to
light up specific organs of the patient
• Prostate: Seen as an indentation in the bladder when enlarged
(may it be due a mass, etc.)
Figure 11. X-ray of a dermoid cyst, showing a cluster of teeth in the
• Seminal vesicles 

pelvic cavity. (University College of London, 2019)
• Epididymis 

• Testicle 
 3. Enlarged prostate
• Note: these organs CANNOT be seen when they are normal. → Indentation in the bladder may indicate an enlarged prostate
→ Normally, the urinary bladder base is smooth as seen with
contrast
→ In females: An enlarged uterus would leave an indentation on
the bladder superiorly
▪ Since normally (if the uterus is anteverted), it sits on the
bladder surface.

Figure 9. Male intravenous pyelogram. This figure shows the urinary Figure 12. Prostate enlargement; prostate impinges on the bladder
bladder with contrast (radiopaedia.org) floor

C. PATHOLOGIES 4. Calcifications
• Mostly just found incidentally, as internal organs cannot usually → may not be immediately pathologic
be seen when normal. → Can be seen in normal patients as normal calcifications
→ If there is an abnormality, these structures can then be seen ▪ BUT, NOT all males have this
 Plain radiographs are not usually requested upon pelvic pain or → If doctor reports this finding, a work-up for accelerated
reproductive anomalies atherosclerosis is usually done for the patient; this may also
• Includes the following: be an early onset diabetes

1. Abnormal implantation of IUD

Figure 13. Calcifications in paired vas deferens (radiopaedia.org)

Figure 10. Abnormality in the position of the IUD (encircled in

yellow). IUD (shaped-like an upside down T) got extruded into the
fallopian tube and entered the peritoneal space (Science Photo
Library, 2019)

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 ▪ A blockage in the terminal fallopian tube can cause the
ACCORDING TO DOC
proximal fallopian tube to be dilated or bigger than its
• NOTE: When reading an X-ray
normal diameter.
→ Compare right and left structures (if normally paired or
• Peritoneal cavity 

symmetrical)
• Note: Uterus and fallopian tubes are soft tissue structures which
→ Check for extra densities
can be seen in hysterogram when you inject dye into the catheter.
▪ Most likely indicates an abnormality
• Doc said we do not need to determine the type of abnormality.
We just need to be able to determine the presence of an
abnormality for now.
III. FLUOROSCOPIC STUDIES
• An imaging technique that uses x-rays to obtain real-time moving
images of the interior of an object
→ Also a form of x-ray imaging except it is done spontaneously
• May be used along with a contrast that is safe for the peritoneum
→ Barium isn’t usually used because it can cause peritonitis
• Traditional Fluoroscopic Imaging vs Modern Fluoroscopic Imaging
→ Traditional Fluoroscopic Imaging: Radiologist conducts
imaging inside the fluoroscopy room and has to wear both
thyroid and body shields
→ Modern Fluoroscopic Imaging: Radiologist can control the
machine from outside the fluoroscopy room, in the reading
station. It makes them safer from effects of radiation

A. HYSTEROSALPINGOGRAPHY (HSG)
• Falls under fluoroscopic imaging
• Provides real-time view of contrast flow through the uterus and
fallopian tubes
• Used to investigate or see in better detail the following organs:
→ Shape of the uterine cavity
→ Shape and patency of the fallopian tubes 
 → Based on the figure, the whole uterine cavity should be
• Entails the injection of a radio-opaque material into the cervical
canal and usually fluoroscopy with image intensification 

Figure 14. Hysterosalpingography of a normal uterus
Pathologies
• Enlarged or dilated fallopian tube
→ Normal fallopian tubes should be thin
opacified. However, the lucency (encircled in green) is caused
by air in the catheter balloon (but uterus is still normal).

Procedures
1. Cannulate the cervix (inserting a catheter)
→ According to patient, it is an extremely painful procedure 

→ Done by the OB-GYN 

2. Radiologist injects contrast media or dye
3. Observe the flow of contrast on monitor (as it enters through the
vagina, into the cervix, and into the uterine cavity) then take X-
rays

→ Follows the contrast as it goes through the fallopian tubes. If
there’s no obstruction, contrast will flow to the peritoneum
4. Check for free communication with the peritoneal cavity

Advantages
• Used for diagnosis of:
Figure 15. Hysterosalpingography of an abnormal left fallopian tube
→ Congenital anomalies of the female genital tract (along with
ultrasound and MRI) 

• Bicornuate uterus
→ Mechanical causes of infertility – most common indication → Common congenital uterine anomaly
for this study (included in infertility work-ups)
 ▪ Didelphys uterus: Two uterine horns
▪ Used for patients who want to determine if their → NOTE: According to Doc, there is no need to take note of
reproductive structures are intact specific abnormal case. Just remember that we can identify
▪ Able see if a fallopian tube is blocked (prevents the this abnormality using hysterosalpingography.
meeting of the egg and/or sperm)
→ Any uterine fibroids, polyps, or congenital and physical
abnormalities
▪ These could distort the shape of the uterus and prevent
embryo implantation into the uterus wall (more
commonly diagnosed with pelvic ultrasound) 

 Simple study
 Not expensive

B. IMAGED STRUCTURES
• Outline of the cervix 

• Uterine cavity
→ Soft tissues of the uterus cannot be seen 

→ Looks small but can expand when it accommodates a growing
fetus 

• Fallopian tubes
Figure 16. Hysterosalphingography of a bicornuate uterus
→ Normal:
▪ Should be thin
IV. ULTRASONOGRAPHY
▪ If dye spills out, fallopian tubes are patent or open,
hence there are no blockages • Imaging of choice for reproductive organs
▪ Dye also outlines the endpoints of the fallopian tubes: → Especially for pathologies in males
fimbriae → Initially used only for pregnant women to evaluate fetal
→ Thick or dilated fallopian tubes may indicate an abnormality development
→ Previously not used for muscles, tendons, etc.

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• One of the two most important imaging modalities for the
reproductive system, along with MRI
→ This is because it does not use ionizing radiation (see
advantages)
• Recall: In ultrasound, fluid is dark
→ Can be used to evaluate pathologies like adenomyosis
(endometrium breaking through the myometrium causing
cramps) or endometriosis (growth of endometrium in areas
outside the uterus)
• Overcomes the limitation of the transabdominal mode (i.e.
presence of gas)

Advantages Uterus
• Safe, particularly for children and pregnant patients
→ Does not use radiation
• Easy to use and fast
• Relatively cheaper (particularly relevant if one is in the province
where there are limited resources)
• Sufficient for depiction of normal and pathologic anatomy
 Sufficient for screening for diseases and diagnosis of basic
pathologic structures
 Once pathology is seen, opt for higher level modalities for
confirmation and better evaluation (CT, MRI)
 Can demonstrate the endometrial layer very well

Disadvantages
• The only structures we can see are those in the field of view
• Insufficient for tumor staging because we cannot see the other
structures anymore
• Insufficient for diagnosing/categorizing (benign/malignant) adnexal
masses
→ Uterus adnexa – accessory structures of the uterus (e.g.
ovaries, fallopian tubes, surrounding connective tissue)
Figure 18. Antiverted uterus viewed transvaginally
(ultrasoundpaedia.com)
Menstrual or Ovarian-Endometrial Cycle
• The endometrium changes as the female patient transitions from
one phase of the menstrual cycle to another

A. IMAGED STRUCTURES Table 4. Appearance of the endometrium in the phases of the menstrual
cycle (ASMPH Batch 2022, 2018)
Table 3. Structures visualized through ultrasound Phase Endometrium
Female Male • Thin (< 2mm), bright echogenic stripe
Uterus Prostate • Minimal fluid within
Ovaries Testes • Day 1 to around 3-7
Epididymis

B. MODES
• Different probes which vary according to size and frequency are
used for different modes Menstrual
→ The higher the frequency, the higher the resolution
→ The lower frequency, the lower the resolution

• Trilaminar appearance
• Echogenic basal layer, hyperechoic
functional layer and central echogenic stripe
• Endometrium starts to prepare for possible
fertilization

Proliferative

Figure 17. Basic probe types (from

https://endo.id/catalog/product/edan-d3) Ovulatory • At 14th day
• Uniformly echogenic, thick endometrial
Transabdominal Secretory lining
• Used for uterus and ovaries
• Convex probe is used
• Limitation: Gas may obscure underlying structures

Transvaginal or Endovaginal
• Probe is inserted through the vagina and into the vaginal canal
→ Transvaginal probe is used
→ Convex probe is not used because of its large size
→ Can directly see the uterus
• Layers of the uterus are best evaluated using this mode

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Ovaries
• Has a stroma at the center and the follicles at its periphery
→ Ova are contained in the follicles
Figure 19. Axial view of the right ovary (ultrasoundpaedia.com)
Transrectal or Endorectal
• Alternative for female patients uncomfortable with probes inserted
into their vagina
→ Could be more painful than transvaginal
→ Convex probe is also not used because, although it might fit,
it would be more difficult to maneuver
• Imaging modality used for males and virgin females
• A special study used to view the prostate gland
→ More advantageous than transabdominal because the
transabdominal mode is hindered by the presence of gas
→ Compared to transabdominal ultrasound, prostate can be
seen very well
• Depicts the normal position of the patient
→ The probe is inserted in the rectum
→ Anterior: Bladder
→ Posterior: Prostate
• Ultrasound can be used as a guide for prostate biopsy
→ Probe is inserted in the rectum, along with a needle inserted
through the skin for the biopsy of the prostate
→ Not very painful
→ There could be bleeding complications
Figure 20. Transrectal Ultrasound Procedure (University of Chicago
Medicine)
Patient Preparation
 Avoid aspirin intake 7-10 days prior to imaging (Recall: Platelets’
lifespan is 7-10 days)
 Take an enema a minimum of 1 hour before the procedure to clean
out the colon
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 Empty the bladder
Procedure
1. The patient will wear a gown throughout the procedure and will be
asked to lay on their side with their knees bent close to their chest
2. A protective cover is then placed on the ultrasound transducer
(probe), lubricated, and placed into the rectum
3. The patient may feel a sensation of fullness or pressure in their
rectum upon the insertion of the transducer
4. The transducer will then direct high-frequency sound waves at the
prostate gland and the echoes created by the sound waves will
generate an image of the prostate gland on a monitor to analyze
for any abnormalities
Diagnostic Uses of Transrectal Ultrasound
• To determine whether the prostate is enlarged (benign prostatic
hyperplasia/BPH)
• To further examine the prostate due to increase in a patient’s PSA
(prostate-specific antigen) level
• To aid in diagnosing the cause of infertility
• To detect any abnormalities that are felt during a digital rectal
examination (DRE)
• To help guide with other medical procedures such as a prostate
biopsy
• To rule out endometriosis
Figure 21. Transrectal ultrasound showing the bladder. On the left is a
coronal-transverse section of the prostate. On sagittal section through
the same organ, the cyst is seen well, midline, and measuring almost
11mm (ASMPH Batch 2019, 2014)
Structures Visualized by Transrectal Ultrasound
• Prostate
→ Walnut-shaped organ lying inferior and behind the bladder
→ Hesitancy and difficulty in passing out urine are symptoms of
a urethra constricted by an enlarged prostate
→ 2 zones:
▪ Central zone
▪ Peripheral zone
o Area where most cancers develop, hence it should
be examined more closely
o When lesions are present, a biopsy is
recommended right away
o It is recommended to get tested at the age of 40 and
above
Figure 22. Prostate ultrasound (radiologyinfo.org)
• Scrotum
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 → Helps evaluate disorders of the testicles, epididymis, and • Sagittal
scrotum → Visualizes seminal vesicles and penis
→ Paired testicles • Transverse
▪ Check for symmetry (same size) → Visualizes penis
o Testes should more or less be symmetrical, as → Probe needs to be pushed higher and deeper
well as the epididymis
▪ Check for difference in color
o Same echogenicity, more or less grayish, if not
there is usually a pathology in the darker one
(patient might have orchitis)

Figure 26. Doppler image of left testicle (radiologykey.com)

Figure 23. Scrotal ultrasound (Koa-Sales, 2019)

Penile Ultrasound with Doppler Study

• Only used with ultrasonography
• Test that uses high frequency sound waves (ultrasound) to
measure the amount of blood flow through arteries and veins
• Not usually done anymore because of the advent of MRI Figure 27. Sagittal image of the prostate at the level of the seminal
vesicle (radiologykey.com)
Indications
Pathologies Diagnosed
• To examine patients with trauma
• To diagnose impotence and infertility • Testicular torsion
• To evaluate blood flow through the penis in cases of impotence, → Causes cessation of blood flow to the testis
hematoma, and erectile dysfunction → An emergency case
→ For measurement of hematoma ▪ If there is no vascularization surgeon is called right away
▪ If left for 4 hours, testis will undergo necrosis
→ For surgeons to determine whether the volume of hematoma
is big enough to evacuate or small enough to let the body → Usually happens in children
absorb it spontaneously • Hematoma
• To predict the response of the erectile tissue to vasodilator → Extravascular localized bleeding, either due to an underlying
medications disease or trauma

Figure 24. Ultrasound of the penis Figure 28. Transverse color Doppler image of both testes show lack of
(http://www.jsm.jsexmed.org/article/S1743-6095(16)00310- blood flow on the right testis (Left image)
6/references) (https://iame.com/online/ultrasound_evaluation_of_acute_scrotal_pain/
content.php)

V. COMPUTED TOMOGRAPHY (CT) SCAN

A. OVERVIEW
• Takes only axial images, which can be used to reconstruct the
sagittal view
• Layers of the uterus cannot be defined compared to ultrasound
• Only a part of the uterus can be visualized unlike the ultrasound
where you can maneuver the probe to see everything
→ Cannot identify where the endometrial cavity is
→ Location and shape of the uterus is dependent on the bladder
▪ Full bladder → More posteriorly located uterus
• Uterus in sagittal view
Figure 25. Penile Doppler Ultrasound Procedure (Preeti Urology and → Anteflexed (tilted towards the bladder) / retroflexed
Kidney Hospital)
→ Anteverted (cervix and vagina facing the bladder)/
retroverted
Views

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 Advantages
• Superior in depicting fat planes and adenopathy

Disadvantages
• Poor soft-tissue contrast
• Poor depiction of zonal anatomy of uterus and prostate
• Radiation risk Figure 32. Sagittal CT scan of a woman that shows the influence the
• Expensive bladder has on the position of the uterus when it is distended or
emptied.
VI. MAGNETIC RESONANCE IMAGING
A. OVERVIEW
• Most expensive and most detailed imaging modality
• True multiplanar imaging
→ Axial
→ Sagittal
→ Coronal
• Can give good depictions of soft tissues and zonal anatomy
• One of the two most important imaging modalities for the
reproductive system, along with ultrasonography
→ This is because it does not use ionizing radiation

Advantages
Figure 29. Axial CT scan of the pelvis of a woman with stage 1B
• Direct multiplanar imaging
cervical carcinoma causing an obstruction of the uterus.
(https://www.glowm.com/resources/glowm/graphics/figures/v4/0540/00 • More detailed images of soft tissue organs
8f.jpg) • Safe for pregnant patients

Disadvantages
• High cost (more expensive with contrast)
• Availability
• Not done on patients with metallic prosthesis or implants
• Claustrophobia (can lead to patient discomfort)

Figure 30. Axial CT scan of the pelvis of a woman in which the uterus
and ovaries are identified.
(https://www.glowm.com/atlas_page/atlasid/rc006.html)

Figure 33. Sagittal MRI cross sectional anatomy of the female pelvis

Figure 31. Axial CT scan of a male revealing the prostate gland

(https://i1.wp.com/prostateanatomy.com/wp-
content/uploads/2019/01/1-25.png?resize=378%2C247&ssl=1)

Figure 34. MRI of a female pelvis that identifies the following:

(1) Rectus abdominis m., (2) Pubis, (3) Bladder, (4) Urethra,
(5) Uterus, (6) Endometrium, (7) Vagina, (8) Rectum, (9) Sacrum
(http://w-radiology.com/p7IGM_images/fullsize/IMG26a_fs_fs.jpg)

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 Figure 35. Axial MRI of a female pelvis: T1-weighted; identifying the
following: (1) Rectus abdominis m., (2) External iliac vein, (3) External
Iliac artery, (4) Obturator internus m., (5) Head of the femur,
(6) Endocervical canal, (7) Rectum, (8) Ischiorectal fossa, (9) Gluteus
maximus, (10) Uterus. (http://w-radiology.com/female_pelvis_mri.php)
Figure 36. Axial MRI of a male pelvis: T1-weighted identifying the
following: (1) Corpus cavernosum, (2) Corpus spongiosum (bulb of the
penis), (3) Ramus ischium, (4) Ischiocavernosus m., (5) Anal canal,
(6) Sphincter ani externus m., (7) Gluteus maximus m.
(http://w-radiology.com/male_pelvis_mri.php)
Figure 37. Coronal MRI of a male pelvis: T1-weighted identifying the
following: (1) Rectus abdominis m., (2) Symphysis pubis, (3) Corpus
cavernosum, (4) Corpus spongiosum, (5) Prostate, (6) Bladder,
(7) Seminal vesicle, (8) Rectum, (9) Sacrum
(http://w-radiology.com/male_pelvis_mri.php)
YL5: 10.04 Reproductive System: Imaging of the Reproductive System
Figure 38. Axial MRI of a male pelvis: T1-weighted identifying the
following: (1) Levator ani m., (2) Rectum, (3) Ischiorectal fossa,
(4) Gluteus maximus m., (5) Gemellus (superior, inferior) m.,
(6) Obturator internus m., (7) Femoral head, (8) Pectineus m.,
(9) Femoral a., (10) Femoral v., (11) Prostate
(http://w-radiology.com/male_pelvis_mri.php)
VII. OBSTETRIC APPLICATIONS
• Imaging for pregnant women
• Usually do not want to expose pregnant women to radiation unless
there is an indication
A. PELVIMETRY
• Radiographic assessment of the female bony pelvis to measure the
diameter
→ Determines if the bony pelvis can accommodate the
development and exit of the fetus
→ Useful in assessing potential for difficulty with a vaginal
delivery
• Can be done by X-ray or MRI in AP & lateral view
→ MRI pelvimetry is preferred because it does not give off
radiation
• Done among pregnant women who are near-term
→ Patients usually undergo pelvimetry during the 3rd trimester
of pregnancy when fetal organogenesis is already complete
→ Not done during the early stages of pregnancy because the
head of the fetus is still small
→ Indicated mainly in borderline pelvic contraction
• 3 Anatomical Cavities (all must be adequate to do normal delivery)
→ Inlet – topmost
→ Midplane – middle
→ Outlet – through ischial tuberosity
• Views
→ AP view – used to visualize the fetus
→ Lateral view – taken to get the 3D view
• Iliopectineal line – used as a landmark to get the diameter
Figure 39. Pelvimetry in the AP view (left) and lateral view (right)
Methods of X-Ray Pelvimetry
Colcher-Sussman Method
• Makes corrections by comparing measured diameters with a
centimeter scale placed at the same distance from the film as the
internal diameters to be measured and projected on the same film
• Main method used in the Philippines
• Must use both the Antero-posterior and Lateral view because using
only one or the other is inadequate
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• Positioning
→ Lateral positioning
→ Antero-posterior positioning
▪ Beam directed towards lower pelvis to avoid fetus

Figure 42. Ultrasound showing a fetus (ASMPH Batch 2019, 2014)

C. 3D IMAGING
• Also known as phased array ultrasonics
• It is a medical ultrasound technique, often used in obstetric
ultrasonography
→ Provides three-dimensional images of the fetus
• Best performed around the 28th-30th week because there is
Figure 40. Illustration of the lateral positioning (above) and antero- sufficient amniotic fluid
posterior positioning (below) (Lopez-Zeno, Ponce School of Medicine) → The amniotic fluid affects the clarity of the photo
• 4D imaging is also possible
Pelvic Diameters → Scans show moving 3D images of the fetus
• AP Diameter → Fourth dimension: Time
→ Can be measured in the lateral view
• Transverse Diameter
→ Can be measured in the AP view
• Oblique Diameter
• All 3 pelvic diameters must be adequate in order to conclude that
a pregnant woman can go through with a normal vaginal delivery

Table 5. Landmarks of the Pelvic Diameters

Anteroposterior
Symphysis pubis
Iliopectineal line
Inlet
Sacrosciatic notch
Sacrum
Symphysis pubis
Midpelvis Between ischial spines
Sacrum
Between ischial
Outlet tuberosities
S5
• NOTE: No need to memorize; just remember sacrum, symphysis
pubis, sacrosciatic notch, and spine to measure inlet and outlet.
Transverse
Widest transverse
diameter of the pelvic
inlet
*Transverse Interspinous
diameter
*Lateral margin of inlet
and lower margin of
ischial tuberosity
Figure 43. 3D Ultrasound of a fetus (University of California Radiology)
VII. BREAST IMAGING
• Techniques:
→ Mammography
▪ Galactography/Galactogram
→ Ultrasonography/Sonomammography
→ MRI
A. MAMMOGRAPHY
• X-ray of the breast
• Indicated for checking of various lumps in the breast and for early
diagnosis of breast cancer
• Imaging of choice for individuals 40 years old and above
→ Breast tissue is more dense in younger women, making
mammograms less effective as a screening tool
• Breasts are compressed to get a good picture if there is a mass
growing

Figure 41. Illustration of the three pelvic levels with the intersecting
diameters (Lopez-Zeno, Ponce School of Medicine)

B. PRENATAL ULTRASOUND or SONOGRAM

• Non-invasive and safe diagnostic test
• Uses sound waves to create a visual image of the baby, placenta, Figure 44. Mammography (medicalexpress.com)
uterus, as well as other pelvic organs
• Can diagnose multi-fetal pregnancies Types
• Film Screen
• Digital
→ Higher Resolution
→ Higher Acquisition Speed
→ Easier for radiologists to commit diagnosis
→ Faster manipulation of image brightness

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 Figure 48. Layers of the Breast (ASMPH Batch 2019, 2014)
Figure 45. Film Screen vs Digital (www.dartmouth.edu)

Views
• Craniocaudal: Top to bottom
• Mediolateral oblique
→ To accommodate as much breast tissue as possible, including
the breast tissue found in the axillary tail

Figure 49. Different appearances of the breasts. A – fatty; B-

scattered fibroglandular; C – dense fibroglandular (ASMPH Batch
2019. 2014)

Figure 46. Types of views (verywellhealth.com)
B. GALACTOGRAPHY
• Uses mammography with the injection of contrast material to
visualize the mammary ducts
• Procedure can be painful and is usually performed under sedation
• Indicated for patients who have nipple discharge which cannot be
properly visualized via ultrasound

Figure 47. Left: Craniocaudal view & Right: Mediolateral Oblique view Figure 50. Galactogram (radiologycases.com)
(www.dartmouth.edu)
C. ULTRASONOGRAPHY or SONOMAMMOGRAPHY
Visualized Parts of the Breast
• Breast Ultrasound
• Skin
• Recommended for younger women (breasts are more dense,
• Pre-mammary fat/Subcutaneous fat mammography is not as effective)
→ In front of the glandular tissue
• Normal breast layer’s visualized
• Glandular Tissue
→ Skin
→ Bright, dense structures → Pre-mammary fat/subcutaneous fat
→ Where cancer usually rises
→ Glandular/fibroglandular area
▪ 80% of all breast cancers are ductal/adeno(glandular)
→ Muscle
carcinomas
→ Rib
→ Becomes replaced by fat (less dense) in old age which allows
categorization of breasts by composition (see image below)
▪ Fatty Breasts
o Seen among older patients
▪ Scattered fibroglandular tissue
o More dense, white tissues more seen on X-ray
▪ Dense fibroglandular tissue
o Usually seen in patients of reproductive age
o More prone to developing cancer
• Retromammary Fat
→ Lucent areas behind the glandular tissues
• Cooper’s ligaments/ anterior suspensory ligament
→ Maintain the integrity of breasts

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 Figure 54. MRI of woman with breast implants and cancer in the
breast (aboutcancer.com)

• Better defines local extent of disease

Figure 51. Layers of the Breast as seen on ultrasound • Can differentiate recurrence from post-surgical and post-radiation
(radiologykey.com) changes

• Can visualize both normal and benign breast cysts

• Can also diagnose a fibroadenoma, or a benign lesion of the
breast

Figure 55. MRI of the breast showing different layers (ASMPH Batch
2019, 2014)

Figure 52. Upper image – Sonomammography of female breast with

cyst (C); Lower image – Breast ultrasound fibroadenoma (star)
(ASMPH Batch 2019, 2014)

D. MRI OF THE BREAST

Figure 56. Breast MRIs pre and post chemotherapy (UCSF radiology)
QUICK REVIEW
SUMMARY OF TERMS
Bony Pelvis
• In the antero-posterior view, the structures that can be identified
are the following:
→ Bones
▪ Iliac crest
▪ Iliac spine
▪ Ischial spine
▪ Ischial tuberosity
▪ Obturator foramen
▪ Iliopectineal line – imaginary (cannot be directly seen)
▪ Sacrum
 Joints
▪ Symphysis pubis
▪ Sacroiliac joint
Figure 53. MRI procedure for the breast (Mayo Clinic)  Soft tissue
▪ Muscles
• Patients are imaged lying prone, with breasts sagging and placed ▪ Fat
inside capsule
• Best modality in the evaluation of implants Plain Radiography (X-Ray)
• Good in depicting cancers • Imaging technique that uses radiation to view the internal
structures of the body 

• Patient lies in a supine position on a radiographic bed, with beam
from the source directed towards center of the pelvis (reproductive
structures), and images are converted to digital format 


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• Structures Visualized → Poor soft-tissue contrast
→ Bone (pelvis: sacrum, iliac crest, iliac spine, etc.) → Poor depiction of zonal anatomy of uterus and prostate
→ Joints (Symphysis pubis, sacroiliac joint) 
 → Radiation risk
→ Some of the soft tissues apart from the internal organs (i.e. → Expensive
gluteus muscles, fat)
• Structures Indirectly Seen MRI
• Females • True multiplanar imaging
→ Ovaries → Axial
→ Fallopian tube 
 → Sagittal
→ Uterus: May be visualized in a patient with an IUD (i.e. can → Coronal
tell the direction to which the uterus is leaning towards) 
 • Can give good depictions of soft tissues and zonal anatomy
• Males • One of the two most important imaging modalities for the
→ Prostate: Seen as an indentation in the bladder when reproductive system, along with ultrasonography
enlarged (may it be due a mass, etc.) → This is because it does not use ionizing radiation
→ Seminal vesicles 
 • Advantages
→ Epididymis 
 → Direct multiplanar imaging
→ Testicle 
 → More detailed images of soft tissue organs
→ Safe for pregnant patients
→ Note: these organs CANNOT be seen when they are normal
• Disadvantages
Fluoroscopic Studies → High cost (more expensive with contrast)
• An imaging technique that uses x-rays to obtain real-time moving → Availability
images of the interior of an object → Not done on patients with metallic prosthesis or implants
→ Also a form of x-ray imaging except it is done spontaneously → Claustrophobia (can lead to patient discomfort)
• May be used along with a contrast that is safe for the peritoneum
• Hysterosalpingography (Hsg) Obstetric Applications
→ Falls under fluoroscopic imaging • Pelvimetry
→ Provides real-time view of contrast flow through the uterus → Radiographic assessment of the female bony pelvis to
and fallopian tubes measure the diameter
▪ Determines if the bony pelvis can accommodate the
→ Used to investigate or see in better detail the following organs:
development and exit of the fetus
▪ Shape of the uterine cavity
▪ Useful in assessing potential for difficulty with a vaginal
▪ Shape and patency of the fallopian tubes 

delivery
• Imaged Structures → Can be done by X-ray or MRI
→ Outline of the cervix 
 ▪ MRI pelvimetry is preferred because it does not give off
→ Uterine cavity radiation
→ Fallopian tubes • Prenatal Ultrasound
→ Peritoneal cavity 
 → Non-invasive and safe diagnostic test

Ultrasonography → Uses sound waves to create a visual image of the baby,

• Imaging of choice for reproductive organs placenta, uterus, as well as other pelvic organs
• One of the two most important imaging modalities for the ▪ Can diagnose multi-fetal pregnancies
reproductive system, along with MRI • 3D Imaging
→ This is because it does not use ionizing radiation (see → It is a medical ultrasound technique, often used in obstetric
advantages) ultrasonography
• Advantages ▪ Provides three-dimensional images of the fetus
→ Safe, particularly for children and pregnant patients → Best performed around the 28th-30th week because there is
▪ Does not use radiation sufficient amniotic fluid
→ Easy to use and fast → 4D imaging is also possible
→ Relatively cheaper (particularly relevant if one is in the
province where there are limited resources)
→ Sufficient for depiction of normal and pathologic anatomy
• Disadvantages
→ The only structures we can see are those in the field of view
→ Insufficient for tumor staging because we cannot see the other Breast Imaging
structures anymore • Mammography
→ Insufficient for diagnosing/categorizing (benign/malignant) → X-ray of the breast
• Modes → Indicated for checking of various lumps in the breast and for
→ Different probes which vary according to size and frequency early diagnosis of breast cancer
are used for different modes → Imaging of choice for individuals 40 years old and above
▪ The higher the frequency, the higher the resolution → Breasts are compressed to get a good picture if there is a
▪ The lower frequency, the lower the resolution mass growing
→ Transabdominal, transvaginal, transrectal, scrotal • Galactography
→ Uses mammography with the injection of contrast material to
Computed Tomography (Ct) Scan visualize the mammary ducts
• Takes only axial images, which can be used to reconstruct the → Procedure can be painful and is usually performed under
sagittal view sedation
• Layers of the uterus cannot be defined compared to ultrasound → Indicated for patients who have nipple discharge which cannot
• Only a part of the uterus can be visualized unlike the ultrasound be properly visualized via ultrasound
where you can maneuver the probe to see everything • Sonomammography
→ Cannot identify where the endometrial cavity is → Breast Ultrasound
→ Location and shape of the uterus is dependent on the bladder → Recommended for younger women (breasts are more
▪ Full bladder → More posteriorly located uterus dense, mammography is not as effective)
• Uterus in sagittal view → Normal breast layer’s visualized
→ Anteflexed (tilted towards the bladder) / retroflexed • MRI of the breast
→ Anteverted (cervix and vagina facing the bladder)/ → Patients are imaged lying prone, with breasts sagging and
retroverted placed inside capsule
• Advantages → Best modality in the evaluation of implants
→ Superior in depicting fat planes and adenopathy → Good in depicting cancers
• Disadvantages → Better defines local extent of disease

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 → Can differentiate recurrence from post-surgical and post-
radiation changes

REVIEW QUESTIONS
1. What are the two most important imaging modalities for the
reproductive system?
a) CT scan and MRI
b) Plain radiography and ultrasound
c) MRI and plain radiography
d) Ultrasound and MRI

2. Based on question 1, why are these two imaging modalities the

most important for viewing and evaluating the reproductive
system?
a) Because they provide good soft tissue resolution
b) Because they pose no risks due to ionizing radiation
c) Because they can be used for all types of patients regardless
of their conditions
d) Because they’re relatively cheaper and more accessible

3. T/F: In pelvimetry, using one view is already adequate to assess

the bony pelvis

4. T/F: Some males can have gynecoid shaped inlets, while some
females can have android shaped inlets.

5. The following structures can be directly seen in a plain radiograph

except?
a) Iliac crest
b) Pubic symphysis
c) Gluteal muscles
d) Testis

6. T/F: In hysterosalpingography, a normal fallopian tube can be

visualized when the dye spills through its length.

7. What is the specific limitation of the transabdominal mode that

other modes overcome, making them the more effective mode?
a) Interference of bowel gas obscured area of interest
b) The probe used emits low frequency waves
c) Since it’s only done on the abdomen, only abdominal
structures can be visualized
d) It is painful for the patient when the probe is used

8. Breast implants can best be evaluated using this imaging modality.

a) X-ray
b) Ultrasound
c) MRI
d) CT scan

Answers
1D, 2B, 3F, 4T, 5D, 6T, 7A, 8C

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 REFERENCES
REQUIRED
(1) Koa-Sales, R. M. 06 March 2019. Imaging of the Reproductive System [Lecture slides].
(2) Koa-Sales, R. M. 06 March 2019. Imaging of the Reproductive System [Audio].
(3) ASMPH Batch 2022. 2018. Imaging of the Reproductive System [Trans].
(4) ASMPH Batch 2019. 2014. Radiology of the Reproductive System [Trans].

APPENDIX

Table 6. Summary of Imaging Modalities for the Reproductive System (ASMPH Batch 2019, 2014)
X-Ray Ultrasound CT Scan MRI
Direct multiplanar imaging
Fast and readily available that can visualize axial,
Sensitive and specific for
sagittal, and coronal views
bone structures and
Can depict normal and Superior in depicting fat
Advantages fractures
pathologic anatomy planes and adenopathy Good soft tissue resolution
Cheap
Safe for pregnant patients Safe for pregnant patients

High cost, not readily

Cannot detect soft tissue Poor depiction of zonal available
Insufficient for tumor
diseases anatomy of uterus and
staging and diagnosis of
prostate Contraindicated for
adnexal masses
Disadvantages Structures are super- patients with metallic
imposed on each other Poor soft tissue contrast implants
Interference of bowel gas
obscured area of interest
Radiation risk Radiation risk Difficult for patients with
claustrophobia
Visualized Structures
• Iliac crest
• Iliac spine
• Ischial tuberosity
Pelvic bone structures • Obturator foramen
• Sacrum
• Symphysis pubis
• Sacroiliac joint
HSG:
• Cervix
• Uterus: endometrium
• Fallopian tubes
and myometrium
• Peritonial cavity • Uterine masses • Entire female pelvis
• Ovaries and follicles
Female soft tissues • Uterus • Ovaries • Uterus: endometrium
• Bladder
• Cervix is visible
• Fallopian tubes (if
Note: Viscera cannot be
pathological)
seen without dye; normally
only indirectly seen
• Seminal vesicles
• Prostate • Seminal vesicles
• Epididymis • Prostate
• Entire male pelvis
• Testicles • Epididymis
• Prostate • Prostate: zones
• Bladder (with IVP) • Testes
Male soft tissues • Seminal vesicles visible
• Scrotum
• Bladder • Scrotum
Note: Viscera cannot be • Penis and its • Penis
seen without contrast; vasculature
normally only indirectly
seen

Transcribed by TG 5: De los Reyes, Demition, Dionisio, Eclipse, Magallanes, Mendoza, Obenza, Palencia
YL5: 10.04
Checked by TG 17: Coloyan, Barin, Bondoc, Fonte, Gob, Montoya, San Lorenzo 15 of 15