Young, Scott W.

This study aims to evaluate the implementation of the uterine sliding sign in routine pelvic ultrasound examinations for improving the diagnosis of deep endometriosis. A retrospective analysis was conducted at Mayo Clinic’s Florida and Arizona campuses, including 200 premenopausal and perimenopausal women with chronic pelvic pain, infertility, or suspected endometriosis. Sonographers performed a uterine sliding maneuver during transvaginal ultrasound, and the acquisition times were recorded. Sonographer experience and the time required to perform the sliding sign were analyzed using Microsoft Excel. The median acquisition time for the uterine sliding sign was 26 seconds, with no statistically significant difference based on sonographer experience. The addition of this maneuver extended the ultrasound examination by <1 minute on average, regardless of sonographer experience level. Incorporating the uterine sliding sign into routine pelvic ultrasound protocols is a quick and efficient method that enhances the detection of deep endometriosis, potentially reducing the significant diagnostic delay associated with endometriosis. This study supports the feasibility and minimal time impact of implementing the Society of Radiologists in Ultrasound (SRU) recommendations for augmented pelvic ultrasound in clinical practice.

Objectives Evaluate the value of ultrasound specialist assessment of ovarian masses over 50 mm with sonograms interpreted as possible hemorrhagic ovarian cysts (HOC). Methods Retrospective review of consecutive endovaginal pelvic US reports of premenopausal women at one organization identified adnexal masses over 50 mm maximum diameter designated as possibly being HOC (large HOC). Four ultrasound specialists reviewed studies, scoring two assessments as true or false: 1) US features are most consistent with either an ovarian hemorrhagic cyst (HOC) or endometrioma; 2) If assessment 1 was true, the mass meets O‐RADS criteria of classic HOC except for size. Results A total of 457 of 51,305 women (0.9%) had reports indicating possible large HOC. For 366 patients with established outcomes, 225 (61.5%) had a large HOC (87.1% ≤ 70 mm). Assessment 1 was true for 318 patients; outcomes showed 224 (70.4%) HOC, 89 (28.0%) endometriomas, 4 (1.3%) TOAs, and 1 (0.3%) cystadenoma. Assessment 1 was false for 48 patients; outcomes showed 1 (2.1%) HOC, 1 (2.1%) endometrioma, 6 (12.5%) other non‐neoplastic cysts, 33 (68.8%) benign neoplasms, 5 (10.4%) borderline tumors, and 2 (4.2%) high‐grade malignancies. The decrease in neoplasms and malignancies with true assessment 1 was significant ( p < .001). Assessment 2 was true for 190 patients (180 [94.7%] HOC, 9 [4.7%] endometrioma, 1 [0.5%] cystadenoma), false for 128 patients (44 [34.4%] HOC, 80 [62.5%] endometrioma, and 4 [3.1%] TOA) ( p < .001), and not applicable for 48 patients. Conclusions Ultrasound specialist review of adnexal masses designated as a possible large HOC adds value since over 10% are neoplasms (nearly 2% malignant). Ultrasound specialist assessment can expedite additional imaging or intervention when necessary and obviate follow‐up when HOC features are typical.

ObjectivesTo combine sonographic Murphy sign (SMS) with clinical parameters to effectively stratify patients into risk groups for acute cholecystitis.MethodsConsecutive emergency department patients from April 1, 2019 to August 31, 2022 with possible acute cholecystitis were grouped using patient age, sex, and white blood cell count to determine the rate of acute cholecystitis found in subgroups. Three distinct clinical risk groups were established and then regrouped by prospective assessment of SMS into three non‐imaging risk groups. Differences in the rate of acute cholecystitis for clinical parameters, clinical risk groups, and non‐imaging risk groups were statistically analyzed.ResultsOf 1231 patients (mean [SD] age, 51.2 [19.5]; 476 [38.7%] male), 156 had acute cholecystitis (mean [SD] age, 62.0 [15.4]; 85 [54.5%] male). Rates differed based on sex (9.4% female vs 17.9% male, P < .001), age group (1.8% for patients <30 years, 9.0% for patients 30–59 years, 22.3% for patients ≥60 years; P < .001), and white blood cell count (23.1% elevated vs 6.6% not elevated; P < .001). The low, average, and high non‐imaging risk groups had acute cholecystitis rates of 1.8%, 14.0%, and 43.1%, respectively. Relative risk (95% CI) for the low non‐imaging group compared with others was 0.07 (0.04, 0.12; P < .001); relative risk for the high non‐imaging risk group compared with others was 7.05 (5.32, 9.43; P < .001).ConclusionsSonographic Murphy sign assessment combined with patient age, sex, and white blood cell count effectively stratifies acute care patients into distinct acute cholecystitis risk groups.

Abstract Introduction Nonischemic priapism typically occurs secondary to penile trauma, resulting in increased blood flow into the penis without decreased outflow resulting in a clinically non-painful, partially rigid erection. Per the American Urologic Association guidelines, surgical treatment is discouraged, and following conservative management, first line treatment is arteriography with selective arterial embolization. This procedure is generally highly successful but it does carry a risk of erectile dysfunction as well as priapism recurrence. Objective Herein we present the first known case of ultrasound guided thrombin injection in an adult for nonischemic priapism treatment after persistent priapism and arterial blush following arterial embolization. Methods A 44-year-old male presented with an eight-month history of partial tumescence and erectile dysfunction after an episode of unwitnessed loss of consciousness resulting in the subsequent development of gross hematuria and dysuria. Physical examination revealed a semi-firm penis with suspected high-flow priapism. He initially presented to the emergency department, whereby a cystogram and cross sectional abdominal imaging were unrevealing. Initial outpatient cystoscopy revealed a urethral polyp which resolved on subsequent repeat testing. Following this an outpatient penile duplex doppler ultrasound was performed demonstrating a right pseudoaneurysm at the penile base measuring 13 mm in diameter with an arteriovenous fistulous communication to the corpus cavernosum. MRI demonstrates fibrotic changes within the right corpus cavernosum and tunica albuginea indicating prior traumatic penile injury. At the time the patient had approximately 25% tumescence at rest and was only able to obtain a slightly firmer erection, but was still able to achieve orgasm. After extensive conversation and given a trial of conservative management, the patient elected to proceed with angioembolization. An angiogram was completed which demonstrated a blush of contrast in the area of the bulbourethral artery. Despite successful deployment and coil embolization of the pseudoaneurysm, there was noted continued filling of the patent pseudoaneurysm from small branched collateral vessels. The patient tolerated the procedure well, and had reduction of his baseline penile tumescence and some erectile function recovery, requiring oral phosphodiesterase-5 inhibitors. There was concern for complete occlusion of the dorsal penile artery with repeat embolization, which may ultimately worsen erectile dysfunction. He remained incompletely satisfied with response to oral therapy. Results It was ultimately decided to pursue an ultrasound guided thrombin injection, which has been reported in a handful of cases as a primary intervention for priapism. During the procedure, 200 units of thrombin was injected into the pseudoaneurysm under ultrasound guidance resulting in immediate cessation of arterial flow. Post-procedure angiography demonstrated effective resolution. Conclusions High-flow priapism is a relatively uncommon condition, managed generally with embolization as first line treatment, with success rates reported at 89 to 100% and recurrence only occurring in 30% of patients. Recurrence is generally treated with repeat embolization which has been reported to cause erectile dysfunction in 15 to 22% of cases. Percutaneous ultrasound-guided thrombin injection has the potential to be an excellent second-line treatment option for pseudoaneurysm closure in correcting nonischemic priapism, albeit with limited data, but suspected high efficacy and potentially diminished rates of erectile dysfunction. Disclosure No.

Linked article: This Correspondence comments on Deslandes and Leonardi. Click here to view the article.

Peripheral arterial and venous examinations are performed regularly in vascular labs and interpreted by physicians of different specialities. Many vascular examinations have nonvascular pathology that is either inadvertently imaged by the sonographer or imaged with intent as it relates to patient's symptoms. It is prudent for every reader of vascular studies to be acquainted with the sonographic appearance of these non‐vascular lesions to enable appropriate and optimal interpretation that has a direct bearing on patient's clinical care. Our review includes a discussion of the nonvascular pathologies like lymph nodes, soft tissue edema, soft tissue fluid collections, musculotendinous injuries, soft tissue masses, and joint and bursal pathologies that may be encountered during interpretation of vascular exams. The pictorial essay includes a discussion of their sonographic appearances and pitfalls in interpretation. Multiple illustrative examples and sonographic images of the non‐vascular pathologies found during interpretation of vascular studies have been utilized to highlight their appearances.

ObjectiveWe evaluated the performance of ACR TI‐RADS when points for lobulated margins are applied only when the margins meet a quantified measure of margin microlobulation and not applied when nodules only demonstrate macrolobulation.MethodsWe retrospectively reviewed ultrasound and pathology records (May 01, 2018 to July 31, 2020) to find all thyroid nodules at one institution characterized as having lobulated margins using the ACR TI‐RADS lexicon and subsequently undergoing fine needle aspiration (FNA). Nodule margins were evaluated to note the presence or absence of microlobulation, quantitatively defined as a protrusion with a base <2.5 mm in length. The impact to detection of malignant nodules and avoidance of benign FNA when margin points for lobulation were added only when microlobulated was analyzed.Results58 of 516 thyroid nodules undergoing US‐guided FNA were classified as lobulated, comprising the study population. 21 (36.2%) had microlobulated margins, with 12 of the 21 (57.1%) being malignant. Comparatively, of the 37 nodules showing only macrolobulated margins without microlobulation, only 2 (5.4%) were malignant (P < .0001). For 53 nodules ≥10 mm, 15 (28.3%) benign nodules would not have met size criteria for FNA had points for margins not been applied when only showing macrolobulation, whereas all 10 malignant nodules would still have been sampled.ConclusionAdding two points to the ACR TI‐RADS score for lobulated thyroid nodules should only apply when microlobulations are present.

Objectives We analyzed growth rates of benign ovarian serous cystadenomas and cystadenofibromas to understand what percentage would show a volume doubling time (DT) of less than 3 years, between 3 and 5 years, or greater than 5 years. Methods We retrospectively reviewed pathology records (January 1, 2014, to June 30, 2019) to find all surgically excised ovarian serous cystadenomas and cystadenofibromas. Imaging records were then reviewed to identify those that had been confidently identified with ultrasound imaging, magnetic resonance imaging, or computed tomography at least twice before surgical removal, with at least a 60‐day interval between studies. Three orthogonal measurements were recorded on the first and last imaging studies on which the mass was detected, with volume calculations by the prolate formula (product of 3 measurements multiplied by 0.52). The volume DT was calculated and grouped into 1 of 5 categories: (1) DT of less than 1 year; (2) DT of 1 to 3 years; (3) DT of 3 to 5 years; (4) DT of 5 to 10 years; and (5) no growth (any mass with a DT >10 years or showing a decrease in volume). Results A total of 102 of 536 cystadenomas and 44 of 227 cystadenofibromas met inclusion criteria. Of the 146 tumors, 40 (27.4%) had a DT of less than 1 year; 38 (26.0%) had a DT of 1 to 3 years; 22 (15.1%) had a DT of 3 to 5 years; 10 (6.8%) had a DT of 5 to 10 years; and 36 (24.7%) showed no growth. Conclusions A total of 53.4% of ovarian serous cystadenomas/cystadenofibromas have a DT of less than 3 years; 15.1% have a DT between 3 and 5 years; and 31.5% have a DT of greater than 5 years or show no growth.