3-Dimensional Endovaginal Ultrasonography of Vulvovaginal Cysts and Masses: A Multicenter Retrospective Review of a Novel Technology

S. Abbas Shobeiri, MD, Lieschen H. Quiroz, MD, Giulio A. Santoro, MD, Elizabeth R. Mueller, MD, Vivian Aguilar, MD, A. Pawel Wieczorek, MD

Objective: To investigate the utility of 3-dimensional endovaginal ultrasonography in assessment of vulvovaginal cysts and masses.

Methods: A retrospective review of 3-dimensional endovaginal ultrasonography performed at five institutions was complete. The procedure had been performed in patients with varied pelvic floor complaints. Each patient’s history was reviewed to determine whether any other imaging modality had been used for comparison, whether surgery was performed, and what the surgical or pathologic findings were.

Results: Forty seven patients with vaginal masses underwent 3D endovaginal ultrasonography. By clinical examination, the following diagnoses were made: 2 (4%) varied symptoms without a clear diagnosis, 17 (36%) vaginal mass, 7 (15%) urethral diverticulum, 1 (2%) hematoma, 7 (15%) Bartholin gland cyst, and 11 (23%) had other miscellaneous diagnosis. By 3D endovaginal ultrasonography examination, the following diagnoses were made: 16 (34%) urethral diverticulum, 5 (11%) hematoma, 10 (21%) Bartholin gland cyst, and 14 (30%) had miscellaneous diagnosis. Pathology confirmation was available in 29 (62%) patients. The clinical and 3D endovaginal ultrasonography diagnosis were significantly different with poor agreement (P<.004, k=0.3). There was substantial interrater agreement for 3D endovaginal ultrasonography diagnosis (k=0.747). There was 78% agreement between MRI performed in18/47 (38%) of patients and 3D endovaginal ultrasonography findings (k=1).

Conclusion: Our study demonstrates that 3D endovaginal ultrasonography may be utilized for the evaluation of vaginal cysts and masses. The ease by which 3D endovaginal ultrasonography can be performed in a clinical setting provides an opportunity to screen for vaginal masses in patients more quickly than is feasible with a CT scan or an MRI. 1) we have described the variety of masses seen by 3D endovaginal ultrasonography, 2) we have described the diagnostic value of 3D endovaginal ultrasonography, and 3) we have shown interobserver agreement for assessment of vaginal masses as visualized by 3D endovaginal ultrasonography. The ability to visualize internal characteristics of vaginal cysts and masses is important because it can help us with management decisions. If the use of 3D endovaginal ultrasonography for visualization of pelvic floor structures gain popularity, the clinicians may become accustomed to this additional modality in their disposal for better diagnosis of clinical problems.

References 1. Shobeiri SA, Leclaire E, Nihira MA, Quiroz LH, O'Donoghue D. Appearance of the levator ani muscle subdivisions in endovaginal three-dimensional

ultrasonography. Obstetrics & Gynecology. 2009;114:66-72. 2. Santoro G, Wieczorek A, Shobeiri S, Mueller E, Pilat J, Stankiewicz A, et al. Interobserver and interdisciplinary reproducibility of 3D endovaginal ultrasound

assessment of pelvic floor anatomy. International Urogynecology Journal. 2010;22:53-9. 3. Quiroz LH, Shobeiri SA, Nihira MA. Three-dimensional ultrasound imaging for diagnosis of urethrovaginal fistula. International Urogynecology Journal.

2010;21:1031-3.

Table 1. Numbers and percentile of patients with clinical diagnoses and 3D endovaginal ultrasonography diagnoses.

Diagnosis Clinical

3D endovaginal ultrasonogra

phy

No diagnosis made 2 (4%) 0

Vaginal mass 19 (40%) 0

Urethral diverticulum 7 (15%) 16 (34%) Hematoma / Seroma 1 (2%) 5 (11%) Bartholin gland cyst 7 (15%) 10 (21%) Other Specific diagnosis 11 (24%) 16 (34%) Total 47 47

Table 2. Details of numbers and percentile of patients with other specific 3D endovaginal ultrasonography diagnoses.

Specific diagnosis by 3D endovaginal ultrasonography

Number (percent)

Bartholin gland cyst 10 (21%) Gartner duct cyst 3 (7%) Paravaginal cyst 1 (2%) Rectovaginal septum cyst 6 (13%) Suburethral solid mass (angiosarcoma)* 1 (2%) Seroma / Hematoma 5 (11%) Urethrovaginal fistula 1 (2%) Urethral diverticulum 16 (34%) Rectal metastasis (vaginal cancer)* 2 (4%) Urethral metastasis (vaginal cancer)* 1 (2%) Perirectal mass (leiomyoma)* 1 (2%) Total 47

Demonstrates the right sagittal view of a circumferential urethral diverticulum with septations in the cavity.

Demonstrates an echogenic mass arising from the urethra. This mass was found to be a malignant angiosarcoma. A: Coronal view, B: Cut view of the paraurethral solid mass from axial and lateral view, C: Axial view of the paraurethral solid mass obtained by 3D endovaginal ultrasonography placed side by side next to the D: Axial MRI view of the same mass.

The caudal axial view of an endometrioma in the right edge of the rectovaginal septum.