Normal or Abnormal? Demystifying Uterine and Cervical Contrast Enhancement at Multidetector CT

Abstract

Computed tomography (CT) is not generally advocated as the first-line imaging examination for disorders of the female pelvis. However, multidetector CT is often the modality of choice for evaluating nongynecologic pelvic abnormalities, particularly in emergent settings, in which all the pelvic organs are invariably assessed. Incidental findings of uterine and cervical contrast enhancement in such settings may easily be mistaken for abnormalities, given the broad spectrum of anatomic variants and enhancement patterns that may be seen in the normal uterus and cervix. The authors' review of CT and magnetic resonance (MR) imaging enhancement patterns, augmented by case examples from their clinical radiology practice, provides a solid foundation for understanding the spectrum of normal uterine and cervical appearances and avoiding potential pitfalls in the diagnosis of benign cervical lesions, adenomyosis, infection, malignancy, and postpartum effects. This information should help radiologists more confidently differentiate between normal and abnormal CT findings and, when CT findings are not definitive, offer appropriate recommendations for follow-up ultrasonography or MR imaging.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis—part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion

“…Sagittal viewing allows appropriate assessment of size, morphology and enhancement patterns of the uterus, the latter markedly varies according to age, menstrual phase and delay between contrast injection and CT acquisition. Additional MRI-like oblique-axial and oblique-coronal reconstructions (perpendicular and parallel to the main uterine axis, respectively) may be helpful to discriminate extra-uterine structures and to better assess topography of uterine abnormalities such as subserosal or pedunculated leiomyomas [1–4, 11].…”

US of the Nongravid Cervix with Multimodality Imaging Correlation: Normal Appearance, Pathologic Conditions, and Diagnostic Pitfalls

“…The hypointense appearance of the inner cervical stroma on T2weighted images has been suggested to reflect a greater number of fibroblasts and smooth muscle cells and less vascularized connective tissue compared with the outer stroma (5,18). The inner and outer cervical stromal layers typically appear contiguous with the uterine junctional zone and the outer myometrium, respectively (19). The zonal anatomy may also be visible on gadolinium-enhanced images because of differential enhancement of the cervical layers (18,19).…”

“…The inner and outer cervical stromal layers typically appear contiguous with the uterine junctional zone and the outer myometrium, respectively (19). The zonal anatomy may also be visible on gadolinium-enhanced images because of differential enhancement of the cervical layers (18,19). The median longitudinal ridges of the plicae palmatae are visible at MR imaging in 47.5%-53.2% of women in their 20s through 40s but less commonly in older women (20).…”

Imaging of the Female Pelvis through the Life Cycle

“…Reformatted images in the sagittal plane help demonstrate the position and true length of the uterus and offer the best view for assessing endometrial thickening. On dynamically enhanced, multidetector CT scans, the appearances of the myometrium and endometrium depend on the interval between intravenous contrast material administration and scanning as well as the age of the patient (17,32). On contrastenhanced CT scans obtained in women of reproductive age, the endometrium exhibits hypoattenuation relative to the inner myometrium during most phases of contrast enhancement, a finding that might be misinterpreted as fluid within the uterine cavity.…”

“…The endometrium may occasionally be identified on contrastenhanced CT images and should appear thin, regular, and hypoenhancing relative to the myometrium (32,61). Patients with an abnormal endometrial appearance at CT should be referred for further evaluation with endovaginal US.…”