Pelvis evaluation

Radiographic imaging studies evaluate the extent of disease involvement. A chest x-ray should be performed to rule out the presence of metastatic spread to the lungs. A CT scan of the abdomen and pelvis is often performed to evaluate hepatic and retroperitoneal involvement and occult abdominal and pelvic disease, and to determine the depth of tumor penetration into the bowel wall and/or invasion to adjacent organs. Detection of lymph node involvement with either smdy is limited by the difficulty of distinguishing inflammatory or reactive lymph nodes from those infiltrated with tumor. Because CT scans may not adequately detect peritoneal seeding, small distant lymph node metastasis, or liver metastasis in colon cancer, an occasional patient may... 

CT of the female pelvis can be performed alone but patients typically undergo CT scans of the upper abdomen and pelvis, especially when CT is done for staging of malignancy. Other indications include determination of the extent of thrombotic disease, evaluation of vascular supply, and diagnostic evaluation of other gynecologic conditions or follow-up of therapy. 

Zawin M, McCarthy S, Scoutt LM, Comite F (1990) High-field MRl and US evaluation of the pelvis in women with leiomyomas. Magn Reson Imaging 8 371-376... 

Crohn s disease is a chronic inflammatory condition that may occur in any part of the gastrointestinal tract but commonly involves the terminal ileum or right colon frame. Gynecologic involvement with inflammation of the organs of the true pelvis or of the vulva is not uncommon. Another manifestation are fistulas between the vagina and the colon or rectum [5]. MRI is the method of choice for the diagnostic evaluation of pelvic fistulas. 

Normal delivery is based on the complex interaction of maternal factors, fetal properties, and adequate labor. If this interaction of Passages, Passenger, and Powers is disturbed, labor is protracted or even arrested. The failure of labor to progress is therefore not a diagnosis but a symptom that is amenable to treatment (e.g. when caused by inadequate uterine contractions) or not (e.g. absolute cephalopelvic disproportion). Isolated evaluation of either of the three factors, passages, passenger, and powers, is of limited value as, for instance, cephalopelvic disproportion can be diagnosed only if one looks at both the maternal pelvis and the fetus ( this pelvis is too small for this fetus ). 

The aim of palpation of the pelvis is to identify prominent bony structures that may obstruct labor. The examiner evaluates the angle of the pubic arch (> 90°), the promontory (cannot be reached), the anterior surface of the sacrum (smooth), the coccy-gis (not prominent and elastic), and the ischial spines (not prominent). 

The remainder of this chapter will focus on the current NYU protocols for acquiring CT data for 3D data interpretation for three specific indications in the abdomen and pelvis, CT enterography, pancreatic and upper abdominal pain evaluation, and in those patients with lower abdominal pain. At the end of the chapter 1 have attached a list of the common CT protocols that we use for various clinical indications in abdomen and pelvis. 

Detailed evaluation of the penile vascular supply is mandatory to plan intervention in patients with postraumatic erectile dysfunction who are candidates for penile revascularization surgery. These patients are frequently young, have often suffered traumatic straddle injuries to the pelvis and may be unresponsive to oral and intracaver-nosal therapy (Golijanin et al. 2007a Golijanin et al. 2007b). 

Besides evaluation of penile blood supply to the penis, MDCT can be indicated to evaluate large postoperative fluid collections and complications of urethral surgery such as diverticula, fistulas and postoperative strictures (Chou et al. 2005). Also prosthesis malfunction can be investigated in patients who are not candidates for magnetic resonance imaging. Moreover, in patients with penile and urethral malignancies, CT is often used after the operation to evaluate the pelvis in suspicious postoperative complications extending into the perineum and into the pelvis, such as fistulas and inflammation. Also tumor recurrence and pelvic lymphadenopathies can be evaluated effectively. 

Due to multiplanar capabilities and excellent soft-tissue contrast resolution magnetic resonance imaging is the imaging modality of choice to evaluate deep tumor recurrence and surgical complications in the pelvis and perineum ofpatients operated for penile or urethral malignancies (Pretorius et al. 2001). Similar to contrast-enhanced CT, pelvic lymphadenopathies can be identified. 

Patients with metallic hip joint replacements will have significant artifacts in the pelvis with limited evaluation of colonic segments in this region. This is a relative contraindication depending on the clinical question asked. Intravenous iodinated contrast allergy is also a relative contraindication as any patient with a history of a mild contrast allergy can be premedicated for the exam or not receive the injection. Claustrophobia is also a relative contraindication to the study. Patients can take an oral sedative prior to the study. An incompetent ileocecal valve is another relative contra-indication for CTC as distention of the colon may be suboptimal. 

In the setting of hemodynamic instability and undetectable extravasation from the pelvis on angiography, further investigation of other vessels including the lumbar branches, branches of the common femoral artery, superficial femoral artery, and profunda femoral artery should be performed. If there is potential for splenic, hepatic, or renal injury, these vessels should also be evaluated. If all other potential arterial sources have been excluded and the patient remains hemodynamically unstable, then empiric embolization of the internal iliac arteries may be performed. 

The lumbar spine consists of five vertebrae, the largest in size is the spinal column. Most congenital anomalies occur to the fifth lumbar vertebra. Both the thoracic spine and the sacrum and pelvis have significant effects on the posture and function of the lumbar spine. When performing an evaluation of the lumbar spine, it is necessary to include these areas in the examination. 

The pelvis will rotate during the evaluation of rotation however, monitoring the ASIS can minimize this. 

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