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You can access the recording of today's conference and previous new conferences by creating a free MRI online account. The link will be provided in the chat box. You can also sign up for a free trial of our premium membership to get access to hundreds of case-based micro learning courses across all key radiology subspecialties. Learn more at MRI online.com. Today, we are honored to welcome Dr. Barbara Pauley for a lecture on the Founding of Youth, Pediatric GU Ultrasound. Dr. Barbara Pauley completed her radiology residency at University of Louisville, followed by a pediatric fellowship at Coaseyre Children's Hospital. She is the immediate past president of AAWR and is currently Associate Professor of Emergency Radiology, as well as Fellowship Director of Emergency Radiology at University of Kentucky. At the end of the lecture, join Dr. Pauley in a Q&A session where she will address questions you may have on today's topic. Please remember to use the Q&A feature to submit your questions so we can get to as many as possible before our time is up. And with that, we are ready to begin our lecture. Dr. Pauley, please take it from here. Hi, I'm Dr. Barbara Pauley and I'm going to talk today about pediatric genital urinary ultrasound, the fountain of youth. So, we have different categories today that we're going to look at and the first is developmental and then infection and trauma, neoplasm, and some incidental findings. Our goals today are to augment our existing knowledge of pediatric GU pathology, make the diagnosis with ultrasound and correlate with CT or MRI whenever possible. I think that we can see things with ultrasound much better if we've had some platform to put them on. So, seeing the CT and MRI or even intraoperative images helps us to be able to see things that we couldn't see before with ultrasound. So we'll start with the developmental case. This is a 13-year-old girl with worsening right lower quadrant dull 80 pain and she's had this for a couple of days and our first thoughts would be a long differential but starting with appendicitis. So that is excluded but then we turn to some other things usually looking at the pelvis. And that's what we did with this patient and you can see marked on this image that it is the uterus and in a sagittal projection. And we are seeing some familiar appearance here. This is the myometrium. So you can see the, instead of the endometrial stripe we're seeing a fluid filled endometrial canal. And it is communicating with this large collection of complex fluid down below it. And that is the vagina.  And additionally, we can see in the left adnexa that there is a tubular structure. It is marked there as the fallopian tube. You might wonder, how do you know that's not a segment of bowel? And the answer to that is that we don't see peristalsis there. So we are more convinced that it's the fallopian tube. And it's also in close proximity to this ovoid structure that we think is the ovary. And proof of that, as we look more carefully at both of those structures, you can see that this fallopian tube is filled with fluid and there's some characteristic findings these folds in the fallopian tube. And ordinarily we don't see the fallopian tube at all. So, only when we see it filled with fluid can we see these features. And we see them again on this transverse view. And you can see those folds again. And this time we can see the ovary in close proximity. And you can see the follicles along the margin. So this is a little bit better view of that. So what is going on with this patient? We have a CT to correlate with it. It's a beautiful example of the similarity of CT and ultrasound. We saw all of these things on our ultrasound, but here they are on the CT as well. You can see that myometrium there, the endometrial canal with the fluid filling it, and this huge vagina. We can see the extent of the vagina to better advantage on the CT. And you can also see how there might be some compromise to the ability to void because of the mass effect from the huge vagina there, fluid filled vagina. So there may be difficulties voiding. There may be difficulties in evacuation of stool as well. Here is a CT. You can see that. See, you can see that here on this image that the uterus at the midline is very thick. So there's the myometrium and the endometrial canal. And over to the left side, and you can see this arrow pointing to the very dilated fallopian tube. So that's just the CT visualization of that. And what does this patient have? We can see that this patient has an imperforate hymen causing hydrometric ovals and bilateral hydrosalpings. This patient had a successful hymenotomy that day and left the hospital the next day. So the presentation of this condition could be in the neonatal time period with an abdominal mass. But more commonly, it presents in an adolescent, and they present with abdominal pain or perhaps delayed onset of menses. The associated conditions due to this mass effect can be bladder outlet obstruction, as I pointed out, as well as some hydronephrosis potentially associated with that, or constipation, as I showed that mass effect from the distended vagina. And there can also be asides because of the retrograde drainage of fluid through the fallopian tubes. We saw that the fallopian tube extended with fluid, and that can make its way out into the peritoneum. The next case is our three-month-old female who came to the emergency department with inguinal hernia. And you can see on image A that this is sort of a midline, slightly left of midline image. You can see the bladder partially filled with fluid, and the green arrows show the defect in the pelvic wall. And through that there is some structure protruding, which we cannot really distinguish on this image. So on image B in the top right corner, we can see a familiar sight. The red arrow is pointing to the uterus with a normal-looking endometrial stripe. And then on either side, the yellow arrows point to what we think are probably ovaries on either side. And we can see those ovaries better and prove that they're ovaries by the fact that there are multiple follicles. The asterisks are indicating where those follicles are. The yellow arrows again point to the ovaries on either side. So very, very unusual finding in the emergency department. We think that we're going to see herniated bowel, but instead we see the entire uterus and both ovaries protruding through the hernia defect. This is an indirect inguinal hernia. It's one of the most common congenital abnormalities in children. And in about 15 to 20% of female patients, the hernia sac contains an abnormal ovary. And some of them we may not be aware of. Maybe we don't investigate the contents of the hernia sac well enough, but containing the whole uterus and both ovaries is quite rare. Although I was quite astounded by this case, the pediatric surgeons did not seem to be quite as excited. So I would assume that they must see similar findings more often than I do. The theories on the mechanism of the occurrence of this include the one herniated ovary that can occur relatively commonly. That and the uterus and the other, the other ovary can herniate into that sac because of internal pressure from the child crying. So that's the mechanism of it. And then we move on to another case in this category, which is a 17 year old exchange student who has not been in the U.S. very long and has no prior medical care in the country. So we don't have any previous records or other information. The patient presents with abdominal pain and it's predominantly in the right upper quadrant. So as we look at this patient with it right up a quadrant ultrasound, that was our first line of evaluation. We can see on image a that the liver parenchyma is quite coarse and ecogenic, and the white arrows point to this tubular structure that once we put color on, we can see that this is the recanalized perinatal vein. And that's something we're not used to seeing in this 17 year old at all. We might see this in a patient with cirrhosis, a little bit older person. But this was a very unusual finding. And as we move on to look at the liver parenchyma, a little bit more carefully on image C, you can see those green arrows pointing to dilated hepatic ducts. These, these biliary ducts are very distended, and we should not be able to see them at all. So the coarse echo texture is very abnormal. Then we go on to look at that a little more closely. The yellow arrow points to that those ducts to see how dilated they are looking at image D. You might be asking yourself, why is this in a talk about to you, and that is coming up as with all right upper quadrant ultrasounds. We look at the right, the right kidney comes with that. And so we had the opportunity to see the right kidney. And as you can see there, it looks very coarse, ecogenic. We can see that there's those cystic tubular structures, even in the kidney. Those are the renal tubules. And this kidney was quite large, measuring 15.1 centimeters in the natural dimension that that's a an extremely large kidney. I asked the technologies to get the other kidney as well. It's the same appearance, and it measured about the same.  You can see those dilated renal tubules. So this is just another look at that right kidney. How coarse and ecogenic it is. This patient went on to get an MRI of the abdomen and you can see that the kidneys are very abnormal looking. They look cystic, but not the typical kind of autosomal dominant polycystic kidney disease that really doesn't present with so many dilated cysts until a little bit later in age. So this patient is just a teenager. And what he actually has is autosomal recessive polycystic kidney disease. And hence we see the dilation of the renal tubules, not the cortex. So we also see that there are cystic changes in the periphery of the liver. And as I mentioned earlier, the biliary ducts are dilated as well. It almost has a corollary disease kind of appearance. And you may remember studying this disease, this autosomal recessive polycystic kidney disease somewhere in your past that you study for a core exam, or maybe as you study for an in-service exam. And so what we see here is classic for that, usually the worst, the kidney disease, the less the liver disease and vice versa. This patient has quite a few findings in both. So he's a very good example of the various things that can be seen. And in this patient, he mostly had right upper quadrant pain. So his pain really wasn't associated with his kidney disease, but rather with his liver disease, he had ascending colonitis. So this is just a really nice case to be able to see all the different findings in that. And then we'll move on to infection. This is a 12 year old who presents to the emergency department with left scrotal pain and fever. The first image on the left side is a typical image that we get of the bilateral testicles, side by side, a comparison image. And you can see here that the vascularity of both testicles is very similar. And so that helps us because you know we want to know, is there hyperremia or is there a lack of flow, and seeing very similar flow is very helpful to us. Then we noticed that there's hyperremia, hypervascularity, more in the peripheral aspect of the left side, and that is in the epididymis. So this patient basically has epididymitis, there's inflammation of the spermatic cord as well, the niculitis, and this patient was treated with an oral antibiotic as most of these types of cases are treated. But with this patient, he came back a few days later, and he still had pain and we redid the ultrasound. And you can see once again the right testicle looks pretty normal. The left testicle is quite edematous, we're not seeing it all the way here, a lot of edema around it. This is that left testicle compared to the normal uniform echo texture of the right. It is quite hypoechoic, it's edematous, and it's heterogeneous. And there's a lot of edema around it. And putting color on that, we can see that there's hyperremia of the testicle now. We didn't see that before, we did not see a large amount of vascularity in that left testicle on the first study. And that is because this is taking the typical pathway, the retrograde pathway of epididymal orchidus. It's a disease process that starts at the urethra, involves the bladder eventually makes its way to the epididymus, and only later will it involve the testicle itself, and then it becomes a vascularitis. And we do see an asterisk there that there is no vascularity there, I will tell you more about that on the next slide. So this patient, because he was doing very poorly, he was treated with an IV antibiotic. He still did not really improve, and he was reevaluated with ultrasound again a couple days later. And again you can see his normal right testicle. Now his left testicle is showing some signs of these white arrows, the demarcated area that is hypoechoic. It's pretty well circumscribed, we put color on it, we can see that there's hypervascularity all around that margin, but not within it, not in this area, but it's all around, and that is a typical look of advancing abscess formation. That's what's going on here, that there was infection throughout that testicle, but now it's becoming walled off creating an abscess. Why no vascularity in the center, because this is just a collection of perulent material, no blood flow into the pus. So we don't have any blood flow there. This patient went to the OR. They thought they might have to do an orchiectomy, but they just drained it and this patient at least at that time did not have to undergo an orchiectomy. So this is the mediastinum pestis, and the infection is centered around that. So that's what's going on at that point. So, this is epididymal orchidus, and it's cause in pre pivotal voice remains controversial. Most cases of epididymitis in adults are related to a sexually transmitted disease, but not all of them. The infection ascends from the bladder or urethra. It's usually treated with a course of antibiotics against the usual urinary pathogens, but in this age patient and STD is not the source of epididymitis in pre pivotal children and pre pivotal children. The bladder is more often associated with constipation and straining leads to retrograde well of urine. So, when I think of epididymal orchidus I always wondered, why do these pre pivotal children get this, because we do see a fair number of them. In this patient we were able to culture that, and it was pseudomonas oligonosa. And so, obviously, that is not a sexually transmitted disease. So, just a nice example of different pathologic pathway. So, the next patient also is infection, had an infection and this is a four year old with fever, and you can appreciate on that chest x-ray why he would be short of air. And you can see the diffuse opacification, the long parankama on the right side and even some on the left. And there was concerned that there might be an empaima. The patient got ACT and this was necrotizing pneumonia and there was in fact empaima. The patient was diagnosed with strep sepsis. So, as part of this chest CT, we always take the chest CT down to the level of the kidneys and that's where the GU part comes in. So, as we do that, we see that the kidneys marked with red arrows have striated nephrogram. And so, at that appearance I thought, wow, why does this person have pylonephritis or nephritis. So, as I reported that, the team started looking at the patient for why he had nephritis and they did ultrasound of the kidneys and bladder. And you can see here a very nice correlation of this striated nephrogram on CT with a striated nephrogram on ultrasound. So, as we have this correlation and it still leaves us asking the question, why does this patient have nephritis when he has no UTI they did not find UTI his urine was clean. And so they did not treat him for UTI. So, as a investigation into that, we can see that the striated nephrogram is synonymous with renal infection. Most nephritis comes from the UTI origin. So, it's mostly that the patient has a bladder infection, and it refluxes up to the kidney through the collecting system, and then ultimately to the renal parankma and even sometimes causing inflammation in the urine if it's bad. So, that is the usual course of the infection. But in our case, patients did not have any UTI. So, there was no bladder infection. How does he get nephritis? It is because he has sepsis. He has pathogen that is delivered hematogenously directly to cortex of the kidneys. And it's bilateral, of course. So, so that's how this patient ends up having nephritis without a bladder infection. So, moving on to the next patient with an infection. This is a 12 year old morbidly obese patient and I add that information because it's very applicable to this patient's case. So, the patient got this study at an outside facility, and you can see that the midline and the uterus looks pretty normal and the bladder looks normal as well. It's partially filled. This patient was having pain in the pelvis. So, of course, we would have to rule out appendicitis first, but ultimately we arrived at looking at the rest of the pelvic structures. As you can see on the right and left side very similar appearance. This is a structure that we have seen already in this talk. So, you can see a tortuous tubular structure, and we see them on both sides. The pink asterisks mark the fallopian tubes, and they're filled with complex fluid. So this is debris, and this is compatible with a pyocel pinks. So these fallopian tubes are very distended filled with infection. And there's bilateral tubular ovarian access. So, the patient at the outside facility got a CT, and so it was a great opportunity to see the same structures on CT. You can see the red arrow on the far left, your left image. This is inflammation that is all around the inferior aspect of the liver margin. There's a trace amount of fluid there. If you go down further in the pelvis, the red arrows, demarcate the very angry looking bowel. There's a lot of inflammation surrounding it. Here, make note of the very endematous loop of bowel and the inflammation around it. So, this is both of them, the right and the left, which we saw on ultrasound, and there's a lot of dilatation, and they're both fluid filled, and this is all infection and inflammation surrounding them. And here on the sagittal view, you can see the very similar appearance of the fallopian tube that we saw on the ultrasound, but there it is. And once again, originally you may think that this is a segment of bowel, but without any peristalsis, and given its position, then we turn our attention to potentially the dilated fallopian tube. And that is it on CT as well. So, the patient did not actually progress to get better. So, eventually another CT was performed, and you can see on this CT, the patient has a walled off abscess. She has only abscess the patient had, but it's good enough to be able to give you the idea of what's going on. So she has multiple abscesses in the peritoneum. You can see some fluid and inflammation around as well. So of course, our first thought on this patient was that this may be sexual abuse. She's only 12. How else would a person get tube ovarian abscesses. So, there was a lot of evaluation done. And also this abscess was, we did a culture of it, and it grew out staff and E. coli, and these are not pathogens that we see from sexually transmitted disease. So, as you may recall, I told you this patient was morbidly obese. And that was a very important factor in her presentation. She was not able to even walk down a hall. She could not stand in the shower long enough to take a shower. So she just didn't. And she had very poor hygiene she also struggled with issues of incontinence. She wore a diaper to bed. And these factors contributed to her situation of infection. This was not sexually transmitted disease, but rather this was result of her hygiene situation. And this is very typical of what you see in Fitzhugh Curtis syndrome, which is perihepatitis inflammation associated with PID. And so this patient had an infection down at the, at the level of the vagina and made its way through the uterus out through the bilateral fallopian tubes, and into, once it gets past the fallopian tubes, it's out in the peritoneum. It can surround the ovaries, but it can also surround loops of bowel. And this patient had inflammation around the loops of bowel as well, and around the liver margin. She did not have any around the dome of the liver. So we didn't see these violent strings which are a result of infection there and adhesions. That's a very good example of Fitzhugh Curtis and how it progresses. This is a companion case, a 16 year old who presented to the ER with left pelvic pain, and she got an ultrasound burst and you can see that she has a structure that you might think is the ovary, but there were other findings around it. And this ovary area measured five and a half centimeters and that is very large for an ovary. Usually they're about three, two to three centimeters, but not five and a half in a otherwise normal young teenager. So this was abnormal finding, along with other findings of inflammation. So she went on to get a CT. And so there's a very nice correlation. This turned out to be a tribo ovarian abscess, which you can see here. And there is the very dilated fallopian tube with the surrounding infection and inflammation, the right ovary area that next to look the same, not quite as far progressed. And as I mentioned earlier, there's a lot of inflammation to the bow there's that thickened valve wall that we saw on the other patient as well. On coronal image, you just see this tuba ovarian abscess in another plane. So the patient and the parents confirm patient was not sexually active at all. And there was a lot of evaluation of this patient. And eventually it was determined that it was probably from a tampon left in too long or a hygiene issue. And so the takeaway point for this is that we've seen two cases of tuba ovarian abscess or PID that was not sexually transmitted disease. I don't know about you, but generally when I see PID, I think sexually transmitted. But I just want to show you that there are other methods of having that same diagnosis. And then moving on to trauma. This young patient, six years old, a female who came to the emergency department, and she had been in an all terrain vehicle accident and thrown forward against the handlebars. And you can see on these multiple images that we did the exam that typically is done for very young patients, children, they don't start out with a CT for their trauma they start out with an ultrasound. We ultrasound all four quadrants. And then we ultrasound the heart area and we're looking for solid organ injury. So when we see all this fluid that you see in the around the liver margin and in the right lower quadrant and bilateral sides of the pelvis. And we start worrying about in a solid organ injury so that warrants a CT. So she went on to get a CT.  You can see the compression of the superior margin of the thoracic vertebrae loss of her tibial height. This confirms her mechanism of injury. And you can see here that she had quite a bit of fluid in her abdomen and pelvis. She might have had a full bladder when she had this accident because we see the typical injury to the dome of the bladder that you see here with the yellow arrow. This is the injury to the dome of the bladder where all the fluid from the bladder is escaping into the nearby area. And in this case, when it's the dome of the liver that's injured. It's usually a peritoneal interperitoneal rupture of the bladder. And so the fluid blows around all these loops of bow, and that is confirmation that it is a peritoneal rupture, not an extra peritoneal. So, here you can see that the contrast was instilled in the bladder through this balloon tip catheter. And you can see that there's some air and contrast is just coming out into the peritoneum. So this patient had to go to the OR because that is how the peritoneal bladder rupture is treated interoperatively. That's in contrast to this patient who came to our ER after a motor vehicle accident, and he probably didn't have a full bladder. So the injury is to the anterior margin of the bladder, and the contrast is escaping into the space anterior to that. It's more of a confined space, and usually into the space of rhexia is a potential space. And that's why on a plane radiograph, it will stay kind of in close proximity instead of flowing all around. And so this patient is able to collect there and it gives that flame shape. And so that is the classic parents. And so it can also flow into the retro peritoneum, but this one seems to be mostly collecting anteriorly, not completely, but here you can see it actually in that anterior space. And so the patient was treated as typical treatment for an extra peritoneal bladder rupture. And that is by placing a catheter in the bladder, decompressing the bladder, keeping it decompressed and allowing it to heal. So the patient was sent home with a bladder catheter, and he returned several days later, nine days later he came back. He had urosepsis. And here you can see his bladder, the injury did not heal. And he has this large collection of fluid with gas lockules throughout it and an air fluid level, some enhancement of that collection. So this patient required a percutaneous brain. So comparing these, we have the extra peritoneal bladder rupture that is generally treated with catheterization to allow healing to the bladder as the bladder is decompressed. But the intraperitoneal bladder rupture is treated with surgery. These people go to the OR because the large absorption of urine leads to electrolyte and metabolic abnormalities. So just the two different pathways that are taken for the different type of bladder injury. And we move on to forget a tumor case. This is a 14 year old male with hematuria for a few weeks. And recently he developed a thuria. So he presents to the ER, like so many people do. And this, as any child presenting with macro hematuria, we want to ask the history, has there been trauma? And in our patient, no. Urinary tract infection, because sometimes they can become hemorrhagic. But he hasn't had that. And personal family or family history of nephrolabiosis, sometimes the movement of the renal stone through the uriner can cause bleeding. So what we want to ask next is the hematuria T colored or pink or red. And this T colored, we think something farther away from the bladder. So we're thinking glomerulonephritis because it is the most common cause of hematuria in a child. But if it's pink or red, then we think something down at the bladder or close to it. And that's what this patient had. So we went on to do an ultrasound of the kidneys and the bladder. And the kidneys were totally normal. So I'm not showing them, but the bladder look like this. And we can see the transverse and the sagittal view of the bladder. And there was this ecogenic focus along the posterior aspect of the bladder. And it's somewhat irregular. This patient has had hematuria. So you could maybe think this might be a thrombus as anybody might think in a patient who is having bleeding. So we then astutely the technologist put color and you can see the usage of color is very helpful. In this case, the blood flow into that area is not compatible with the thrombus. We didn't see blood flowing into pus and we don't see blood flow into thrombus. But since we see blood flow into this area, it is a concerning finding. So now we must go to investigate this more fully. And the patient got a CT. And so we can see a nice correlation here. This looks very sinister. It looks like a mad scientist. These are the bronze extending from this. It has a single stalk. And in fact, it is very sinister. This turned out to be a transitional cell carcinoma in a 14 year old male. So very unusual did not expect to see this in the ER. So the takeaway there is that you want to see if you see blood flow into a structure. It's not something inert, like a thrombus. And then a couple of incidental cases. This is a 16 year old male with right scrotal pain that began at 5am and now it has been present for three and a half hours and he said no trauma. He has just a small hydro seal on that right side. And here you can see that the comparison image of the testicles shows pretty symmetric flow of vascularity. So things are looking pretty good there. I mean, we're thinking about because he has trauma, I mean, no trauma, but a sudden onset scrotal pain. I have to think it could be a torsion, but it doesn't look that way on this image. The patient then got the typical images to look for the vascular flow and we can see the submitted images include a normal arterial waveform and a normal venous waveform. But at first glance, this looks like a pretty normal study and doesn't explain the patient's pain. But if you look in epithelial spermatic cord, you can see this whirlpool kind of appearance of the vascularity that is concerning. So we have normal right arterial flow, but as we interrogated the technologists a little more about this and there was concern. I asked her, is there a lot of venous flow there or did you have trouble getting a venous waveform and she said no, that was the only venous waveform she could get throughout the testicle. And she did not declare that on her tech sheets. So that was unfortunate. But nevertheless, you can see on this ultrasound, this whirlpool kind of appearance of this of this traumatic cord. There it is. And the patient went to surgery. The patient was found to have right testicular torsion with twisting of this traumatic cord by 360 degrees. That was on the op report, and the testicle appeared dusky at first but as it was detourced. It became more viable looking and patient escaped an orchiectomy, which is a great thing for this patient. So, this is testicular torsion. If we look at this rapidly, and didn't investigate any further. We might have thought that this patient had a normal exam. But the important thing is to be aware of the difficulty to find the venous flow, which is much more affected by torsion than arterial flow, because that the venous structures are just more pliable and easy to crimp. And it's in very, very important to look for the torsion of this traumatic core. And the next patient was not so lucky. This is a 23 month old, who had fertile swelling. And they thought maybe the patient had an inguinal hernia. So the patient came in and we see this left testicle in the area of concern. And it looks maybe a little bit heterogeneous. They're definitely inflammation around it. And you can see that they used power Doppler to get some flow in this testicle. And there's a lot of flow around it. And the epididymis. And ultimately they, with using power Doppler, they were able to get this arterial waveform. And you can see the inflammation around that testicle and in the epididymis. And you can see that there's inflammation up at this chromatic cord, and a lot of hypervascularity around that. So the latest was evaluated was that it was thought to be epididymitis causing inflammation of this chromatic cord, veneculitis, and power Doppler showed a single focus of vascular flow, which redirected the impression away from torsion. So, so then this patient was sent home on antibiotic because they thought he had epididymitis, and he came back 24 hours later, at which point, I saw this patient and you can see that there's a lot of inflammation around the left hemi scrotum, the left testicle and the epididymis, they're all edema, heterogeneous, maybe a little worse than yesterday. They did manage to give me an arterial waveform there, there's the cursor. And then in the left spermatic cord region, we can see this area that looks sort of circular. I didn't like it. But I did look back, I have to say that I, I looked back at the previous exam on previous day. And when I saw this, I just did not like it for this patient because the testicle looked so bad. And this looks like the, you know, the flow toward the probe and the flow away. It's kind of as a ying and the yang, it's making it circle there. I called GU, I said, please take this patient to the OR and they did and this patient had a necrotic left testicle. And so, that was a sad case because there was not enough attention given to this chromatic cord. So that's my takeaway for that. I don't want to leave the females out on the torsion issue. This is a 12 year old female with acute onset of nausea and vomiting and pain. And she had an ultrasound, you can see her right ovary is very abnormal looking there. The follicles are seen along the margin. This is a genic test of sorry ovary. And here on this image is the clincher. This ovary measures eight centimeters by 5.4 centimeters so we could not find her left ovary. And so even though we couldn't find it we know that this is very abnormal. This is just way too big. And the follicles along the margin and the echo texture, possibly a teeny bit of fluid there are all consistent with ovarian torsions very classic look for it. And this patient went to the OR and sure enough that was ovarian torsion so just nice to show a comparison of ovarian torsion as well as testicular torsion. And here on our own points are indirect inguinal hernia is one of the most common congenital abnormalities in the children about a fifth to a sixth of the female patients, the hernia sac contains its lateral ovary. Something I just wasn't aware of before I saw this case. Adult epididymitis is a result of STD quite frequently not always but quite frequently. It ascends from the urethra, but in pre pubertal children, it's not from STD but more from constipation straining leads to retrograde flow of urine. And nephritis is mostly from reflux from infection from the bladder to the collecting system but with sepsis the infection can be introduced hematogenously into the kidneys without a UTI. Pelage inflammatory disease is not always sexually transmitted disease. I know I think that immediately but here you can see that it is can be related to hygiene. Intraperitoneal bladder rupture is treated surgically due to electrolyte imbalance and extra peritoneal with a catheter, which usually works but not in the one patient I showed you. This is a distinguished thrombus from math with color Doppler. If we had stopped thinking, just with thinking that was Thomas from the hematuria then we would have really missed an important finding. And the world pool sign of the spermatic cord is the most definitive evidence of testicular torsion. And that concludes these are my references, and I'm grateful for them. And that's the end of my presentation. So, now I am going to see if we can answer some questions. So, let's see. And I'll just ask if Ashley has anything to tell me or I'll just read some of these off for the kidney size or use age as sole evaluation of enlargement for the kidney size. Well, it is very good to make that kind of evaluation. And when people are, when you have a pediatric patient, and you are being evaluated for a pediatric condition, I would say that you would want to refer to the charts to sort of give guidance to that, but in the ER. And this is, even though this is a young patient 17, the enlargement really don't have to look at a chart for that age patient. This age patient is pretty much an adult size. And we know adult sizes. It's up to 15 centimeters. And you have an abnormal look. We know that's enlarged. But yes, I have definitely in my pediatric practice, use charts to look at sizes to get an idea. So I would say it's good to do that. And cortical width on renal ultrasound. I would say you would just make sure that you have your ultrasound probe in the correct position. And you might take a couple of different images and see what the measurements are. You might take measurements that are very close to each other. And then ultimately you'll be able to get probably a median of those, those measurements. So, in, in these cases, the exact measurement of the kidney was not as critical as it may be in some other instances. Well for indirect radio-nuclide cystography and evaluation of the reflux. This is actually not a thrust of my talk, but I do know that we don't like to do the fluoroscopy evaluation like we used to. So a radio-nuclide study can be useful. I would say that if you have a patient who has significant factors like multiple infections, UTI infection, you have ultrasound that demonstrates that there's abnormalities in the dilatation of the collecting system and ureters that getting to the bottom of that. With looking at a, our reflux evaluation is very important. And I think it would justify doing that either by fluoroscopy or radio-nuclide either way, either one. And then the distinguish between intra and extra peritoneal fluid in the case of bladder rupture. As I mentioned, it is best to, if you see the fluid flowing around the leaps of bowel, then you can be sure that you are in the peritoneum. The leaps of bowel are, you don't see those in the extra peritoneum. So that is a very good way. And the other way is just like if you're trying to inject into a patient, say, through a tube and it extravisates into soft tissue. That's the same kind of thing that you see in an extra peritoneal bladder rupture. It just stays confined. And that's a very good way to be able to tell that. When it stays confined, you get that flame shape and instead of flowing. So that's the best way. And how common it fits your cortis syndrome in patients with PID. Not very common and honestly, as I have looked, now I'm not in the field of GYN. So I may not see all the cases that they see, but I can tell you lots about cases in the emergency department, which a lot of them will come through, that I have not really seen other cases if it's your cortis syndrome. So it's, it's not very common, but often talked about how do you see the liver to avoid Rydale lobe. Well, I, I think it's kind of a gestalt of looking at the configuration of the liver in all three planes, your coronal, your sagittal, your axial. And, and you should be able to get a good idea whether that's a Rydale lobe and not included if it, if it is a Rydale lobe. So, in fact, the importance of knowing if you have the petomegaly is probably going to hinge more on whether you have caudate enlargement and left lobe enlargement that's usually the cases that you see it in. So that's going to be a big help to you to evaluate those the relative hypertrophy of the left lobe and renal cause extra renal causes in case of changes as initial presentation. I'm not trying to understand that. But there's, can we find any relation between a topic testicular and indirect hernia relationship, not that I'm aware of. So, I'm sorry I can't really help you with that particular question. So, no open questions. All right. I thank everyone for joining me. And I had, I'm very glad that I got to share this information. So thank you. Thank you so much for your lecture today and thanks for everybody for participating in our new conference and a special thanks to our co-sponsor AAWR. You can access the recording of today's conference and all our previous new conferences by creating a free MRI online account. Be sure to join us next Thursday, January 19th at 12 p.m. Eastern for a lecture by Dr. Marcelo de Ebreu on spine degeneration and inflammation. Our next AAWR co-sponsored lecture is January 26th with Dr. Bissau who will give a talk on breast advocacy updates. You can register for these lectures at mrnline.com and follow us on social media for updates on future new conferences. Thanks again and have a great day.