{"paper_id":"6d3d0d89-cf7a-457d-b688-eb36715fdc9f","body_text":"Vaginal lesions are detected at physical gynecological examination and, in a large\nportion of cases, the diagnosis is made by means of biopsy and anatomopathological\nanalysis. Ultrasonography is utilized for complementary evaluation, but with a narrower\nscanning area and, consequently, limitation for locoregional staging. Computed\ntomography (CT) has poor contrast resolution and is limited to the diagnosis of pelvic\nlymph nodes in malignant diseases. Thus, over the past years, magnetic resonance imaging\n(MRI) has become the method of choice for the diagnosis of vaginal lesions, tumor\nstaging, postoperative follow-up and treatment (chemotherapy and radiotherapy) response\nevaluation ( 1 , 2 ) .\nMRI has gained ground in the evaluation of vaginal diseases due to its increasing\navailability and technological developments, which has allowed the development of faster\nand better quality protocols. Such protocols characterize the vaginal anatomy in detail,\nas well as its relationship with pelvic structures, besides allowing for a dynamic study\nduring Valsalva maneuver, in the clinical suspicion of perineal descent. Additionally,\ndiffusion and perfusion techniques have the potential to provide functional data to the\ntraditional anatomical study.\nThus, the present study illustrates the role played by MRI in the evaluation of vaginal\ndiseases, describing the main findings of relevance in the decision making about the\nclinical approach.\n\nA 1.5 T MRI apparatus (General Electric; Milwalkee, USA) was utilized for images\nacquisition with T2-weighet fast spin echo (FSE) sequences, in the axial, sagittal and\ncoronal planes, and T1-weighted gradient-echo (GRE) sequences. The diffusion technique\nwas utilized with a high b value (~ 1.000 s/mm 2 ) that is useful in the pre-\nand posttreatment evaluation of tumor lesions, as well as in the detection of lymph node\ninvolvement. Contrast-enhanced T1weighted sequences are routinely utilized in\nvagina-dedicated protocols; however, in some cases such images acquisition was not\nnecessary. The use of aqueous gel is desirable and should be done whenever possible as\nit distends the vaginal cavity, allowing for a better evaluation of intraluminal lesions\nand parietal infiltration.\n\nThe vagina is a median fibromuscular tubular structure that extends from the uterine\ncervix to the vulva, with an estimated length between 7 and 9 cm. whose wall consists of\nthree layers as follows: mucosa, muscle and adventitia. Its anatomy is better studied at\nT2-weighted sequences, which can demonstrate the mucosa and intraluminal secretions with\nhigh signal intensity in contrast with the muscle layer, which presents with markedly\nlow signal intensity ( Figure 1 ).\nNormal female pelvis. Axial ( A ) and sagittal ( B ) MRI\nT2-weighted images showing anterior compartment containing the urethral ostium\n(Ur) and the ostium of the bladder (B), the medial compartment containing the\nuterus (U), the uterine cervix (C), the vagina distended with gel (V), the\nanterior wall of the vagina (AW), the posterior wall of the vagina (PW), the\nvaginal vestibule (VI) and the posterior compartment with the rectum (R).\n\nIt is a vertical fusion defect that occurs around the 20th gestational week, like\nother congenital vaginal malformations. It divides the vagina into two segments,\nreducing its functional length and causing obstruction of the vaginal canal.\nMRI is indicated for planning the septoplasty, as it evaluates the septum thickness\nand allows for the identification of the uterine cervix. It also can differentiate\nbetween upper vaginal septum and cervical agenesis, a relevant information to define\nthe surgical approach ( 2 , 3 )  ( Figure 2 ).\nUterus didelphys, longitudinal and transverse vaginal septa. MRI T2- weighted\n( A,B,C ) and T1-weighted ( D ) sequences\ndemonstrating longitudinal septum (thin arrow) dividing the vagina into two\nparallel cavities. The left hemivagina (asterisks) is obstructed by a\ntransverse septum (thin arrowhead) and distended by hematic contents (high\nsignal on T1- weighted image). Displaced and compressed right hemivagina at\nright (stars), right uterine horn (bold arrowhead), left uterine horn (bold\narrow).\nLongitudinal vaginal septum is a lateral fusion defect of the Müllerian ducts,\nresulting in duplication of the uterus and vagina, in variable degrees ( 2 )  ( Figures 2  and  3 ).\nLongitudinal vaginal septum. Contrast-enhanced MRI T2- weighted\n( A,D ) and T1-weighted ( B,C ) images showing\nlongitudinal vaginal septum (arrows) dividing the vagina into two chambers. Ur,\nurethra; V, vagina. The identification at MRI may be difficult as the presence\nof the vaginal septum is not associated with obstruction.\nThe hymen is a dermal membrane that wholly or partially occludes the external orifice\nof the vagina and is generally perforate. Imperforate hymen represents a failure in\nthe vaginal recanalization process, and the diagnosis occurs mainly in the infancy by\nthe bulging of the vaginal ostium caused by mucous secretion secondary to maternal\nestrogen stimulation, or during menarche ( 2 )  ( Figure 4 ).\nImperforate hymen (arrow). MRI T2-weighted ( A ) and T1- weighted,\nsagittal ( B ) and coronal ( C ) sequences demonstrating\nuterus (U) and vagina (V) distended by hematic contents, which extends\ninferiorly protruding the ostium.\nAndrogen insensitivity syndrome determines failure in the development of the external\ngenitalia in individuals with the 46,XY karyotype. Such syndrome results in decrease\nor absence of biological activity of androgens due to mutations in their receptor\ngene located in the X chromosome. Clinically, it may manifest as female phenotype\nwith several degrees of virilization, secondary to partial or complete androgen\ninsensitivity.\nThe diagnosis is usually made in puberty due to primary amenorrhea, and the testicles\nmay be found in the inguinal canal, in the labia majora and in the abdomen ( 4 )  ( Figure 5 ).\nPartial androgen insensitivity syndrome. Multiplanar MRI T2- weighted sequences\n( A,B,C ) and T2- weighted sequence with fat saturation\n( D ) demonstrating masculine false hermaphroditism (46,XY) in a\n21 years old patient with female phenotype and ambiguous genitalia,\ncharacterized by a short vagina (V) and presence of a micropenis (thin arrows).\nThe images of the pelvis demonstrate neither uterus nor ovaries, and the\ntesticles are located in the inguinal canals (bold arrows). Observe the\nhypertrophic rectoabdominal muscles, and the scarcity of subcutaneous fat\ncaused by testosterone activity.\nIt is a syndrome characterized by vaginal aplasia associated with other anomalies of\nthe Müller ducts. The classical presentation consists in the absence of the uterus\nand of the proximal two thirds of the vagina, with variable degrees of compromising\nof these structures. Type I is characterized by isolated absence of the proximal two\nthirds of the vagina, while type II is characterized by the presence of other\nmalformations such as vertebral, cardiac, urological and otological\nanomalies ( 5 )  ( Figure 6 ).\nMayer-Rokitansky-Kuster- Hauser syndrome (complete presentation). Multiplanar\nT2-weighted sequence ( A,B,C ) showing absence of the uterus and of\nthe upper third of the vagina (V) between the rectum (R) and the urethra (Ur).\nThe pelvic images confirm the presence of normal ovaries and large cystic mass\nin the left ovary.\nTurner syndrome (or 45,X) is the most common chromosomal sexual abnormality in women,\nand one of the main causes of primary amenorrhea. It is characterized by the absence\nof a copy of the X chromosome (45,X0), and is associated with hypertension, glucose\nintolerance, inflammatory bowel disease, hypothyroidism and gonadal dysgenesis.\nTypical MRI findings include streak uterus and ovaries, and short vagina ( 4 )  ( Figure 7 ).\nTurner syndrome. Multiplanar MRI T2-weighted sequence ( A,B )\ndemonstrate streak uterus and ovaries (arrow), short vagina (V) located between\nthe rectum (R) and the urethra (Ur).\nGartner duct cyst is related to incomplete involution of the vaginal portion of the\nmesonephric duct. Generally, such cysts are small and asymptomatic, however they may\ncause dyspareunia, interfere with obstetric delivery and associate with urogenital\ntract malformations. They are located in the anterolateral and upper walls of the\nvagina, above the pubic symphysis ( 1 , 3 )  ( Figure 8 ).\nGartner duct cyst – axial ( A1 ) and sagittal ( B1 ) MRI\nT2-weighted sequences demonstrating a cyst located in the left lateral vaginal\nwall, above the level of the pubic symphysis. Bartholin gland cyst – axial\n( A2 ) and sagittal ( B2 ) T2-weighted sequences of\nanother patient demonstrating cystic lesion outside the vaginal canal, on the\ndistal posterior wall of the vagina at right.\n\nBartholin glands are derived from the urogenital sinus, secrete mucus and are located\nin the vaginal vestibule. Bartholin gland cysts develop due to duct obstruction and\nare located either at the same level or below the pubic symphysis. They are generally\nasymptomatic, but may require drainage due to infection or development of\nabscess ( 1 , 6 )  ( Figure 8 ).\nSkene glands are small periurethral glands located in the vaginal dome, adjacent to\nthe inferior border of the dis-tal urethra and visible in cases of infection or\nobstruction. They are the equivalent to the male’s prostate and the main producers of\nPSA in women. Additionally, they are hormonedependent, increase in size during\npregnancy and present atrophic in the climateric ( 6 , 7 )  ( Figure 9 ).\nCysts of the Skene glands. Multiplanar MRI T2-weighted ( A,B ) and\ncontrast- enhanced T1-weighted ( C,D ) sequences identifying distal\nperiurethral cysts (Ur) (arrows) located between the urethra and the\nvagina.\nGiant condyloma acuminatum or Buschke-Loewenstein tumor of the perianal or anorectal\nregions is a rare entity.\nGenerally, such lesions are large-sized and aggressive, prone to ulceration and\ninfiltration into deeper tissues. They present high rate of recurrence (66%) as well\nas high rate of malignant transformation into squamous cell carcinoma (56%), but\nwithout distant metastases ( 8 ) \n( Figure 10 ).\nGiant condyloma acuminatum. Contrast-enhanced, multiplanar MRI T2- weighted\n( A,B ) and T1-weighted ( C,D ) sequences of the\npelvis demonstrating multiple cauliflower-like verrucous lesions in the\nanogenital region (arrows). After contrast medium injection, marked contrast\nuptake by the lesion was observed.\nEndometriosis is defined by the presence of endometrial glands and stroma outside the\nuterine cavity. Frequently, it is found in pelvic fibromuscular structures such as\nuterosacral ligaments and ovaries. Vaginal location is frequent and may manifest with\ndeep dyspareunia and dysmenorrhea ( 9 )  ( Figure 11 ).\nMultiplanar MRI T1-weighted ( B ) and T2- weighted\n( A,C,D ) sequences of the pelvis demonstrating the presence of a\nfocus of endometriosis with low signal intensity in the vaginal dome (bold\narrows), with signs of local tissue retraction and extension to the anterior\nwall of the rectum, characterizing infiltrative endometriosis intermingled with\na focus of high signal intensity corresponding to hemorrhagic focus (thin\narrow). V, vagina; R rectum.\n\nPrimary vaginal neoplasms are rarely found. Spinocellular carcinoma represents\napproximately 85% of the primary malignant tumors of the vagina and develops from the\nposterosuperior vaginal wall ( Figure 12 ). Other\nprimary tumors are mainly adenocarcinoma, melanoma ( Figure 13 ) and sarcomas ( 10 ) .\nSpinocellular carcinoma. Axial ( A,B ), coronal ( C ) and\nsagittal ( D ) multiplanar MRI T2- weighted sequences showing the\npresence of a solid, lobulated mass in the posterior and right lower vaginal\nwalls (V). The tumor infiltrates the rectovaginal fat plane (arrows).\nVaginal melanoma. Sagittal ( A1 ) and axial ( B1 ) MRI\nT2-weighted sequences showing the presence of a lobulated mass with low signal\nintensity (arrows) affecting the anterior and posterior vaginal walls,\nextending throughout its entire length up to the vaginal ostiuml. MRI of\nanother patient – contrast-enhanced T1-weighted sequence with fat saturation\n( A2 ) demonstrates a hypervascular lesion deeply invading the\nvagina. Diffusion-weighted image ( B2 ) acquired with b = 750\ns/mm 2  shows significant diffusion restriction (arrows).\nStaging: stage 0 – carcinoma  in situ ; stage I – tumor limited to the\nvaginal wall; stage II – tumor involving subvaginal tissue, without extension to the\npelvic wall; stage IIItumor extending to the pelvic wall; stage IV – tumor extending\nto the true pelvis or involving the mucosa of the bladder or rectum; stage IV a –\ninvolvement of adjacent organs; IV b – involvement of distant organs.\nSecondary neoplasms of the vagina are more common than the primary ones and represent\n80% of the vaginal tumors ( 10 ) ,\noccurring by direct dissemination of tumors from adjacent pelvic organs ( Figure 14 ), and rarely being of lymphatic or\nhematogenic origin. Most commonly, ovaries, endometrium, uterine cervix and rectum\nare sites of origin of such neoplasms ( Figure\n15 ).\nUterine cervix adenocarcinoma with locally invasive tumor. Sagittal\n( A ) and axial ( B ) MRI T2-weighted sequences\ndemonstrating a heterogeneous and infiltrative lesion extending towards the\nvaginal dome, rectovaginal septum and mesorectal fascia (arrows). V, vagina; U,\nuterus.\nVaginal metastasis from ovary adenocarcinoma – Axial ( A1 ) and\nsagittal ( B1 ) multiplanar MRI T2-weighted sequences demonstrate\nlymph node enlargement (asterisk) and peritoneal carcinomatosis, including an\ninfiltrating lesion in the vaginal dome (arrows). V, vagina. Vaginal metastasis\nfrom endometrial carcinoma – Axial ( A2 ) and sagittal\n( B2 ) MRI T2-weighted sequences demonstrating the primary tumor\nfilling the endometrial cavity (U) and a well-defined nodule (skip lesions)\nwith intermediate signal intensity in the right anterior wall of the vagina\n(arrow). V, vagina. Vaginal metastasis from uterine cervix squamous cell\ncarcinoma – MRI T2-weighted ( A3 ) and contrastenhanced T1-weighted\n( B3 ) sequences demonstrating ill-defined mass originating from\nthe uterine cervix and extending towards the lower uterine segment and lower\nthird of the vagina (arrows).\n\nIt is a prevalent and debilitating symptom caused by the weakening of the pelvic\nfloor and looseness of suspension structures. Main risk factors include multiparity,\nadvanced age, menopause, obesity, conjunctival tissue diseases, smoking and chronic\npulmonary obstructive disease. The symptoms are related to urinary and bowel\nincontinence, and sexual dysfunction ( 11 )  ( Figure 16 ).\nPelvic floor prolapse. Sagittal ( A ) and dynamic axial\n( B ) MRI T2-weighted sequences demonstrate large prolapse of the\nurogenital hiatus characterized by inversion of the vaginal dome, small bowel\nloops and abdominal fat protrusion.\nRadiotherapy is widely utilized in the treatment of gynecological cancer,\nparticularly in the case of uterine cervix cancer, and may trigger the development of\nfistulas, induce progressive obliterating endarteritis, resulting in mucosal surfaces\nnecrosis/rupture. Approximately 2% of the patients submitted to radiotherapy for\nuterine cervix cancer develop fistulas that may occur up to 30 years after the\ntreatment ( 12 )  ( Figure 17 ).\nPost-radiotherapy complications.  A1:  Fistulous path (thin arrows)\nbetween the anterosuperior vaginal wall and the vesicouterine pouch. A small\namount of heterogeneous fluid (asterisk) and anterior displacement of the\nperitoneal fold (bold arrow) are observed. V, vagina; U, uterus; B, bladder.\n A2:  Fistulous path (arrows) between the rectum and the vagina.\n A3:  Large vesicovaginal communication (arrows). Distension of\nuterine cavity determined by cervix stenosis (U). V, vagina; B, bladder; R,\nrectum.  A4  Stenosis of the upper third of the vagina, 10 months\nafter radiotherapy (late complication).\nSex reassignment surgeries have been performed for more than 30 years. The surgical\nprocedure includes bilateral orchiectomy and penectomy and creation of urethrostomy,\nneovagina, labial structures and neoclitoris. MRI is the best imaging method to\nevaluate the pelvic anatomy in such patients ( 13 )  ( Figure 18 ).\nSurgical evaluation for maleto- female sex reassignment. Axial\n( A,B ) sagittal ( C ) and coronal ( D )\nMRI T2- weighted sequences demonstrate neovagina (bold arrows) and the remains\nof the corpora cavernosa and of the corpus spongiosum and urethra (thin\narrows).\n\nMRI is a very useful tool to evaluate the vagina and can provide essential data for\ndiagnosis, therapeutic planning, detection of complications and follow-up. Thus,\nradiologists must be familiar with the scan protocols and with the data that must be\nreported for appropriate clinical decisions making.","source_license":"CC-BY-4.0","license_restricted":false}