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Keyanoosh Hosseinzadeh, MD • Matthew T. Heller, MD • Golbahar
The female perineum is a diamond-shaped structure inferior to the
pelvic diaphragm and between the symphysis pubis and coccyx. The
perineum is divided into the anterior urogenital triangle and the pos-
terior anal triangle; the vulva represents the external genitalia. A wide
array of diseases affect the female perineum in adults. Vulvar trauma,
infection (including Fournier gangrene), developmental lesions, and
thrombophlebitis can be investigated with various imaging modalities;
vulvar malignancies are best imaged with magnetic resonance (MR)
imaging to identify local-regional extent of disease. MR imaging is also
the modality of choice for imaging of the distal urethra, although imag-
ing of a urethral diverticulum also includes voiding cystourethrography
and ultrasonography. The distal vagina at the level of the introitus is best
imaged with MR imaging for assessment of Bartholin gland cysts and
malignancies. Diseases encountered in the anus include anal carcinoma,
fistula-in-ano, and anovaginal fistula, which can all be imaged with vari-
ous modalities offering different sensitivities and fields of view. Lastly,
musculoskeletal neoplasms affecting the perineum and vulva include
mesenchymal, lipomatous, nerve sheath, and osseous neoplasms. These
neoplasms can be imaged with both computed tomography and MR
imaging, although the latter provides higher soft-tissue contrast and
greater anatomic detail for diagnosis and determination of the extent of
necessary surgery. Familiarity with the anatomy of the female perineum
and appropriate selection of imaging modalities facilitate prompt and
accurate diagnosis and treatment.
©RSNA, 2012 • radiographics.rsna.org
Imaging of the Female
Perineum in Adults1
After completing this
will be able to:
■Describe the anat-
omy of the female
perineum in adults
and identify relevant
unique to the female
perineum in adults.
strengths and weak-
nesses of the various
for appropriate diag-
nostic imaging and
planning of therapy.
Abbreviations: AAM = aggressive angiomyxoma, FDG = 2-[fluorine 18]fluoro-2-deoxy-d-glucose, MRSA = methicillin-resistant Staphylococcus aureus,
NHL = non-Hodgkin lymphoma, VCUG = voiding cystourethrography.
RadioGraphics 2012; 32:E129–E168 • Published online 10.1148/rg.324115134 • Content Codes:
1From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Presby South Tower, Suite 3950, Pittsburgh, PA 15213.
Presented as an education exhibit at the 2010 RSNA Annual Meeting. Received June 21, 2011; revision requested July 19 and received September 1;
accepted September 2. For this journal-based CME activity, the authors, editor, and reviewers have no relevant relationships to disclose. Address cor-
respondence to K.H. (e-mail: firstname.lastname@example.org).
E130 July-August 2012 radiographics.rsna.org
The female perineum, the inferior outlet of the
pelvis, is a diamond-shaped structure inferior
to the pelvic diaphragm between the symphysis
pubis and coccyx. There are limited articles in
the literature describing the intricate imaging
anatomy of the female perineum. The impetus
behind most of the publications to date has
been the importance of the supporting struc-
tures of the perineum related to incontinence
and pelvic organ prolapse (1–3). However, a
variety of conditions affect the female perineum
in adults; these include inflammatory, infec-
tious, traumatic, developmental, and neoplastic
conditions that primarily arise in the perineum
or secondarily involve the perineum by direct
extension through the pelvic diaphragm. Dis-
tant metastases are rarely encountered. Many of
these disease processes are clinically suspected
on the basis of symptomology, and are identified
with various imaging modalities with different
accuracies. Unfamiliarity with the anatomy of
the perineum can lead to diagnostic difficulties
for the radiologist; knowledge of the anatomy of
both the anterior urogenital and the posterior
anal triangles serves not only as a foundation
for accurate localization of disease as to site of
origin but also allows disease extent to be estab-
lished with more confidence.
The purpose of this review is to familiarize
readers with the relevant anatomy by using illus-
trations that detail the structures of the perineum.
Various disorders and diseases with characteris-
tic imaging findings encountered in the female
perineum in adults are discussed for each organ or
region. Specific topics discussed are clinical fea-
tures, natural history, and treatment. The imaging
appearance of each disease process is described,
with appropriate selection of the imaging modality
on the basis of inherent strengths as evidenced in
the literature, which is ultimately important in lim-
iting the differential diagnosis and providing the
The pelvic floor is a complex structure of
muscles, ligaments, and fascia with multiple
functions. Although often considered as a single
muscular layer, the pelvic floor is composed of
layers that include endopelvic fascia, the mus-
Figure 1. Illustration of the muscles of
the female perineum in the axial view.
The perineum is divided into the anterior
urogenital triangle and the posterior anal
triangle. The muscles of the superficial peri-
neal pouch are shown on the left side of the
urogenital triangle. On the right side of the
urogenital triangle, the muscles overlying
the clitoral crus and vestibular bulb have
been removed. The perineal membrane,
formerly known as the urogenital dia-
phragm, is deep to the superficial perineal
pouch. The levator ani and coccygeus mus-
cles form the muscular floor of the pelvis.
lig.= ligament, m. = muscle.
RG • Volume 32 Number 4 Hosseinzadeh et al E131
Figure 2. Illustration of the three-dimen-
sional sagittal profile of the pelvic diaphragm
and perineum. The anterior urogenital tri-
angle consists of the perineal membrane and
superficial perineal pouch and slopes down-
ward from the symphysis pubis. Ischioanal
fossa fat of the posterior anal triangle extends
anteriorly into the anterior recess (inset).
The muscles of the levator ani form a funnel-
shaped sling extending from the symphysis
pubis to the coccyx.
cular pelvic diaphragm, the perineal membrane,
and the superficial perineal pouch (4). The fe-
male perineum is a diamond-shaped structure
inferior to the pelvic diaphragm, between the
symphysis pubis and coccyx and between the
inner aspects of the thighs. It is bounded poste-
riorly by the coccyx, anteriorly by the symphysis
pubis, anterolaterally by the ischiopubic rami
and ischial tuberosities, and posterolaterally by
the sacrotuberous ligaments (Fig 1). An imagi-
nary (interischial) line between the ischiopubic
rami divides the perineum into the anterior
urogenital triangle and the posterior anal tri-
angle. In a sagittal view, the urogenital triangle
faces anteriorly and downward and the anal
triangle faces posteriorly and upward (Fig 2).
The perineum contains the distal two-thirds of
the urethra, the distal vagina at the level of the
introitus, and the anal canal.
The anal triangle contains the anal canal,
sphincters, fat-containing ischioanal fossa, and
neurovascular bundles and is lined by the su-
perficial and deep fascia (4). Although the term
ischiorectal fossa has been used interchangeably
with ischioanal fossa, the latter is more appropri-
ate, as the fossa is adjacent to the anal sphincter
and not the rectum, which lies superior to the
pelvic diaphragm. The ischioanal fossa extends
from the undersurface of the pelvic diaphragm to
the perineal skin and is filled with loose adipose
tissue, with the anal canal and its sphincters ly-
ing at the center of the fossa (Fig 2). The pelvic
diaphragm comprises the levator ani (pubococ-
cygeus, puborectalis, iliococcygeus) and coc-
cygeus muscles (Figs 1–3) (1,4). The internal
pudendal vessels and accompanying nerves lie in
E132 July-August 2012 radiographics.rsna.org
the lateral wall of the ischioanal fossa. Anteriorly,
the ischioanal fossa continues as the anterior
recess, superior to the perineal membrane, as far
anteriorly as the posterior surface of the pubis
symphysis inferior to the attachment of levator
ani muscle (Figs 4, 5). The anal canal is a 4–6
cm long and extends from the anorectal junction
superior to the anal verge. The anal sphincter is a
Figure 3. Axial T2-weighted MR images (repetition
time msec/echo time msec = 3500/86) of the normal
anatomy of the perineum from superior at the level of
the pelvic diaphragm (a) to inferior at the level of the
vulva (e). A = anus, B = bladder, BC = body of clitoris,
C = coccyx, CC = crus of clitoris, CM = coccygeus
muscle, EAS = external anal sphincter, IAF = ischio-
anal fossa, IAS = internal anal sphincter, IC = iliococcy-
geus muscle, LM = labium majus, MO = mons, OI =
obturator internus muscle, P = pubis, PB = perineal
body, PM = perineal membrane, PR = puborectalis
muscle, R = rectum, TPM = transverse perinei muscle,
U = urethra, V = vagina, VB = vestibular bulb. The yel-
low triangle in c demarcates the boundaries of the uro-
genital triangle. Inert gel distends the vagina.
RG • Volume 32 Number 4 Hosseinzadeh et al E133
Figure 5. Coronal T2-weighted MR images (3500/86) of the normal anatomy of the perineum from
anterior at the level of the bladder (a) to posterior at the level of the anorectal junction (d). A = anus,
APL = anterior pubic ligament, AR = anterior recess of the ischioanal fossa, B = bladder, BC = body of
clitoris, CC = crus of clitoris, EAS = external anal sphincter, IAF = ischioanal fossa, IC = iliococcygeus
muscle, LM = labium majus, OI = obturator internus muscle, PM = perineal membrane, PR = puborec-
talis muscle, R = rectum, V = vagina, VB = vestibular bulb.
Figure 4. Coronal-view illustra-
tion of the muscles of the female
perineum at the level of the vagina
and contents of the superficial
perineal pouch. The levator ani and
perineal membrane provide support
to the lower third of the vagina and
urethra. Note the anterior recess of
the ischioanal fossa, which is con-
tinuous with the anal triangle. m. =
E134 July-August 2012 radiographics.rsna.org
Figure 6. Sagittal T2-weighted MR image (3500/85)
of the perineal body and the course of the perineal
membrane, with distension of the rectum (R) and va-
gina (V) with inert gel. The yellow line demarcates the
course of the perineal membrane within the urogenital
triangle. B = bladder, IAF = ischioanal fossa, P = pubis,
PB = perineal body.
multilayered cylindric structure, with the follow-
ing layers extending outward from the innermost
mucosal lining: the smooth muscle layer of the
internal sphincter, the fat-containing inter-
sphincteric space, and the outer striated muscle,
with the upper half of the latter consisting of the
outer sling of the puborectalis muscle, and the
lower half representing the cylindric external
sphincter (Figs 1, 3, 5) (4).
The urogenital triangle forms a sloping tri-
angular plane from its attachment to the pubic
bones to the level of the perineal body (Figs 2, 6).
Anteriorly and laterally, it is bounded by the sym-
physis pubis and ischiopubic rami. The urogenital
triangle is divided into two parts, the superficial
perineal pouch and the perineal membrane, also
known as the urogenital diaphragm (Figs 4, 5).
The perineal membrane fuses superiorly to the
fascia of the levator ani muscle and inferiorly to
the investing muscle fibers of the superficial peri-
neal pouch. The perineal membrane is considered
a musculofascial unilayer structure that contains
several muscles: the deep transverse perinei
muscle, extending across the perineal membrane,
and the intrinsic muscles of the urethral sphincter
mechanism, including compressor urethra and
sphincter urethrovaginalis. The perineal mem-
brane also blends with the perineal body and aids
in urinary continence. The superficial perineal
pouch lies inferior to the perineal membrane and
contains the ischiocavernosus, bulbospongiosus,
and superficial transverse perinei muscles; it is
traversed by the urethra and vagina and contains
the clitoris (Figs 1, 3–5). The superficial transverse
perinei muscle lies across the posterior margin of
the superficial pouch, inferior to the deep trans-
verse perinei muscle. The bulbospongiosus mus-
cles are paired structures that flank the vagina and
urethra, covering the superficial parts of the vestib-
ular bulbs and greater vestibular glands (Bartholin
glands). The muscle fibers extend anteriorly from
the perineal body and attach to the paired corpora
cavernosa of the clitoris, which form the body of
the clitoris, and then continue to the glans clitoris
(5,6). The bulbospongiosus muscles act to express
the secretions of the greater vestibular glands and
contribute to erection of the clitoris. The ischio-
cavernosus muscle covers the crus clitoris and is
attached to the ischiopubic ramus, aiding in erec-
tion of the clitoris.
A structure deserving of special attention is
the perineal body, which represents strong fibro-
muscular tissue located in the midline between
the anal canal and urogenital triangle. Anteriorly,
it receives contributions from the deep and su-
perficial transverse perinei and bulbospongiosus
muscles; posteriorly, it merges with fibers from
the external sphincter; superiorly, it is continu-
ous with fibers of the levator ani and rectovaginal
septum (Figs 1, 3, 6) (3).
The vulva is the female external genitalia. The
mons pubis is composed of adipose tissue that
overlies the symphysis pubis and separates inferi-
orly into the thick folds of skin known as the labia
majora. The labia minora, the two thinner skin
folds lying between the labia majora, fuse at the
level of the glans of the clitoris. The area between
the labia minora is the vestibule of the vulva, con-
taining the vaginal introitus and external urethral
The external female genitalia can be affected by
developmental, traumatic, inflammatory, and
Developmental Lesions of the Vulva
Vascular Malformations.—The classification
of congenital vascular malformations is based
on their biologic behavior and clinical appear-
ance (7). The anomalies can be divided into two
main groups: hemangiomas and vascular mal-
RG • Volume 32 Number 4 Hosseinzadeh et al E135
formations. Hemangiomas are true neoplasms
characterized by rapid postnatal growth followed
by slow regression during childhood. Vascular
malformations are developmental defects com-
posed of dysmorphic vessels that persist or grow
slowly. Vascular malformations can be subdivided
on the basis of flow characteristics and channel
pattern. Slow-flow lesions include capillary, lym-
phatic and venous malformations, and high-flow
lesions include arteriovenous malformations and
fistulas. Of these, venous malformations are the
most common and can involve the lower genital
tract, although their prevalence and incidence
in this region has, to our knowledge, not been
determined. Their involvement can be isolated
or can be associated with extensive lower limb
venous malformations (8). Venous malformations
of the vulva are often symptomatic, presenting
in late adolescence but more commonly in early
adulthood, particularly in pregnancy or early
Figure 7. Labial venolymphatic malformation of
the venous type in a recently postpartum 42-year-
old woman who presented with an enlarging
purple nontender left labial mass. Axial (a) and
sagittal (b) T2-weighted MR images (3500/89)
show a cluster of hyperintense serpiginous tubu-
lar structures expanding the left labium majus.
(c) Axial contrast-enhanced T1-weighted image
shows brisk enhancement of the vessels compos-
ing the venolymphatic malformation. Localized
resection of the left labium was performed.
menses (9,10). Symptoms include sudden pain,
tenderness, and ecchymosis and are thought to
be related to localized thrombosis with phlebolith
development within the malformation (8–10).
Venous malformations of the vulva can be treated
conservatively if small. Repeated treatment with
various sclerotherapy agents or with embolization
of larger lesions can be combined with surgery to
remove the nidus of malformed vessels.
Radiologic evaluation of superficial lesions
is not typically necessary, except in the case of
extensive lesions. Color and spectral Doppler
ultrasonography (US) are helpful in differentiat-
ing low-flow states such as venous malformations
from the high-flow states in arterial malforma-
tions (11). For deep lesions and lesions close
to air and bone interfaces, magnetic resonance
(MR) imaging is most valuable in assessing the
extent of the malformation. Slow-flow venous
malformations are hyperintense on fat-sup-
pressed T2-weighted images, whereas high-flow
arteriovenous malformations and fistulas contain
signal voids (Fig 7). After administration of con-
trast material, these vessels enhance and phlebo-
liths and calcification show signal voids (12).
E164 July-August 2012 radiographics.rsna.org
Figure 38. Plexiform neurofibromatosis (NF-1) in a 47-year-old woman who underwent surveillance
imaging for neurofibromatosis. (a) Axial T2-weighted MR image (3500/85) shows innumerable hyperin-
tense fusiform neurofibromas (arrows) in the ischioanal fossa, following the course of the pudendal nerves.
Bilateral tumors with a femoral and sciatic nerve distribution are also present. (b) Axial contrast-enhanced
CT image at the same level shows soft-tissue attenuation in the tumors (arrows).
in multiple masses along the course of the affected
nerves; involvement of the pelvis results in sym-
metrically arranged masses along the pudendal
nerves within the ischioanal fossa (Fig 38).
of Osseous Abnormalities
Owing to the proximity of the perineum to the
bony pelvic girdle, primary benign (osteochon-
dromas) and malignant (sacrococcygeal chor-
domas and metastases) bone-based lesions may
occasionally extend into the perineal soft tissues
Chordomas comprise 2%–4% of all primary
malignant bone tumors; approximately 50% of
these arise in the sacrococcygeal region and are
twice as frequent in men 40–70 years old (104).
Pathologic analysis shows that the tumors contain
abundant intra- and extracellular mucin. Clini-
cally, the tumors are typically discovered because
of mass effect or after invasion of adjacent pelvic
structures. Depending on the extent of the tu-
mor, treatment is usually surgical; the prevalence
of local recurrence of sacrococcygeal chordoma
is approximately 46%–70%, and the prevalence
of metastasis is 10%–43% (105). Sacrococcygeal
chordomas usually arise in the midline, a feature
that in some cases permits differentiation from
other tumors arising in this region, such as gi-
ant cell tumors, plasmacytomas, and neurogenic
tumors (104). Sacrococcygeal tumors commonly
extend anteriorly as a soft-tissue mass; when
arising sufficiently inferiorly, the soft tissue can
extend into the perineum. At CT, chordomas ap-
Other sarcomas can be included in the differ-
ential diagnosis of perineal soft-tissue masses and
include leiomyosarcoma, malignant fibrous his-
tiocytoma, and hemangiopericytoma. Differentia-
tion at imaging is difficult, and biopsy is required
Nerve Sheath Neoplasms
Nerve sheath neoplasms comprise schwannoma
(neurilemmoma), neurofibroma, and neurogenic
sarcoma (malignant schwannoma); more than
90% of nerve sheath tumors are benign. The true
prevalence of nerve sheath tumors is not known,
as most schwannomas are asymptomatic and
discovered incidentally, and the actual number of
neurofibromas in patients with neurofibromatosis
type 1 is often difficult to determine because of
the multiplicity of lesions. Schwannomas occur
twice as often in females, whereas neurofibromas
occur more commonly in males. Malignant nerve
sheath tumors have an equal gender distribution.
Overall, nerve sheath tumors typically affect pa-
tients 20–50 years old (103).
Imaging cannot be reliably used to distinguish
benign from malignant nerve sheath tumors; how-
ever, progressive enlargement and pain related to
the tumor suggest malignant transformation (103).
At CT, nerve sheath tumors are commonly seen as
poorly enhancing, elongated soft-tissue-attenua-
tion masses. At MR imaging, they are hypointense
on T1-weighted images and hyperintense on T2-
weighted images. Plexiform neurofibroma results
RG • Volume 32 Number 4 Hosseinzadeh et al E165
Figure 39. Sacrococcygeal chordoma in a 69-year-old woman who presented with a perirectal mass.
(a) Axial unenhanced CT image shows the inferior soft-tissue component of a lytic mass (arrow) arising
from the sacrum and containing tumoral calcification; it displaces the anorectum anteriorly. (b) Sagittal
T2-weighted MR image (3500/75) shows a large, well-defined heterogeneous hyperintense mass aris-
ing from the sacrum and containing fibrous hypointense septa. The mass involves the presacral space
and extends inferiorly, displacing the anorectum anteriorly (arrow). The mass was resected and was
revealed to be a chordoma invading the rectal wall.
spontaneously or from multiple hereditary exos-
toses, an autosomal dominant disorder. The pel-
vis is an uncommon location, with 66% arising
from the ileum, most frequently the pubis and
ischium (106). No gender predilection has been
cited, and the mean age at presentation is the 4th
decade. Clinically, the lesion is usually seen as a
palpable, painless abnormality or a slowly grow-
ing mass. Complications of osteochondroma can
include obstructive labor and, rarely, malignant
degeneration, which is more common in the set-
ting of multiple hereditary exostoses. Treatment
is surgical for symptomatic lesions.
The imaging appearance of a solitary osteo-
chondroma is often pathognomonic because the
lesion consists of cortical and medullary bone
protruding from and continuous with the un-
derlying bone. Radiography (Fig 40), CT, and
MR imaging can all demonstrate the cortical and
medullary continuity with the parent bone.
The female perineum is an important anatomic
region that traditionally has been described in the
literature in relation to its physiologic contribution
pear as a lytic process with an adjacent lobulated
soft-tissue component containing tumoral calci-
fications. At MR imaging, hyperintensity on T2-
weighted images is due to extensive mucin; foci
of hyperintensity on T1-weighted images are due
to focal areas of hemorrhage and high protein
content; regions of hypointensity on T2-weighted
images are due to hemosiderin (Fig 39) (104).
The enhancement pattern of sacrococcygeal
chordomas is variable, with homogeneous, septal,
and heterogeneous patterns reported (104).
Osteochondromas (exostoses) are develop-
mental lesions rather than true neoplasms and
consist of cartilage-covered bony excrescences
that arise from the surface of a bone. Osteochon-
dromas may be solitary or multiple and may arise
Figure 40. Exostosis in a 29-year-old woman
who presented with deformity of the mons
pubis. Pelvic radiograph shows a large ex-
ostosis (arrowheads) arising from the pubic
E166 July-August 2012 radiographics.rsna.org
to continence. However, a wide spectrum of dis-
eases arise within the female perineum in adults,
and knowledge of the diseases and spatial anatomy
allows the radiologist to confidently identify the
site of origin and extent of disease with the ap-
propriate selection of imaging modality. For many
diseases, MR imaging is the preferred modality for
diagnosis and definition of disease extent.
1. Margulies RU, Hsu Y, Kearney R, Stein T, Umek
WH, DeLancey JO. Appearance of the levator ani
muscle subdivisions in magnetic resonance images.
Obstet Gynecol 2006;107(5):1064–1069.
2. Brandon CJ, Lewicky-Gaupp C, Larson KA,
Delancey JO. Anatomy of the perineal membrane
as seen in magnetic resonance images of nullipa-
rous women. Am J Obstet Gynecol 2009;200(5):
3. Larson KA, Yousuf A, Lewicky-Gaupp C, Fenner
DE, DeLancey JO. Perineal body anatomy in liv-
ing women: 3-dimensional analysis using thin-slice
magnetic resonance imaging. Am J Obstet Gynecol
4. Stoker J. Anorectal and pelvic floor anatomy. Best
Pract Res Clin Gastroenterol 2009;23(4):463–475.
5. Suh DD, Yang CC, Cao Y, Garland PA, Maravilla
KR. Magnetic resonance imaging anatomy of the
female genitalia in premenopausal and postmeno-
pausal women. J Urol 2003;170(1):138–144.
6. O’Connell HE, DeLancey JO. Clitoral anatomy in
nulliparous, healthy, premenopausal volunteers us-
ing unenhanced magnetic resonance imaging. J Urol
7. Mulliken JB, Glowacki J. Hemangiomas and vas-
cular malformations in infants and children: a clas-
sification based on endothelial characteristics. Plast
Reconstr Surg 1982;69(3):412–422.
8. Enjolras O, Ciabrini D, Mazoyer E, Laurian C, Her-
breteau D. Extensive pure venous malformations in
the upper or lower limb: a review of 27 cases. J Am
Acad Dermatol 1997;36(2 Pt 1):219–225.
9. Marrocco-Trischitta MM, Nicodemi EM, Nater C,
Stillo F. Management of congenital venous malfor-
mations of the vulva. Obstet Gynecol 2001;98(5 Pt
10. Wang S, Lang JH, Zhou HM. Venous malformations
of the female lower genital tract. Eur J Obstet Gyne-
col Reprod Biol 2009;145(2):205–208.
11. Trop I, Dubois J, Guibaud L, et al. Soft-tissue ve-
nous malformations in pediatric and young adult
patients: diagnosis with Doppler US. Radiology
12. Hyodoh H, Hori M, Akiba H, Tamakawa M, Hy-
odoh K, Hareyama M. Peripheral vascular mal-
formations: imaging, treatment approaches, and
therapeutic issues. RadioGraphics 2005;25(Spec
13. Schwartz A, Peyser MR. Nuck’s hydrocele (hydro-
cele muliebris). Int Surg 1975;60(2):91–92.
14. Anderson CC, Broadie TA, Mackey JE, Kopecky
KK. Hydrocele of the canal of Nuck: ultrasound
appearance. Am Surg 1995;61(11):959–961.
15. Park SJ, Lee HK, Hong HS, et al. Hydrocele of the
canal of Nuck in a girl: ultrasound and MR appear-
ance. Br J Radiol 2004;77(915):243–244.
16. Stickel WH, Manner M. Female hydrocele (cyst of
the canal of Nuck): sonographic appearance of a
rare and little-known disorder. J Ultrasound Med
17. Safak AA, Erdogmus B, Yazici B, Gokgoz AT.
Hydrocele of the canal of Nuck: sonographic and
MRI appearances. J Clin Ultrasound 2007;35(9):
18. Virgili A, Bianchi A, Mollica G, Corazza M. Serious
hematoma of the vulva from a bicycle accident. A
case report. J Reprod Med 2000;45(8):662–664.
19. Kunishima K, Takao H, Kato N, Inoh S, Ohtomo K.
Transarterial embolization of a nonpuerperal trau-
matic vulvar hematoma. Radiat Med 2008;26(3):
20. Iqbal CW, Jrebi NY, Zielinski MD, et al. Patterns
of accidental genital trauma in young girls and in-
dications for operative management. J Pediatr Surg
21. Thurman AR, Satterfield TM, Soper DE. Methicil-
lin-resistant Staphylococcus aureus as a common
cause of vulvar abscesses. Obstet Gynecol 2008;112
22. Miller LG, Perdreau-Remington F, Bayer AS, et al.
Clinical and epidemiologic characteristics cannot
distinguish community-associated methicillin-resis-
tant Staphylococcus aureus infection from methi-
cillin-susceptible S. aureus infection: a prospective
investigation. Clin Infect Dis 2007;44(4):471–482.
23. Kulas T, Habek D, Hrgović Z. Massive labia minor
hypertrophy following vulvar edema and abscess in
pregnancy—case report. Z Geburtshilfe Neonatol
24. Addison WA, Livengood CH 3rd, Hill GB, Sutton
GP, Fortier KJ. Necrotizing fasciitis of vulvar origin
in diabetic patients. Obstet Gynecol 1984;63(4):
25. Roberts DB. Necrotizing fasciitis of the vulva. Am J
Obstet Gynecol 1987;157(3):568–571.
26. Levenson RB, Singh AK, Novelline RA. Fournier
gangrene: role of imaging. RadioGraphics 2008;28
27. Veltman LL, Ostergard DR. Thrombosis of vulvar
varicosities during pregnancy. Obstet Gynecol 1972;
28. Ninia JG, Goldberg TL. Treatment of vulvar vari-
cosities by injection-compression sclerotherapy and
a pelvic supporter. Obstet Gynecol 1996;87(5 Pt 1):
29. Scultetus AH, Villavicencio JL, Gillespie DL, Kao
TC, Rich NM. The pelvic venous syndromes: anal-
ysis of our experience with 57 patients. J Vasc Surg
30. Bell D, Kane PB, Liang S, Conway C, Tornos C.
Vulvar varices: an uncommon entity in surgical pa-
thology. Int J Gynecol Pathol 2007;26(1):99–101.
31. Meier CR, Jick H. Tamoxifen and risk of idiopathic
venous thromboembolism. Br J Clin Pharmacol
32. Hernandez RK, Sørensen HT, Pedersen L, Jacob-
sen J, Lash TL. Tamoxifen treatment and risk of
deep venous thrombosis and pulmonary embolism:
a Danish population-based cohort study. Cancer
RG • Volume 32 Number 4 Hosseinzadeh et al E167
33. Rapoport S, Sostman HD, Pope C, Camputaro CM,
Holcomb W, Gore JC. Venous clots: evaluation with
MR imaging. Radiology 1987;162(2):527–530.
34. Westerbeek RE, Van Rooden CJ, Tan M, et al. Mag-
netic resonance direct thrombus imaging of the
evolution of acute deep vein thrombosis of the leg. J
Thromb Haemost 2008;6(7):1087–1092.
35. What are the key statistics about vulvar cancer?
American Cancer Society Website. http://www.cancer
cancer-key-statistics. Updated July 19, 2011. Ac-
cessed August 21, 2011.
36. Hampl M, Deckers-Figiel S, Hampl JA, Rein D,
Bender HG. New aspects of vulvar cancer: changes
in localization and age of onset. Gynecol Oncol
37. Ghurani GB, Penalver MA. An update on vulvar
cancer. Am J Obstet Gynecol 2001;185(2):294–299.
38. van der Steen S, de Nieuwenhof HP, Massuger L,
Bulten J, de Hullu JA. New FIGO staging system of
vulvar cancer indeed provides a better reflection of
prognosis. Gynecol Oncol 2010;119(3):520–525.
39. Rouzier R, Haddad B, Dubernard G, Dubois P,
Paniel BJ. Inguinofemoral dissection for carcinoma
of the vulva: effect of modifications of extent and
technique on morbidity and survival. J Am Coll
40. Kirby TO, Rocconi RP, Numnum TM, et al. Out-
comes of Stage I/II vulvar cancer patients after nega-
tive superficial inguinal lymphadenectomy. Gynecol
41. Salom EM, Penalver M. Recurrent vulvar cancer.
Curr Treat Options Oncol 2002;3(2):143–153.
42. Sohaib SA, Richards PS, Ind T, et al. MR imaging
of carcinoma of the vulva. AJR Am J Roentgenol
43. Kataoka MY, Sala E, Baldwin P, et al. The accuracy
of magnetic resonance imaging in staging of vulvar
cancer: a retrospective multi-centre study. Gynecol
44. Bipat S, Fransen GA, Spijkerboer AM, et al. Is there
a role for magnetic resonance imaging in the evalu-
ation of inguinal lymph node metastases in patients
with vulva carcinoma? Gynecol Oncol 2006;103
45. Cohn DE, Dehdashti F, Gibb RK, et al. Prospective
evaluation of positron emission tomography for the
detection of groin node metastases from vulvar can-
cer. Gynecol Oncol 2002;85(1):179–184.
46. Robison K, Holman LL, Moore RG. Update on
sentinel lymph node evaluation in gynecologic ma-
lignancies. Curr Opin Obstet Gynecol 2011;23(1):
47. Ferry JA, Young RH. Malignant lymphoma, pseu-
dolymphoma, and hematopoietic disorders of the
female genital tract. Pathol Annu 1991;26(Pt 1):
48. Kosari F, Daneshbod Y, Parwaresch R, Krams M,
Wacker HH. Lymphomas of the female genital tract:
a study of 186 cases and review of the literature. Am
J Surg Pathol 2005;29(11):1512–1520.
49. Vang R, Medeiros LJ, Malpica A, Levenback C,
Deavers M. Non-Hodgkin’s lymphoma involving
the vulva. Int J Gynecol Pathol 2000;19(3):236–242.
50. Kaplan EJ, Chadburn A, Caputo TA. HIV-related
primary non-Hodgkin’s lymphoma of the vulva.
Gynecol Oncol 1996;61(1):131–138.
51. Koh LP, Wong LC, Ng SB, Poon ML, Low JJ. Pri-
mary cutaneous anaplastic large cell lymphoma of
the vulva: a typical cutaneous lesion with an ‘atypi-
cal’ presenting site. Int J Hematol 2009;90(3):
52. Mikhaeel NG, Hutchings M, Fields PA, O’Doherty
MJ, Timothy AR. FDG-PET after two to three
cycles of chemotherapy predicts progression-free
and overall survival in high-grade non-Hodgkin
lymphoma. Ann Oncol 2005;16(9):1514–1523.
53. Schöder H, Moskowitz C. PET imaging for re-
sponse assessment in lymphoma: potential and
limitations. Radiol Clin North Am 2008;46(2):
54. Griffin N, Grant LA, Sala E. Magnetic resonance
imaging of vaginal and vulval pathology. Eur Radiol
55. Lee JW, Fynes MM. Female urethral diverticula.
Best Pract Res Clin Obstet Gynaecol 2005;19(6):
56. Stewart M, Bretland PM, Stidolph NE. Urethral
diverticula in the adult female. Br J Urol 1981;53
57. Hosseinzadeh K, Furlan A, Torabi M. Pre- and post-
operative evaluation of urethral diverticulum. AJR
Am J Roentgenol 2008;190(1):165–172.
58. Takeuchi M, Matsuzaki K, Nishitani H. Clear cell
adenocarcinoma of the female urethra: magnetic
resonance imaging. J Comput Assist Tomogr 2009;
59. Patel AK, Chapple CR. Female urethral diverticula.
Curr Opin Urol 2006;16(4):248–254.
60. Siegel CL, Middleton WD, Teefey SA, Wainstein
MA, McDougall EM, Klutke CG. Sonography of
the female urethra. AJR Am J Roentgenol 1998;170
61. Foster RT, Amundsen CL, Webster GD. The utility
of magnetic resonance imaging for diagnosis and
surgical planning before transvaginal periurethral
diverticulectomy in women. Int Urogynecol J Pel-
vic Floor Dysfunct 2007;18(3):315–319.
62. Reuter KL, Young SB, Davidoff A, Colby JM. Mag-
netic resonance imaging of an infected urethral
diverticulum: a case report. Magn Reson Imaging
63. Prasad SR, Menias CO, Narra VR, et al. Cross-sec-
tional imaging of the female urethra: technique and
results. RadioGraphics 2005;25(3):749–761.
64. Liang CC, Tsai CC, Chen TC, Soong YK. Manage-
ment of perineal endometriosis. Int J Gynaecol Ob-
65. Amin MB, Young RH. Primary carcinomas of the
urethra. Semin Diagn Pathol 1997;14(2):147–160.
66. Noorani S, Rao AR, Callaghan PS. Urethral me-
tastasis: an uncommon presentation of a colonic
adenocarcinoma. Int Urol Nephrol 2007;39(3):
67. Ikeda R, Suga K, Suzuki K. MRI appearance of a
leiomyoma of the female urethra. Clin Radiol 2001;
68. Eilber KS, Raz S. Benign cystic lesions of the vagina:
a literature review. J Urol 2003;170(3):717–722.
69. Siegelman ES, Outwater EK, Banner MP, Ram-
chandani P, Anderson TL, Schnall MD. High-res-
olution MR imaging of the vagina. RadioGraphics
E168 July-August 2012 radiographics.rsna.org
70. Ben-Baruch G, Schiff E, Menashe Y, Menczer
J. Immediate and late outcome of vaginal myo-
mectomy for prolapsed pedunculated submucous
myoma. Obstet Gynecol 1988;72(6):858–861.
71. Panageas E, Kier R, McCauley TR, McCarthy S.
Submucosal uterine leiomyomas: diagnosis of pro-
lapse into the cervix and vagina based on MR imag-
ing. AJR Am J Roentgenol 1992;159(3):555–558.
72. Creasman WT. Vaginal cancers. Curr Opin Obstet
73. Chang YC, Hricak H, Thurnher S, Lacey CG.
Vagina: evaluation with MR imaging. Part II. Neo-
plasms. Radiology 1988;169(1):175–179.
74. Beller U, Sideri M, Maisonneuve P, et al. Carci-
noma of the vagina. J Epidemiol Biostat 2001;6(1):
75. Parikh JH, Barton DP, Ind TE, Sohaib SA. MR
imaging features of vaginal malignancies. Radio-
76. Lamoreaux WT, Grigsby PW, Dehdashti F, et al.
FDG-PET evaluation of vaginal carcinoma. Int J
Radiat Oncol Biol Phys 2005;62(3):733–737.
77. Shadbolt CL, Coakley FV, Qayyum A, Donat SM.
MRI of vaginal leiomyomas. J Comput Assist To-
78. Shimada K, Ohashi I, Shibuya H, Tanabe F, Akashi
T. MR imaging of an atypical vaginal leiomyoma.
AJR Am J Roentgenol 2002;178(3):752–754.
79. Hubert KC, Remer EM, Rackley RR, Goldman
HB. Clinical and magnetic resonance imaging
characteristics of vaginal and paraurethral leiomyo-
mas: can they be diagnosed before surgery? BJU
80. Parks AG, Gordon PH, Hardcastle JD. A classifica-
tion of fistula-in-ano. Br J Surg 1976;63(1):1–12.
81. Laniado M, Makowiec F, Dammann F, Jehle EC,
Claussen CD, Starlinger M. Perianal complications
of Crohn disease: MR imaging findings. Eur Radiol
82. Morris J, Spencer JA, Ambrose NS. MR imaging
classification of perianal fistulas and its implica-
tions for patient management. RadioGraphics
2000;20(3):623–635; discussion 635–637.
83. Makowiec F, Jehle EC, Starlinger M. Clinical
course of perianal fistulas in Crohn’s disease. Gut
84. Barker PG, Lunniss PJ, Armstrong P, Reznek RH,
Cottam K, Phillips RK. Magnetic resonance imag-
ing of fistula-in-ano: technique, interpretation and
accuracy. Clin Radiol 1994;49(1):7–13.
85. Beckingham IJ, Spencer JA, Ward J, Dyke GW,
Adams C, Ambrose NS. Prospective evaluation of
dynamic contrast enhanced magnetic resonance
imaging in the evaluation of fistula in ano. Br J
86. Buchanan G, Halligan S, Williams A, et al. Effect
of MRI on clinical outcome of recurrent fistula-in-
ano. Lancet 2002;360(9346):1661–1662.
87. Stoker J, Rociu E, Schouten WR, Laméris JS.
Anovaginal and rectovaginal fistulas: endoluminal
sonography versus endoluminal MR imaging. AJR
Am J Roentgenol 2002;178(3):737–741.
88. Dwarkasing S, Hussain SM, Krestin GP. Magnetic
resonance imaging of perianal fistulas. Semin Ultra-
sound CT MR 2005;26(4):247–258.
89. Deans GT, McAleer JJ, Spence RA. Malignant anal
tumours. Br J Surg 1994;81(4):500–508.
90. Uronis HE, Bendell JC. Anal cancer: an overview.
91. Ryan DP, Mayer RJ. Anal carcinoma: histology,
staging, epidemiology, treatment. Curr Opin Oncol
92. Glynne-Jones R, Northover J, Oliveira J; ESMO
Guidelines Working Group. Anal cancer: ESMO
clinical recommendations for diagnosis, treatment
and follow-up. Ann Oncol 2009;20(suppl 4):
93. Koh DM, Dzik-Jurasz A, O’Neill B, Tait D, Hus-
band JE, Brown G. Pelvic phased-array MR imag-
ing of anal carcinoma before and after chemoradia-
tion. Br J Radiol 2008;81(962):91–98.
94. Roach SC, Hulse PA, Moulding FJ, Wilson R, Car-
rington BM. Magnetic resonance imaging of anal
cancer. Clin Radiol 2005;60(10):1111–1119.
95. Vercellino L, Montravers F, de Parades V, et al.
Impact of FDG PET/CT in the staging and the
follow-up of anal carcinoma. Int J Colorectal Dis
96. Graadt van Roggen JF, Hogendoorn PC, Fletcher
CD. Myxoid tumours of soft tissue. Histopathol-
97. Fetsch JF, Laskin WB, Lefkowitz M, Kindblom
LG, Meis-Kindblom JM. Aggressive angio-
myxoma: a clinicopathologic study of 29 female
patients. Cancer 1996;78(1):79–90.
98. Amr SS, el-Mallah KO. Aggressive angiomyxoma
of the vagina. Int J Gynaecol Obstet 1995;48(2):
99. Blandamura S, Cruz J, Faure Vergara L, Machado
Puerto I, Ninfo V. Aggressive angiomyxoma: a sec-
ond case of metastasis with patient’s death. Hum
100. Outwater EK, Marchetto BE, Wagner BJ, Siegelman
ES. Aggressive angiomyxoma: findings on CT and
MR imaging. AJR Am J Roentgenol 1999;172(2):
101. Lewis SJ, Wunder JS, Couture J, et al. Soft tissue
sarcomas involving the pelvis. J Surg Oncol 2001;
77(1):8–14; discussion 15.
102. Benjaminov O, Gutman H, Nyabanda R, Keinan
R, Sabach G, Levavi H. Myxoid liposarcoma:
an unusual presentation. AJR Am J Roentgenol
103. Rha SE, Byun JY, Jung SE, Chun HJ, Lee HG, Lee
JM. Neurogenic tumors in the abdomen: tumor
types and imaging characteristics. RadioGraphics
104. Sung MS, Lee GK, Kang HS, et al. Sacrococcy-
geal chordoma: MR imaging in 30 patients. Skel-
etal Radiol 2005;34(2):87–94.
105. York JE, Kaczaraj A, Abi-Said D, et al. Sacral chor-
doma: 40-year experience at a major cancer cen-
ter. Neurosurgery 1999;44(1):74–79; discussion
106. Brewster MB, Pitman I, Abudu A. Clinico-patho-
logical review of pelvic osteochondromas [abstr]. J
Bone Joint Surg Br 2006;88-B(SUPP_II):296.
This journal-based CME activity has been approved for AMA PRA Category 1 Credit
TM. See www.rsna.org/education/rg_cme.html.
Teaching Points July-August Issue 2012
Imaging of the Female Perineum in Adults
Keyanoosh Hosseinzadeh, MD • Matthew T. Heller, MD • Golbahar Houshmand, MD
RadioGraphics 2012; 32:E129–E168 • Published online 10.1148/rg.324115134 • Content Codes:
The female perineum is a diamond-shaped structure inferior to the pelvic diaphragm, between the
symphysis pubis and coccyx and between the inner aspects of the thighs. It is bounded posteriorly by
the coccyx, anteriorly by the symphysis pubis, anterolaterally by the ischiopubic rami and ischial tuber-
osities, and posterolaterally by the sacrotuberous ligaments (Fig 1).
CT can play a defining role and guide the surgical approach for vulvar infections, in particular to delin-
eate the location of an abscess, help assess tissue planes, and help in evaluation for osteomyelitis (Fig 10).
MR imaging is the modality of choice for evaluation of the extent of more locally advanced vulvar cancer
and its relationship to adjacent structures, to aid in surgical planning on an individual basis and to re-
duce surgical morbidity.
Gardner duct cysts have a similar imaging appearance to that of Bartholin gland cysts, but they typically
occur in the anterolateral walls of the proximal one-third of the vagina, superior to the perineal mem-
brane and posterior to the symphysis pubis. Skene gland cysts are of urethral origin and are thus periure-
thral and separate from the anterior vaginal wall.
Studies suggest that MR imaging provides more information than does clinical assessment of fistula-in-
ano (84) and is more helpful in revealing features associated with an unfavorable surgical outcome (85).