Table 2. Summary of preferred imaging modalities and protocol adaptations for evaluation of transgender patients.
| Indication | Imaging modality | Protocol selection | Patient considerations |
|---|---|---|---|
| Breast augmentation | |||
| Peri-implant hematoma, seroma, or abscess | US | ▪ Apply color Doppler to assess for hyperemia (infection), active hemorrhage, or pseudoaneurysm | ▪ Maintain sensitivity to patient’s pain from US probe pressure and during image-guided procedures |
| ▪ Consider image-guided aspiration or drain placement | |||
| Silicone implant rupturea | US | ▪ Assess surrounding tissues for extracapsular silicone collections | ▪ Maintain sensitivity to patient emotions and provide support as implant rupture could be perceived as a disheartening “step back” for the patient |
| MRI | ▪ Apply silicone suppression sequences | ||
| Silicone injections | MRI | ▪ Apply silicone suppression sequences | ▪ Required for breast cancer screening in patients with free tissue silicone injections |
| ▪ Gadolinium contrast material administration for detection of enhancing lesions | |||
| Masculinizing chest surgery | |||
| Pre-operative breast cancer screening | Mammography | ▪ As per standard evaluation | ▪ Adapt intake processes and waiting room environments to ensure patient comfort. |
| ▪ Practice extreme sensitivity to disrobing and gowning. | |||
| ▪ Use terms like “chest tissue” rather than direct reference to breasts | |||
| Post-operative fluid collections (hematoma, seroma, abscess) | US | ▪ Apply color Doppler to assess for hyperemia (infection), active hemorrhage, or pseudoaneurysm | ▪ Post-operative fluid collections (hematoma, seroma, abscess) |
| ▪ Consider image-guided aspiration or drain placement | |||
| Evaluation of post-operative residual breast tissue or palpable abnormalities of the chest wall | Mammography | ▪ May not be feasible in patients with small volumes of residual tissue or significant scarring | ▪ Allow patient to assist in manipulation of tissue, as appropriate |
| ▪ Use small compression paddles | ▪ Allow patient to indicate the location of the palpable abnormality | ||
| ▪ Use radio-opaque skin markers over site of palpable abnormality | ▪ Use terms like “chest tissue” rather than direct reference to breasts. | ||
| US | ▪ As per standard evaluation | ||
| MRI | ▪ May not require prone positioning | ||
| ▪ Use skin markers over site of palpable abnormality | |||
| · Gadolinium contrast material administration for detection of enhancing lesions | |||
| Feminizing genital surgery (vaginoplasty) | |||
| Post-operative fluid collections (hematoma, seroma, abscess) | CT | ▪ Contrast-material enhanced | ▪ Maintain sensitivity to patient’s pain during image-guided procedures |
| ▪ Delayed imaging or CT cystography for evaluation of the ureter and bladder | |||
| ▪ Extend coverage through the upper thigh | |||
| ▪ Consider image-guided aspiration or drain placement | |||
| Neoanatomical evaluation; assess for residual erectile tissue | MRI | ▪ Gadolinium contrast material administration for detection of enhancing pathology | ▪ Invite patient to insert dilator instrument themselves if more comfortable |
| ▪ Insert a non-metal containing (silicone or plastic) neovaginal dilator instrument to improve assessment (patient may bring their own) | |||
| Diagnosis of stenosis or fistula | Fluoroscopy, CT or MRI | ▪ Instill 60–120 mL of neovaginal or rectal dilute iodinated contrast material (fluoroscopy, CT) or water-based gel (MRI) using a 60-mL syringe | ▪ Invite patient to introduce syringe and contrast material, if more comfortable |
| Diagnosis of neovaginal or rectal prolapse | Dynamic MRI | ▪ Consider neovaginal or rectal water-based contrast material | |
| ▪ Dynamic maneuvers (rest, Kegel, Valsalva, rectal evacuation) prior to instillation of contrast material | |||
| Masculinizing genital surgery (hysterectomy/oophorectomy, phalloplasty and metoidioplasty) | |||
| Evaluation of pelvic pain (pre-op and post-op) | US | ▪ Apply color Doppler | ▪ Reference anatomy with terms agreed upon by the patient, or avoid anatomic references altogether during the exam |
| ▪ Consider sonohysterography as appropriate | ▪ Invite patient to insert US probe themselves if more comfortable | ||
| ▪ Consider alternate approaches than transvaginal US (e.g., transabdominal, transperineal, transrectal) | ▪ Maintain sensitivity to patient’s pain from US probe pressure | ||
| ▪ Provide specialized technologist training for performance of sensitive examinations in and interactions with TGD patients | |||
| ▪ If none acceptable or of diagnostic quality, consider alternate modalities (e.g., CT or MRI) | |||
| Pre-operative planning and vascular mapping for anterolateral thigh flap phalloplasty | US and/or CT angiography | ▪ Z-axis coverage from umbilicus to knee | ▪ Allow patient to remove undergarments in a private and sensitive manner |
| ▪ 3D and MIP reconstructions | ▪ Provide adequate draping during examination | ||
| ▪ Report using Cartesian coordinates to include perforator vessel (arteries and veins) size, branching pattern, and craniocaudal distance to the anterior superior iliac spine and lateral patella; include inferior epigastric arterial pedicle length and any anatomic variations; include thigh subcutaneous tissue thickness | |||
| Postoperative vascular compromise | US, CT angiography, or digital subtraction angiography | ▪ Apply color Doppler | ▪ Maintain sensitivity to patient’s pain from US probe pressure and during image-guided procedures |
| ▪ Collaboration with interventional radiologist before procedure | ▪ Provide adequate draping during examination | ||
| ▪ Consider image-guided revascularization (angioplasty, stent placement) as appropriate | |||
| Diagnosis of neourethral stricture, leak, or fistula | Urethrogram | ▪ Retrograde or antegrade, the latter may be accommodated if the patient has an indwelling suprapubic catheter | ▪ Allow patient to assist in manipulation of tissue and introduction of syringe and contrast material, as appropriate |
| ▪ Allow extra time to for the patient to void | |||
| ▪ Provide adequate draping during examination | |||
| Evaluation of erectile devices or scrotal implants | CT or MRI | ▪ Z-axis coverage from iliac crests to lower thigh | ▪ Allow patient to inflate and deflate the device, as appropriate |
| ▪ Position the neophallus in dorsal orientation | |||
| ▪ Tumescent and de-tumescent series | |||
a, Saline implant integrity is best assessed initially at clinical examination without the need for imaging (9). US, ultrasound; MRI, magnetic resonance imaging; CT, computed tomography; MIP, maximum intensity projection; 3D, three-dimensional.