HYSTEROSALPINGOGRAPHY

MAJOR EQUIPMENT *• fluoroscope room• Table • Gynecologic stirrups

Accessory & Optional EquipmentRoutinely, a sterile, disposable HSG tray is used.speculum, cotton balls, cup, gauze, drapes, sponge-holding forceps, 10 ml syringes, lubricating jelly extension tube.

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In addition to the HSG tray, sterile gloves, an antiseptic solution, a 6 fr foley’s or sholkoff balloon catheter, and contrast media are necessary.

Contrast MediaTwo categories of radio-opaque iodinated contrast

used.

Water-soluble iodinated CM, e.g. Omnipaque 300.

absorbed easily, does not leave a residue within reproductive

tract, provides adequate visualization. however, cause pain &persist for hours after

procedure.

... CONTINUED In the past, oil-based contrast media was

used. Allowed maximal visualization of uterine

structures however very slow absorption rate

persists in body cavities for extended time. Introduces risk of oil embolus that could

reach lungs.

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Amount of contrast medium to be introduced is variable. On average, approx. 5 ml is necessary to fill uterine cavity, and additional 5 ml needed to demonstrate uterine tube patency. Fractional injections may be performed during study.

CATHETER PLACEMENT &INJECTION PROCESS

Patient lies in lithotomy position. Patient is draped & speculum inserted. Vaginal walls & cervix are cleansed. Catheter is inserted into cervical canal. Dilation of balloon helps to occlude cervix,

preventing contrast medium from flowing out.

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Once placement of catheter obtained, pt put in slight Trendelenburg position.

This position facilitates flow of contrast media into uterine cavity.

Contrast filled Syringe attached to catheter. Using fluoroscopy, contrast slowly injected into uterine cavity.

RADIOGRAPHIC CRITERIA • The pelvic ring as seen on an AP projection

should be centered within the collimation field.

• The cannula or balloon catheter should be demonstrated within the cervix.

• An opacified uterine cavity and uterine tubes are demonstrated centered to the IR.

FLUOROSCOPY/SPOT FILMING

Imaging most commonly acquired with use of spot-film fluoroscopy or, digital fluoroscopy.

Scout image obtained. During injection of contrast, series of images

taken while uterine cavity &tubes are filling. After injection of contrast, additional image

taken to document spillage.

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Pt most commonly remains in supine position during imaging, but additional images may be taken with pt in an LPO or RPO position to adequately visualize pertinent anatomy.

Image taken at the end for evaluation of lower uterine segment.

NORMAL ANATOMY

SCOUT IMAGE

Spot radiograph obtained during the early filling stage of the uterus. Small filling defects are best seen at this stage.

On a radiograph obtained with the uterus fully distended with contrast material, portions of both fallopian tubes are opacified. Like images obtained during the early filling stage of the uterus, images obtained at full uterine distention allow evaluation for filling defects and contour abnormalities. However, small filling defects may be obscured when the uterus is well opacified

Spot radiograph clearly depicts the interstitial, isthmic, and ampullary portions of both fallopian tubes.

Spot radiograph shows intraperitoneal contrast material spillage from the fallopian tubes. In this case, the spillage outlines the convexity of the uterine fundus

DETECTABLE PATHOLOGY Conditions which may be detected with HSG

include: Uterine uterine congenital anomalies . 15% submucosal uterine fibroids uterine malignancy adenomyosis intrauterine adhesions uterine (endometrial) polyps

Unicornuate uterus. Spot radiograph demonstrates a single uterine horn . A single fallopian tube is also visualized.

Bicornuate uterus. Spot radiograph shows two markedly splayed uterine horns.

HSG image shows a bicornuate bicollis uterus with two HSG cannulas due to two cervices. There is a fundal linear defect (arrow) with filling of two symmetric uterine horns through the right cannula (arrowhead) due to communication in the lower uterine segment.

Septate and arcuate uterus. Spot radiograph demonstrates a depression of the uterine fundus, a finding that may represent a short septum or an arcuate deformity

Double uterus

Uterus didelphys. (a, b) HSG images show catheterization of two separate cervices with opacification of two widely divergent noncommunicating endometrial cavities

LUMINAL FILLING DEFECTS Common finding. Includes : Air bubbles Uterine folds Synechiae

AIR BUBBLES

Flush catheter thoroughly Well- circumscribed filling defect Non- dependent portion of

uterus Transient and mobile

Air bubbles. Spot radiograph shows air bubbles (arrow) in the left side of the uterus.

Spot radiograph no longer depicts the air bubbles seen in the left cornua of the uterus in . Air bubbles are often mobile or transient when they are expelled into the fallopian tubes.

UTERINE FOLDS

Linear filling defects Due to under-distended uterus Parallel to long axis of uterus May extend into horns

Uterine folds. HSG spot radiograph demonstrates uterine folds (arrows) as linear filling defects that parallel the longitudinal axis of the uterus. Uterine folds are normal findings that are occasionally seen at HSG.

SYNECHIAE

Intra uterine adhesions Post curettage and infection Linear filling defect Arising from one wall Multiple+infertility= Asherman

syndrome

Synechiae. Spot radiograph shows a central oval filling defect within the uterus, a finding that represents a synechia

UTERINE CONTOUR DEFECTS

Polyps: Endometrial over growths. Sonohysterography.

Leiomyoma's: sub-serosal, intra mural, sub-mucosal. only sub mucosal depicted,

early stage filling

Endometrial polyp. Anteroposterior (left) and oblique (right) hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows).

Leiomyomas. Spot radiograph obtained during the early filling stage shows a well-defined filling defect (arrow) in the fundus

On a spot radiograph obtained with the uterus more distended with contrast material, the fibroid (arrow) is less apparent

Spot radiograph obtained in a different patient reveals a large leiomyoma distorting the endometrial cavity as it drapes over a mass in the left myometrium.

Submucosal fibroids. Oblique (left) and anteroposterior (right) hysterosalpingograms demonstrate smooth filling defects distorting the uterine cavity and representing submucosal fibroids..

ADENOMYOSIS Endometrium extends into

myometrium. Focal or diffuse. Nests of endometrium connect

to uterine cavity. Out pouching of endometrial

cavity.

Diffuse adenomyosis. Spot radiograph shows irregularity of the uterine contour with small outpunching's of contrast material, findings that represent diffuse adenomyosis.

Spot radiograph demonstrates an irregular mass-like filling defect in the fundus with small contrast material–filled diverticula, findings that represent focal adenomyosis

Cesarean section scar. Spot radiograph shows the uterine incision from a cesarean section (arrows) in the typical location (i.e., oriented transverse in the lower uterine segment in the region of the isthmus). At HSG, a cesarean section scar can have a linear appearance (as in this case) or can occasionally manifest as a wedge-shaped outpouching or diverticulum.

Tubal obliteration of fallopian tubes : usually

secondary to previous pelvic inflammation. must be differentiated from incomplete tubal opacification due to tubal spasm, or underfilling of uterus with contrast .

tubal polyps . tubal malignancy hydrosalpinx salpingitis isthmica nodosa (SIN) . tubal spasm : can be physiological

SALPINGITIS ISTHMICAS NODOSA

Out pouchings of isthmus Unilateral or bilateral Unknown cause Associated with infertility, PID

and ectopic pregnancy

 SIN. Spot radiograph demonstrates SIN as small outpouchings or diverticula from the isthmic portion of the fallopian tubes. SIN can be either unilateral or (as in this case) bilateral.

TUBAL SPASM Cornual portion encased in

myometrium If msl spasm tube appears

occluded HSG cannot differntiate b/w

spasm & true occlusion Msl relaxant can occasionally

help.

Cornual spasm. On an HSG spot radiograph obtained during the early filling stage of the uterus, the right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the pelvis. These calcifications were also present on the scout image

On a spot radiograph obtained after the instillation of additional contrast material, the right fallopian tube opacifies to the ampullary portion. Right-sided SIN and a left-sided hydrosalpinx are also noted. Amorphous calcifications (arrowheads) are again seen on the right side of the pelvis

Occluded fallopian tubes

Hydrosalpinx. Steep right oblique spot radiograph shows dilatation of the ampullary portion of the right fallopian tube (arrow). The left fallopian tube is normal in caliber. Mucosal folds are visible in the ampullary portions of both fallopian tubes, a finding that helps confirm the presence of contrast material within the tubes

Spot radiograph shows dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is abruptly cut off, a finding that is consistent with previous tubal ligation.

 Peritubal adhesions. Spot radiograph demonstrates a round collection of contrast material adjacent to the left fallopian tube, a finding that suggests peritubal adhesions. Note the free contrast material spillage on the right side.

Spot radiograph demonstrates cutoff of contrast material in the isthmic portions of both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen with postsurgical occlusion (eg, following tubal ligation).

Irreversible tubal occlusion with a microinsert. Scout radiograph obtained prior to the instillation of contrast material shows a microinsert that has been placed hysteroscopically into the proximal fallopian tube.

Radiograph obtained after instillation shows no contrast material filling of the fallopian tube beyond the microinsert, a finding that helps document tubal occlusion.

 Tubal polyp. Spot radiograph shows a small filling defect (arrow) in the proximal left fallopian tube, a finding that typically represents a tubal polyp.

COMPLICATIONS

Common but self limitingAbdominal crampingPV spotting

Rare but seriouspelvic infectioncontrast reactionPerforation

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