Hysterosalpingography (HSG) anatomy, imaging and pathology revisited

Transcription

1 Hysterosalpingography (HSG) anatomy, imaging and pathology revisited Poster No.: C-335 Congress: ECR 2009 Type: Topic: Educational Exhibit Genitourinary Authors: A. M. Browne, E. DeLappe, H. Khosa, G. Colleran, K. Cronin, C. Roche; Galway/IE Keywords: DOI: uterus, Genitourinary, Hysterosalpingography, fallopian tubes /ecr2009/C-335 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives 1) To provide a brief overview of the technique of Hysterosalpingography. 2) To discuss the indications for and complications of HSG. 3) To illustrate the characteristic appearances of HSG pathology and differentiate these from other pathologies where appropriate Background Hysterosalpingography (HSG) is the radiographic evaluation of the uterus and fallopian tubes with the use of radiographic contrast medium. The number of HSG examinations has increased in recent years. This is likely to be due to advances in in vitro fertilization procedures and the trend towards women delaying pregnancy until later in life(1,2). Indications for HSG The most common indications for performing HSG are infertility recurrent spontaneous abortion recurrent preterm delivery evaluation of the uterus and fallopian tubes post tubal surgery preoperative evaluation of the uterus prior to surgery HSG Technique The examination is scheduled for days 6-10 of the menstrual cycle. The patient is instructed to abstain from sexual intercourse from the day 1 of the menstrual cycle to avoid irradiating a potential pregnancy. The patient is placed supine on the fluoroscopy table in the lithotomy position. The area is prepared with povidone-iodine solution(betadine) and draped with sterile towels. Page 2 of 16

3 A speculum is placed into the vagina and the cervix is localised. A 5-F HSG catheter is positioned into the cervical os and canal and the balloon is inflated. Water-soluble contrast material is slowly instilled under fluoroscopic guidance with intermittent images obtained to evaluate the uterus and fallopian tubes. Pain relief A recent cochrane review (2007) found little evidence for the benefit of pain relief administered duirng or immediately after HSG. There is limited evidence of pain reduction with any administered analgesia 30 minutes after the procedure(3). Contraindications to HSG Contraindications to HSG include; pregnancy current pelvic infection active menses recent uterine surgery Complications Complications include; Bleeding and infection (<3%) are the two most common infections. Patients should be instructed that if they notice foul smelling vaginal discharge or become feverish days after the procedure they should attend their primary doctor and receive antibiotic therapy. Many patients have light spotting after the procedure Some patients may experience cramping during and after the procedure which can be due to uterine distension and irritation of the peritoneal cavity due to contrast Contrast media reaction is very rare especially with the use of low-osmolar nonionic contrat agents. Page 3 of 16

4 Lymphatic (fig. 1) on page or vascular intravasation (fig.2) on page is clinically insignificant and not dangerous(1). Perforation of the uterus or fallopian tubes is extremely rare and usually presents with increasing abdominal pain. Irradiation of an early, unsuspected pregnancy is possible but timing of the examination in the menstrual cycle should avoid this (fig. 3) on page. Images linked within the text of this section: Page 4 of 16

5 Fig.: Spot radiograph of HSG showing vascular intravasation of contrast(yellow arrows). Fig.: Spot radiograph shoiwng lymphatic intravasation(yellow arrow). There is also a left fallopian tube clip(blue arrow). Page 5 of 16

6 Fig.: Spot radiograph of HSG demonstrating an intrauterine pregnancy. Page 6 of 16

7 Imaging findings OR Procedure details Information obtained from HSG includes UTERUS the width of the cervical canal the contour of the uterine cavity the orientation of the uterus - anteverted(fig. 4) on page / retroverted an outline of the lumen of the fallopian tubes and cornua the presence or abscence of spillage of contrast from the fimbriated ends of the tubes. an outline of peritoneal structures. The size of the uterus varies depending on the patients age and parity. HSG is only helpful in the evaluation of the uterine cavity. At HSG, the uterus should resemble an inverted triangle with well-defined smooth contours. Congenital Uterine Abnormalities Congenital abnormalities of uterine shape are due to abnormal fusion of the mullerian ducts during early (6-12 weeks)gestation(4). A Unicornuate uterus is due to complete or almost complete arrested development of one mullerian duct. Incomplete arrest of development is present in 90% of patients. It may be associated with a rudimentary horn arising from the contralateral mullerian duct. A Didelphys uterus is due to complete nonfusion of the mullerian ducts. Usually 2 cervices are present. The individual horns are fully developed and almost normal in size. A longitudinal or transverse vaginal septum may be present. Patients with didelphys uterus have been known to carry full term pregnancies(fig. 7) on page. A T shaped uterus is associated with in-utero diethylstilbestrol(des) exposure. Typically the uteri are Page 7 of 16

8 hypoplastic. The T-shaped uterine cavity is due to myometrial hypertrophy(fig. 8) on page. A Bicornuate uterus is due to partial failure of fusion of the mullerian ducts. It is distinguished from didelphys uterus, as it demonstrates some degree of fusion between the 2 horns whereas in didelphys uterus, the 2 horns and cervices are completely separated. The horns of bicornuate uteri are not fully developed and are typically smaller than in didelphys uterus(, ). A Septate uterus is due to failure of resorption of the medial septum. THe sseptum can be partial or complete. The septum can be of variable length and can be formed from myometrium or fibrous tissue. Women with septate uterus have the highest incidence of reproductive complications(fig. 11) on page. An Arcuate uterus has a single uterine cavity with a flat or convex uterine fundus. It is considered to be a normal variant(fig. 12) on page. Filling defects within the lumen The catheter should be flushed well with contrast material to avoid injecting air bubbles. Air bubbles are demonstrated as well-circumscribed, mobile lucencies that collect in the nondependent portion of the uterus. Synechiae are demonstrated as irregular filing defects. Multiple synechiae associated with infertility are known as asherman syndrome. Abnormalities of Uterine Contour Fibroids or leiomyomas are benign tumours of the smooth muscle of the uterus. They can be subserosal, intramural or submucosal within the uterine wall. They are demonstrated as well-defined filling defects at HSG(). Endometrial polyps appear as smooth walled filling defects arising from the uterine wall and protruding into the uterine lumen (). Caesarian section scars appear as a linear irregularity at the isthmic portion of the lower uterine segment(). Occasionally a caesarean section scar may appear as a wedge-shaped outpouching or diverticulum. Page 8 of 16

9 Fallopian Tubes Fallopian tubes allow the ovum to travel from the ovary to the uterus. They are 10-12cm in length and are situated in the superior aspect of the broad ligaments. The Fallopian tubes vary in location within the pelvis and degree of tortuousity. They consist of cornual, isthmic and ampullary portions of fallopian tube(). HSG is the best method for evaluating and imaging the fallopian tubes. At HSG, the fallopian tubes should be identified as thin, smooth lines that widen at the ampullary portion Tubal abnormalities most commonly seen at HSG can be Spasm congenital due to spasm occlusion infection The cornual portion of the fallopian tube is surrounded by smooth muscle of the uterus. If there is spasm of the muscle during HSG the fallopian tube will not fill. This cannot be differentiated from tubal occlusion at HSG. Antispasmodic agents (buscopan/glucagon) can relax smooth muscle and lead to fallopian tube opacification(, ). It is important to differentiate between tubal occlusion and tubal spasm as the two entities can have very different impact on the patient's fertility treatment. Infection Pelvic inflammatory disease(pid) is the most common cause of tubal occlusion leading to infertility. Tubal occlusion is seen as a cut-off of contrast material with nonopacification of the more distal fallopian tube. It can affect any portion of the fallopian tube and be unilateral or bilateral(4)(). Page 9 of 16

10 If the blockage is in the ampullary portion, the tube may dilate leading to a hydrosalpinx(). Peritubal adhesions most commonly manifest as loculation of contrast material around the ampullary portion of the tube(4)(). Therapeutic effect of HSG In addition the HSG also has therapeutic effect, which are associated with increased fecundability in the months after the procedure(5). Suggested mechanisms for this include, mechanically dislodging substances (mucus, cells) obsructing the fallopian tubes, enhancing endometrial receptivity, stimulating tubal cilia and thus enhancing the transport of gametes, improving cervical mucus to enhance passage of sperm and that iodine in the contrast medium has a bacteriostatic effect on mucous membranes(5). Future developments 64 slice MDCT has been used to image the uterus and fallopian tubes.this technique reports to have a lower radiation dose, shorter procedure time and lower level of discomfort for the patient (6). It is however more costly. It also does not allow the direct visualization of contrast while injecting the dye into the endometrial cavity. It does not have the diagnostic and therapeutic potential of fluoroscopic HSG in patients with proximal tubal occlusion, in allowing immediate tubal cannulation(6). MR hysterosalpingographycan also be used to demonstrate the fallopian tubes and uterus. MRI can provide high-resolution images of the uterine cavity. Fallopian tube clips can cause imaging artefact. It is not possible to perform MRI in some patients i.e. patients with claustrophobila, pacemakers. Page 10 of 16

11 Images linked within the text of this section: Fig.: Spot radiograph of HSG showing an anteverted uterus. Page 11 of 16

12 Fig.: Spot radiograph of HSG showing a septate uterus. Page 12 of 16

13 Fig.: Spot radiograph of HSG demonstrating a T shaped uterus. Page 13 of 16

14 Fig.: Spot radiograph of HSG demonstrating a didelphys uterus. Page 14 of 16

15 Conclusion HSG is a valuable imaging modality in the evaluation of the uterus and fallopian tubes. A wide variety of uterine and tubal abnormalities can be demonstrated with hysterosalpingography. Accurate diagnosis allows for early management of treatable conditions including those affecting patient fertility. We thus provide an interesting, informative and concise radiological guide of HSG technique, anatomy and pathology. Personal Information References 1) Simpson WL, Beitia LG, Mester J. Hysterosalpingography: A reemerging Study. Radiographics 2006; 26: ) Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology. Oct 2004; ) Ahmad G, Duffy J, Watson AJS. Pain relief in hysterosalpingography. Cochrane Database Syst Rev 2007; CD ) Ott DJ, Fayez JA.Tubal and adnexal abnormalities. In: Ott DJ, Fayez JA,Zagoria RJ, eds. Hysterosalpingography:a text and atlas.2nd ed. Baltimore,Md:Williams & Wilkins, 1998; ) Johnson N, Vandekerckhove P, Watson A, et al. Tubal flushing for subfertility. Cochrane Database Syst Rev 2005; CD ) Akaeda T, Isaka K, Nakaji T, Kakizaki D, Abe K. Clinical application of virtual hysteroscopy by CO2-multidetector-row computed tomography to submucosal myoma by virtual hysteroscopy. J Minim Invasive Gynecol 2005;12: Page 15 of 16

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