2. INTRODUCTION:
Hysterosalpingography is the radiological investigation of uterus and fallopian
tubes following the injection of contrast medium into the cervix through the
vagina.
GENERAL ANATOMY OF UTERUS:
Hollow, muscular, pear shaped organ, flattened anteroposteriorly.
Lies in pelvic cavity between the urinary bladder and rectum.
Weight:30-40 gms .
3. Has three parts : Fundus , Body and Cervix(neck).
FUNDUS: dome-shaped,above the opening of uterine tube.
BODY: main part , narrowest inferiorly at the internal os where it is
continuous with the cervix.
CERVIX: protrudes through the anterior wall of vagina , opening into at the
external os.
Wall consists of three layers: Perimetrium , Myometrium and Endometrium.
4. Arterial Supply: by the uterine arteries,branches of internal iliac arteries.
Venous drainage: Uterine vein into internal iliac veins.
Lymph drainage: Deep and superficial lymph vessels drain lymph from uterus
and uterine tubes to aortic lymph nodes.
Nerve Supply: Parasympathetic fibres from sacral outflow and sympathetic fibres
from the lumbar outflow.
UTERINE TUBE/FALLOPIAN TUBE/OVIDUCTS:
Are 10cm long.
Extend from the sides of uterus between the body and fundus.
End of each tube has finger like projection called fimbriae.
Each uterine tube consists of isthmus , ampulla and infundibulum.
STRUCTURE:
Outer covering of peritoneum.
Middle layer of smooth muscle and lined with ciliated epithelium.
Blood supply , lymph drainage and nerve supply: as for the uterus.
5. INDICATIONS:
Infertility
Recurrent Miscarriages
To demonstrate patency of fallopian tubes.
Migrated IUCD
Uterine and tubal lesions like tuberculosis,submucous fibroids(non-
cancerous growths),polyps(projecting growth of tissue).
To demonstrate congenital abnormalities such as unicornuate(person have
only half of a uterus , only one working fallopian tube),bicornuate (irrerular
shaped i.e. heart shaped uterus),septed(septum runs down the middle of
uterus and divides it into two separate parts).
Following tubal surgery to monitor the effect of tubal surgery.
E.g:To demonstrate patency and length of fallopian tubes after surgical
intervention to restore patency of obstructed tubes.
6. CONTRAINDICATIONS:
Pregnancy
Sensitivity to contrast media
Recent dilatation and curettage
Active pelvic sepsis
The week prior to and the week following onset of menstruation.
Severe renal or cardiac disease
Cervicitis / purulent(pus containing) vaginal discharge
EQUIPMENT:
Contrast media : HOCM or LOCM can be used.(270/300 mg I/ml )
-Non ionic dimer has lower incidence(occurring rate) and decreased severity of
delayed pain.
-Dose:10-20 ml
-Water soluble.E.g:Urograffin 60%,Conray 280, Trivideo 280
7. 20 cc syringe.
Canula: Leech Wilkinson, Jarcho type ,Spackman.
Uterine sound and dilator.
Sims speculum.
Tenaculum : Trauma is less,so, ideal for nulliparous women.(Vulsellum
forceps can also be used but trauma is more.)
Fluoroscopy unit with spot film devices.
Leech wilkinson Jarchotype Spackman
Canulas
9. Ideal time for procedure:
Between 8th and 10th day of menstrual cycle i.e. 2-3 days after the stoppage of
menstruation so that menstruation tissue or fluid is not carried to oviduct or
peritoneal cavity. Done before 12th day because oocyte undergoes meiosis during
this time and is radiosensitive.Thus radiation exposure during this time should be
avoided.
PATIENT PREPARATION:
Patient should be advised to abstain from intercourse between booking the
appointment and the time of examination unless a reliable method of
contraception is used to avoid the possibility of irradiating an early pregnancy.
Patient should be fasting 4 hours prior to the procedure.
Apprehensive(anxious,fearful) patient may need premedication.5-10 mg of I.V
diazepam 30 minutes before procedure is helpful to prevent the tubal spasm
which can be provoked by anxiety.
Patient must micturate just before examination.Full bladder will elevate fallopian
tubes and may cause apparent tubal blockage with radiological appearance
of a hydrosalpinx.(fluid filled dilatation of fallopian tube)
Explain the procrdure to patient and take written consent.
10. PROCEDURE:
This procedure can be carried out using two techniques:
1.Using a canula.
2.Using Foley’s Catheter.
1.USING A CANULA:
The patient is placed in lithotomy position at the edge of X-ray table.
A speculum is introduced into the vagina and the anterior lip of cervix is held
with tenaculum and gentle traction(drawing/pulling something over a
surface) is applied.
The canula is inserted into the cervical canal. Speculum is then removed and
patient is carefully moved up the X-ray table in supine position.
Care must be taken to remove all the air bubbles from the syringe and
canula before injecting, as these may mimic polyps or fibroids.
Under fluoroscopic control, 2ml of the contrast media is injected to outline
the uterine cavity.The injection is then continued slowly governed by the
patient’s tolerance until oviducts have been outlined and free
intraperitoneal spill of the dye is visualized.
11. FILMING:
Preliminary film(supine position, centering on midline 2.5cm below the ASIS.)
As the tubes begin to fill.
When peritoneal spill has occurred.
2.USING FOLEY’S CATHETER:
The cervix is exposed with a vaginal speculum and swabbed with an antiseptic solution
with the patient in lithotomy position.
After the lumen of catheter is filled with the contrast(to prevent air bubbles),the catheter
is inserted through the cervical os using a cervical forceps to guide it when the balloon
lies within the uterine cavity,it is gently inflated with water(2-3 ml).
Before the injection of contrast,the balloon is pulled downwards against the internal
os.The speculum is withdrawn and the catheter is attached to the syringe.The patient
assumes a more relaxed supine position.
Contrast injection and filming is same as with using a canula.
12. COMPLICATIONS:
Pain may occur at the following times:
-Using the vulsellum forceps.
-During insertion of canula.
-Tubal distension proximal to block.
-Distension of uterus if there is tubal spasm.
-Generalised lower abdominal pain due to peritoneal irritation by the contrast
media.
Venous intravasation due to:
-excessive injection pressure
-traumatization of endometrium by the tip of canula.
Exacerbation(worsening) of pelvic infection.
13. AFTERCARE:
It must be ensured that patient is in no serious discomfort before she leaves.
She must be cautioned that there may be mild bleeding per vagina for 1-2
days.
Analgesics may be given for mild pain.
