ULTRA-SONOGRAPHY, HYSTERO-SALPINGOGRAPHY (HSG) SON O-HYSTEROGRAPHY, COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING (MR HSG), PLAIN RADIOGRAPHY

1. RADIOLOGICAL
INVESTIGATION OF FEMALE
REPRODUCTVE SYSTEM
PRESENTER:
RINU MAHARJAN
B.SC.MIT-2015
BPKIHS

2. FEMALE EXTERNAL GENITALS
Vestibule

3. Parts of uterus: cervix, isthmus and body/corpus
Parts of fallopian tube: Interstitial, Isthmic, Ampullary,
Infundibular

5.  Hymen: thin ring of tissue covering the opening of the
vagina, divides external and internal sex organs.
 Vagina: empty passageway leading from vaginal opening
to the uterus.
Main functions :
 channel for menstrual flow
 Receptacle for the male penis during intercourse
 Birth canal
 Cervix: opening of the uterus, strongest muscle in
women’s body, closed during pregnancy, open during
birth
 Uterus: hollow, muscular organ shaped like a pear. Main
function is to protect and nourish a fetus until it is ready
to live outside the womb

6.  Fallopian tubes: 2 tubes which carries the egg cell
toward the uterus and the sperm cell toward the egg
cell. Also location for fertilization.
 Ovaries: two solid egg shaped structures
 Main functions: produce female sex hormones estrogen
and progesterone and stores and release the female egg
cell

7. Radiological Investigations
 ULTRSONOGRAPHY
 HYSTEROSALPINGOGRAPHY
 SONOHYSTEROGRAPHY
 COMPUTED TOMOGRAPHY
 MAGNETIC RESONANCE IMAGING
 PLAIN RADIOGRAPHY

8. ULTRASONOGRAPHY
 Commonly used diagnostic test due to safety, more
acceptance and low cost.
 TYPES: Transabdominal and Transvaginal
ultrasonography and can be coupled with color doppler
and 3D/4D scan
 INDICATIONS:
 Assement of adnexal pelvis masses
 Diagnosis of polycystic ovaries
 Investigation of postmenopausal bleeding (endometrial
thickness imaging and measuring), menorrhagia (fibroids
and adenomyosis)
 Monitoring of follicle number and growth for IVF (In
Vitro Fertilization)
 Evaluation of pelvic pain (limited role)
 Screening for ovarian cancer

9. Contd…
 IUCD and implantation location
 Treatment of ovarian cysts and ectopic pregnancy
 Tubal patency study in infertility
 Evaluation of primary amenorrhoea

10. TRANSABDOMINAL
ULTRASONOGRAPHY
 Bladder full needed (it displaces bowel loops, acoustic
window), consent verbally, maintain privacy, brief
gynaecological history
 3.5 MHz curved probe used

11. TRANSVAGINAL ULTRASONOGRAPHY
 5-7.5 MHz frequency probe
used.
 Post void before examination
start.
 Introduce through vagina.
DRAWBACKS:
 unmarried
 Elderly
postmenopausal
women
 Children
 Psycho-sexual
disorder, etc

12. FINDINGS OR OBSERVATION
 Identify bladder
 Uterus size, position (anteverted or retroverted)
 Myometrium
 Cervix for growth like polyps and fibroid
 Endometrial lining
 Bilateral ovaries
 Any other adnexal masses- ovarian or fallopian tubal
masses
 color Doppler- flow of blood in a vessel can be identified
 Fluid in the pouch of douglas.

13. 28 Days cycle

14. HYSTEROSALPINGOGRAPHY
 radiographic investigation of uterine cavity and
fallopian tubes with the introduction of contrast
media.
 First line radiologic examination for most women
undergoing an infertility.

15. INDICATIONS
 Investigation of infertility
 Recurrent miscarriages
 Congenital uterine anomalies
 Postoperative evaluation following tubal ligation and
reversal of tubal ligation.
 Checking efficacy of tubal sterilization
 Assessment prior to myomectomy.
 Evaluation of uterine cavity after metroplasty.
 In staging and grading of uterine synechiae (fibrous
scar).

16. CONTRAINDICATION
• Metrorrhagia (abnormal bleeding from uterus)
• Acute pelvic infection
• Contrast sensitivity
• Pregnancy (UPT, Beta-hcG (beta-human chorionic
gonadotropin is mandatory).
• Recent dilatation and curettage.
• Severe cardiac and renal disease

17. Patient Preparation
 Done in first half of menstrual cycle in proliferative phase
between 7th to 12th day following cessation of bleeding
(10 DAYS RULE)
 Pt. to avoid unprotected sexual intercourse from the
date of her period until investigation is over of possible
risk of pregnancy
 If periods are irregular, do UPT to rule out pregnancy
 Exclude active pelvic infection
 Prophylactic antibiotics, in case of bacterial endocarditis

18. Equipment
EXTRA
Valsellum forceps

19. OTHERS
 Fluoroscopy unit
 1 pair sterile gloves
 Sterile HSG tray
 Antiseptic solution
 Contrast media (300 mg I/ml)
 Foley’s catheter (6F)

20. PROCEDURE
 Informed consent taken
 Antispasmodic drugs given before procedure.
 Pt. is asked to empty bladder immediately before
procedure.
 Control Coned view PA of bladder taken
 Lithotomy position
 Perineum cleaned with antiseptic solution
 Speculum inserted into vagina, cervix localized and also
cleaned with antiseptic solution (povidine-iodine
solution).
 Grasped anterior lip of cervix with valsellum forceps.
 cannulated with cannula (Leech Wilkinson) into
cervical canal and fixed which is made air free before
administration of contrast

21.  Alternatively, 5-F HSG catheter or 8-F paediatric Foley’s
catheter can be used.
 When catheter is used, there is no need to grasp the
cervix with vulsellum forceps.
 In cases when catheter is used, ballon is inflated fully.
 Water soluble CM is slowly instilled under intermittent
fluroscopic control to evaluate uterus and fallopian tube.

22. FILMING
 Scout film bladder
 Early filling phase of
uterus
 Distended uterus
 Tube filling phase
 Peritoneal spillage

24.  Early filling phase to ensure small filling defects are
not obliterated by contrast during filling before the
isthmic portions are obscured by contrast
 Complete filling of the tubes to demonstrate free
peritoneal spill
 Additional oblique views help to demonstrate the
position of the uterus and any fibroids.
 Post procedure images taken at the end for evaluation of
lower uterine segment.

25. Complications
 Pain
 Infection
 Light spotting(<24 hrs)
 Vascular or lymphatic intravasation
 Vasovagal reactions
 Venous intravasation
 Allergic reaction
 Uterine and fallopian tube perforation.

26. ANOMALIES
Unicornuate uterus Bicornuate uterus
Bicornuate bicolis uterus

27. Double uterus

30. COMPUTED TOMOGRAPHY
 Role of CT in pelvis evaluation has declined since the
advent of endovaginal and MRI.
 Staging of malignant disease requires CT or MRI
depending on the site of the primary tumour (benign
disease investigated by US and MRI).
 CT has a role in ovarian carcinoma because of its ability
to detect peritoneal deposits.
INDICATION:
 pain of lower abdomen.
 determine the site of origin of a mass.

33. MAGNETIC RESONANCE IMAGING
 MRI is superior to CT for staging cervical and uterine
carcinoma.
 Primary technique of choice in the staging of pelvic malignancy.
 Most accurate examination for detection and localization of
myomata and characterization of congenital malformations.
PATIENT PREPARATION:
• Empty bladder, remove all the metallic objects
• Satisfactory written consent should be taken from the patient
before entering the scanner and explain the risk and benefits of
contrast injection
• Ask the patient to undress and change into a hospital gown.
• Offer earplug or headphone possibly with music for extra
comfort

34. INDICATION:
• Cervical lesions, uterine lesions,
bladder lesions, rectal lesions,
infertility
• Benign uterine tumours
(leiomyoma and fibroids)
• Better soft tissue resolution
• Characterization of pelvic masses
• Staging of pelvic malignancies
• Evaluation of congenital anomalies
• Treatment follow up
• Evaluation of pelvic pain in
pregnancy
• Most sensitive for detection of
endometriosis
CONTRAINDICATION:
• Metallic implants
• Clautrophobia
• Anxiolytics
• Anti-peristaltic agents (small
bowel motion artefacts)

35. EQUIPMENT:
 Body coil/phased array pelvic coil/multi array coil
 Earplugs/head phones
 Foam immobilization pad
PATIENT POSITIONING [PELVIS]:
• Supine on examination couch with head pointing towards the
magnet
• Give a pillow under the head and cushion under the legs for extra
comfort.
• Secure tighten the body coil using straps to prevent respiratory
artefacts
• Longitudinal alignment light lies in midline and center the laser
beam localizer over the iliac crest.

37. Three plane localizer taken in the beginning to
localize and plan the sequence

38. Plan the sagittal slices on axial plane : angle the position block
perpendicular to the sacrum and in coronal parallel to lumbosacral
spine.

39. Plan the axial slices on coronal plane : angle the position
block parallel to the line along the right and left iliac crest
and perpendicular to the lumbar spine in sagittal plane

40. Plan the coronal slices on the sagittal plane : angle the
position block parallel to the lumbar spine and parallel to
the right and left hip joint in axial plane.

41. Technical Considerations
 For infertility evaluation, axial, sagittal and coronal fast
spin echo sequences images of the uetrus is done.
 Gadolinium enhanced MR imaging is important for
diagnosis of complex adnexal masses and distinguishing
them from malignant processes.

42. IMAGING PLANES IN MRI PELVIS
 Axial: for pelvic anatomy and parametrial assessment
 Sagittal: uterine zonal anatomy
 Coronal: complementary information in assessment of
uterus, cervix, parametrium, vagina and ovaries.
 Oblique: evaluation of parametria in cervical cancer

43. SEQUENCES
 T2WI: better uterine, cervical and ovarian anatomy
 T1WI: pelvic soft tissues, lymph nodes and bone
marrow
 T1WI + FS: differentiate fat and blood
 T1WI CONTRAST + FS:
 characterising adnexal lesions
 Ovarian and cervical ca staging
 Assessing vascularity of leiomyoma prior to therapy
 DWI/ADC
low ADC often associated with malignancy(overlap do
exist)
high ADC – low cellularity tumors and mucinous tumors

44. Fig: sagittal T2W MR image in reproductive age women
(normal)

45. ADVANTAGES:
 Problem solving modality
when sonography
findings are inconclusive.
LIMITATION:
 Higher cost
 Limited availability
 Longer scanning time

46. MR HSG
 MR imaging is performed after cannulation of cervix and
injection of dilute gadolinium contrast into endometrial
cavity.
 Can evaluate for tubal patency as well as structural
abnormalities.

47. NEWER MODALITIES
 A newer technique using MR for the visualization of the
tubal patency, so called 3D-MR-HSG, is a promising
imaging alternative, although still in the development
stage, to the conventional HSG and avoids exposure of
the ovaries to ionizing radiation.

48. SONOHYSTEROSALPINGOGRAPHY
 Technique that evaluate the uterus and fallopian tube
after the uterine cavity has been distended with
sonographic contrast media.
 Saline, most commonly used agent, other contrast
agent include air, positive contrast agents such as
echovist.
 Sensitive technique to detect uterine synchiae,
endometrial polyps and also in evaluation of tubal
patency

49. PLAIN RADIOGRAPHY
 Very limited gynaecological practice.
INDICATION:
 Look for an IUCD that cannot be found with US.
 Abdominal radiography requested to assess bowel
dilatation in postoperative patient and to exclude bowel
obstruction as a cause of abdominal distension in
patients with advanced ovarian cancer.

50. Contn…CONTRAST STUDIES
 Cystogram and barium enema are used to demonstrate
vaginal fistulas usually due to surgery or radiotherapy for
malignant disease.
 Investigation of cyclical rectal bleeding and pain may
require a barium enema to exclude the short smooth
stricture typical of endometriosis
 barium studies of the small and large bowel can be used
to demonstrate the typical serosal metastases of ovarian
carcinoma.