hysterosalpingography procedure and some cases

1. HYSTEROSALPINGOGRAPHY
DR. VISHAL LADAGE
Junior Resident
Radiodiagnosis
RKCH,Raipur.
1 1

2. HYSTEROSALPINGOGRAPHY
Hysterosalpingography is the radiographic
evaluation of uterus and fallopian tubes under
fluoroscopic guidance.
3-Jan-16 2
2

3. INDICATION
1. Infertility (main role)
2. Recurrent spontaneous abortions
3. Congenital anomalies of uterus
4. Postoperative evaluation following (a)tubal
ligation (b) reversal of tubal ligation
5. Suspected case of genital tuberculosis
6. To prove tubal occlusion after insertion of
transcervival sterilization microinsert (essure)
HSG also has a potential therapeutic role in increasing the probability of
pregnancy ( especially if oil soluble contrast –lipiodol is used) 3
3

4. 4
CONTRAINDICATION
• Suspected pregnancy
• Acute pelvic infection
• Active vaginal bleeding
• Recent dilation and curettage
• Active vaginal bleeding
• Tubal or uterine surgery within last 6 wks
• Contrast sensitivity

5. 5
PATIENT PREPARATION
• Done in first half of menstrual cycle in
proliferative phase between 8th to 12th day
• Patient to avoid unprotected sexual intercourse
from the date of her period until investigation is
over to avoid possible risk of pregnancy
• If periods are irregular , do urine b- hcg test to
rule out pregnancy
• Exclude active pelvic infection
• Prophylactic antibiotics not routinely
recommended (considered in case of bacterial
endocarditis)

6. 6
EQUIPMENT
• Fluoroscopy room
• HSG tray – speculum,tenaculum, cotton balls, cup,
gauze, drapes, sponge holding forcep, 10 ml syrimges,
lubricating jelly
• Others- sterile gloves, antiseptic solution, foleys,
contrast media

7. 7
Different types of cannula used
1. leech wilkinson cannula
2.acorn tip metallic cannula
3.cervical vaccum cup
4. balloon catheter or pediatric foley’s catheter
6F

8. Cervical vacuum cup cannula
8

9. Acorn tip metal cannula
9
leech wilkinson cannula

10. BALLOON CATHETER
10

11. 11
PROCEDURE
• Informed consent is taken
• Antispasmodic (im drotin) given before procedure.
• Patient is asked to empty bladder immediately before
procedure
• Scout film may be taken.
• Patint is placed in lithotomy position
• The perineum is cleaned with antiseptic solution
(Betadine) and draped with sterile towel. A speculum
is inserted into the vagina to expose cervix. The cervix
is localized and cleansed with povidone-iodine
solution.

12. 12
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian
tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given
and patient is informed about vaginal spotting for 1-2
days

13. 13
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian
tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given
and patient is informed about vaginal spotting for 1-2
days

14. 14
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian
tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given
and patient is informed about vaginal spotting for 1-2
days

15. 15
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian
tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given
and patient is informed about vaginal spotting for 1-2
days

16. 16
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian
tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given
and patient is informed about vaginal spotting for 1-2
days

17. 17
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given
• 3 ml contrast to fill uterine cavity and another 3 ml to
fill tube. ( up to 10 ml)
• 4 spot films are taken
• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian
tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given
and patient is informed about vaginal spotting for 1-2
days

18. BALLOON CATHETER VS METAL
CANNULA
Less fluoroscopic time
Small amount of contrast
Less pain
Easier for physician to use
Good seal at cervix
Single use/disposable(costly)
Superior to metal cannula
BALLOON CATHETER
18
• Balloon catheter obscures lower uterine
segment. Need to be deflated to visualise
lower segment

19. 19
COMPLICATION
• Pain (because of dilatation of uterus , spillage into
peritonium).
• Infection (pelvic).
• Bleeding.
• Vascular or lymphatic Intravasation
• Pregnancy irradiation.
• Allergic reaction (to iodinated contrast media).
• Uterine perforation

20. 20
HISTORY OF HSG
• First report on HSG using oil soluble contrast
(collargel) published by Carey in 1914.
• Collargel – significant tissue damage and
painful
• Because of these serious adverse events, its
use was abandoned and a tubal insufflation
test was introduced by Rubin in 1920 (Rubin,
1920)

21. 21
HISTORY....
• Rubin insufflated oxygen (later carbon dioxide)
under pressure through the cervical canal into
the uterine cavity. Tubal patency was determined
by presence of air under the diaphragm on X-ray,
by auscultation of air flow into the abdomen or a
drop in pressure during insufflation
• Heuser was the first to report on the use of
lipiodol in HSGs (Heuser, 1925)
• Lipiodol- oil soluble, low viscosity, less toxic,
became widely accepted

22. 22
• Lipiodol was gradually replaced by water
soluble contrast media for several reasons
LIPIODOL is 40% iodine in poppy seed oil
Manufactured by guerbert ,france
WHY WATER SOLUBLE CONTRAST MEDIA ARE PREFERRED ?

23. CONTRAST MEDIA
LIPID SOLUBLE CONTRAST
(lipiodol)
• Sharp image
• Minimal pain
• Delayed absorption
• Risk of lipogranuloma
formatation in case of tubal
block or hydrosalpinx
• Intravasation of contrast and
possible risk of oil embolism
• Need of delayed film
• Less often used
WATER SOLUBLE CONTRAST
(iohexol-omnipaque,meglumine
diatrizoate-urograffin
• Ampullary rugae clearly
visualised
• Gets absorbed within hours,
does not leave residue
• Granuloma formation rare
• Pain persists after procedure
• Prompt demonstration of
tubal patency, delayed film not
needed.
• Widely used and preferred
23

24. NORMAL HSG
• Triangular uterus
• Opacification of fallopian
tubes
• Spillage of contrast into
peritoneum
24

25. At least 4 spot films taken
4.Peritoneal
spillage
2. Uterus fully
distended
1.Early filling
phase
3.Tubal filling
phase
NORMAL HSG
25

26. DETECTABLE PATHOLOGY
UTERINE
1. Uterine anomaly
2. Fibroid ( submucosal)
3. Adenomyosis
4. Endometrial polyp
5. Intrauterine
adhesions/synaechiae
6. Endometrial TB
7. Cervical incompetence
TUBAL
1. tubal block
2. Tubal spasm
3. Tubal polyp
4. Hydrosalpinx
5. Salpingitis isthmic
nodosum (SIN)
6. Peritubal adhesions
7. TB salpingitis
26

27. 27
NON PATHOLOGIC FINDINGS
• Air bubble- round, often multiple, welldefined
mobile filling defect ,usually displaced to
fallopian tubes if additional contrasts given
• Normal myometrial folds-longitudinal folds
with parallel orientation to uterine cavity
• Prominent cervical glands-tubular structure
with their origin in both cervical walls
• Previous caeserean section scar

28. 28
Luminal filling defects
• Common finding.
• Includes :
Air bubbles
Uterine folds
Synechiae
endometrial polyp
submucosal fibroid

29. 29
AIR BUBBLE

30. Filling defects on consecutive images at the uterine fundus, that disappear
progressively after the administration of contrast, compatible with air bubbles.
30
DISAPPEARS
DDs
1) Fibroid
2) Endometrial polyp 3) Synechiae

31. FIBROID UTERUS
Multiple filling defects
31

32. ADENOMYOSIS
Irregular outline, multiple diverticulum
(arrows)
32

33. 33
SYNECHIAE
• Intra uterine adhesions
• Post curettage and infection
• Linear filling defect
• Arising from one of the uterine walls
• Multiple+infertility= Asherman syndrome

34. Central oval filling defect within the uterus
34
SYNECHIAE

35. SYNECHIAE
Multiple irregular filling defects in uterine
cavity
35

36. 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.
36
UTERINE FOLDS

37. Lower uterine segment
Transverse
37
CESAREAN SECTION SCAR

38. 38
UTERINE ANOMALIES
class anomaly
i Partial / complete agenesis
ii Unicornuate
iii Didelphys
iv Bicornuate
V Septate
Vi Arcuate
vii DES-associated anomalies
(IU exposure to Diethyl stilbesterol- T
shaped uterus)
AMERICAN SOCIETY OF REPRODUCTIVE MEDICINE

39. 39

40.  Diagnosis:.
 Description:.
40

41. UNICORNUATE UTERUS
Single right uterine horn with single right fallopian
tube. Right side spillage seen
41

42. 42

43. UTERUS DIDELPHYS
2 Uterine cavities, 2 cervical canals, 2 vagina..
(nonfusion of the two Müllerian ducts.)
VAGINAL SEPTUM
43

44. Diagnosis :
44

45. BICORNUATE UNICOLLIS
2 uterine cavities, 1 cervical canal
45
1 CERVIX

46. BICORNUATEBICOLLIS
46
 Diagnosis:.
 Description:.

47. 2 uterus
2 cervix
2 vagina
2 uterus
2 cervix
1 vagina
47

48. DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed to DES while in utero. 48

49. 49
Bicornuate and Septate Uteri
• Bicornuate:
– Fundus indented
– Intercornual angle >
105*
– Intercornual distance
> 4cm
– Partial fusion of
mullerian ducts
• Septate:
– Normal external surface
– Cavities are close
together
– Intercornual angle
<75*
– Intercornual
distance <2 cm
– Defect in canalization or
resorption of midline
septum between
mullerian ducts.

50. ARCUATE UTERUS
Depression of uterine fundus
50

51. SEPTATE UTERUS: PARTIAL AND
COMPLETE
There is incomplete resorption of the final fibrous
septum between the two uterine horns.
51
SEPTUM
PARTIAL COMPLETE

52. SEPTATE UTERUS
52

53. slight separation (forming acute angle).
SEPTATE UTERUS
53

54. 54
SALPINGITIS ISTHMICA NODOSA
(Diverticulosis of the fallopian tube)
• Irregular benign extensions of the tubal epithelium into the myosalpinx
mainly at the isthmic/proximal portion
• Out pouchings of isthmus
• Unilateral or bilateral
• Unknown cause
• Associated with infertility,
PID and ectopic pregnancy

55. SALPINGITIS ISTHMIC NODOSUM (SIN)
small outpouchings or diverticula from the isthmic
portion of the fallopian tubes. SIN can be either
unilateral or (as in this case) bilateral.
3-Jan-16 53
55

56. LEFT SALPINGITIS ISTHIMICA NODOSUM
Multiple outpouchings from isthmus ( arrow)
56

57. HYDROSALPINX
Bilateral distal fallopian tube block with fluid-filled dilatation of the tubes and
without peritoneal spillage.
57

58. BILATERAL HYDROSALPINX
58

59. 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.
59
LEFT HYDROSALPINX ,RIGHT TUBAL LIGATION

60. 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 se3
-
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a
nn
-
1
w6 ith postsurgical occlusion (eg, following tubal ligation).
TUBAL LIGATION
60
60

61. TUBAL POLYP
small filling defect (arrow) in the proximal left
fallopian tube, a finding that typically represents a
tubal polyp
3-Jan-16 57
61

62. TUBAL POLYP . (FILLING DEFECT)
62

63. LEFT PERITUBAL ADHESION
A round collection of contrast material adjacent to the left
fallopian tube, suggests peritubal adhesions. Ja
f
nr
-1
e
6 e contrast
material spillage on the right side. 61
63

64. 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
CORNUAL SPASM
images
65
64
Cornual block presents with a history of
primary or secondary infertility. It may occur
due to nonspecific salpingitis following
abortion. Cornual spasm mimics cornual block
in hysterosalpingography. Approximately two-
thirds of the fallopian tubes resected for
cornual block reveal transient cornual spasm.
It is necessary to identify cornual block from
cornual spasm to avoid unnecessary
intervention.

65. LEFT CORNUAL SPASM
65

66. B/L FALLOPIAN TUBE LIGATION
No peritoneal spillage of contrast
66

67. VASCULAR INTRAVASATION 67
In venous intravasation, contrast transits from
the uterine cavity, through the myometrium,
and directly into draining pelvic veins. Contrast
may also drain into the lymphatic system
(lymphatic intravasation).
On HSG, intravasation is characterized by the
opacification of myometrial vessels which
appear as a fine lace-like network surrounding
the uterine cavity. The contrast then enters
larger pelvic veins and is washed out. This is
unlike free intraperitoneal contrast spillage,
which does not demonstrate these
characteristics and, in particular, does not
washout.
Venous intravasation can cause pulmonary
embolism along with associated systemic side
effects

68. SCOUT FILM
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
69
fallopian tube.
68

69. Radiograph obtained after instillation shows no contrast
material filling of the fallopian tube beyond the microinsert, a
finding that helps document tubal occlusion.
3-Jan-16 70
69

70. HSG FINDINDS IN GENITAL
TUBERCULOSIS
FALLOPIAN TUBES
SPECIFIC
Beaded tube
Golf club tube
Pipestem tube
Cobblestone tube
Leopard skin tube
NON SPECIFIC
Hydrosalpinx
Mucosal thickening
Peritubal adhesion
UTERUS
 SPECIFIC
T shaped uterus
Pseudounicornuate
uterus
Trifoliate uterus
NONSPECIFIC
endometritis
Syneciae
distortion of uterine
contour
Venous, lymphatic
intravasation
3-Jan-16
71 70

71. TUFTED TUBE
Multiple small diverticular like appearance surrounding
the ampulla produced by caseous ulceration gives the
tubal outline a Rosette-like appearance
71

72. TB SIN-like
Penetration of contrast medium between the mucosal folds
produces small diverticular-like outpouchings with a bizarre
pattern. Entire of both tube involved (arrows).
72

73. cotton-wool plug appearance
Distribution of contrast medium in a reticular pattern
producing a " cotton-wool plug" appearance [arrow]
73

74. BEADED TUBE
Multiple constrictions along the fallopian tube giving rise to
a " beaded" appearance [arrows]
74

75. GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golf club-like appearance
(arrows).
75

76. PIPE STEM APPEARANCE
Absence of normal tortuosity and a curved or straight pipe like
appearance show fibrotic stage of tuberculous salpingitis. Irregular
contour of the uterine cavity with diminished capacity in the fundual
portion resembling a septate uterus.
76

77. FLORAL APPEARANCE
Twisted hydrosalpinx resembles a floral
appearance of left side tube (arrow).
77

78. LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal granuloma
formations within the hydrosalpinx, resembling a " leopard skin"
appearance [arrows]
78

79. COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective radiographic sign of
intraluminal adhesions
79

80. CORK SCREW APPREANCE
Vertically fixed tubes secondary to dense peritubal
adhesions. Dense connective tissue causes the lack of tubal
mobility. The hyperconvulated right tube and manifests a "
cork screw" like appearance [arrows] 80

81. PERITUBAL HALO
Thickening of the tubal walls due to peritubal adhesions
(arrows) represents a cloudy sign on hysterosalpingograms.
T3
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J
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n
i-
1
s6
finding is a non-specific feature of tubal tuberculosis. 82
81

82. TOBACCO POUCH APPREANCE
Terminal hydrosalpinx with the conical narrowing is seen in the
right tube (arrow). Eversion of the fimbria secondary to adhesions,
with a patent orifice produces the tobacco pouch appearance in the
left terminal.
82

83. A.Uterine cavity is normal in shape and size. Terminal sacculation are seen
in both tubes. B. Irregularity, multiple filling defects and obliteration of right
ostium secondary to extensive synechiae formation in this site. Obstruction of
left tube is also seen.
83
A B
INTRAUTERINE ADHESION AND DISTORTION

84. A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an
asymmetric intrauterine obliteration, resembling a unicornuate uterus. the
irregular contour and vertical orientation of long axis. B. True unicornuate
uterus. the smooth contour, more horizontal orientation of long axis and
normal ipsilateral fallopian tube.
84

85. T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS
T-shaped configuration in two different patients. A. " T-shaped"
tuberculosis uterus. Irregular contour of the uterine cavity with diminished
capacity resembling a T-shaped uterus. Both tubes are obstructed from
isthmic portion.B. T-shaped uterus due to DES exposure. Narrow
3e-Jann-d16ocervicalcanal and small uterine cavity. Note both tubes are normal. 86
85

86. TRIFOLIATE SHAPED UTERUS
Synechiae formation at the uterine borders and partial
obliteration in the fundus produce a trifoliate like
appearance. Both tubes are obstructed in the isthmic portion
86

87. 87
DIAGNOSTIC ACCURACY
(Hsg vs laparoscopy)
• Hsg-minimally invasive
-superior to laparoscopy for detecting
intrinsic tubal and uterine pathology.
- false negative rate due to undected
peritubal adhesion,incomplete filling of a dilated
hydrosalpinx
- false positive rate due to tubal spasm,
inadequate contrast injection
both are complementary methods in evaluation
of infertility

88. 89
88