Hysterosalpingography

CHAPTER 20


Hysterosalpingography



Hysterosalpingography involves radiography of the female reproductive system after instillation of a contrast agent. This procedure requires sterile technique, and it is usually performed in a room equipped for specialized genitourinary radiography. Physicians as well as ancillary personnel are required to wear sterile gowns and operating room caps during the procedure. Hysterosalpingography (HSG) is of value in infertility studies and is considered a safe and painless procedure. “Radiation risks from a typical HSG are low, but they may be elevated if fluoroscopic and/or radiographic exposures are prolonged for any reason.”1



ANATOMIC CONSIDERATIONS


The female reproductive organs are divided into external and internal groups. Hysterosalpingography involves mainly the internal group of reproductive organs—the ovaries, uterine tubes, uterus, and vagina (Fig. 20-1).




Ovaries


The ovaries are almond-shaped, slightly flattened structures. Their size fluctuates, depending on patient age and stage of ovarian cycle. The average size is approximately 2.5 to 5 cm long, 2 cm wide, and 1 cm thick. They are located near the lateral walls of the pelvis. Before pregnancy, the ovaries are approximately at the level of the anterior superior iliac spine lying lateral to the uterus. During pregnancy, however, the uterus rises into the abdomen, pulling the ovaries away from this general location. After pregnancy, they usually assume their original position.


The ovaries are attached to the uterus by the ovarian ligament, which passes from the uterine end of the ovary to the body of the uterus.


The function of the ovaries is to produce the ova and the female sex hormones.



Uterine Tubes


The uterine tubes, or oviducts, provide the path for the ova into the uterus. The spermatozoa travel into the uterine tubes from the uterus after intercourse. Fertilization of the ovum usually occurs in the oviducts.


The oviducts can be subdivided into three parts—the isthmus, ampulla, and infundibulum.1 The isthmus is thick-walled and narrow and is attached to the uterine wall. The ampulla is the longest and widest part of the oviduct. Its walls are relatively thin. The funnel-shaped infundibulum terminates in finger-like structures called fimbriae. At this point, the oviduct is opened to the peritoneal cavity. There is, however, one finger of the fimbriae that makes a physical connection with the ovary.



Uterus


The uterus is a thick-walled, muscular organ lying within the pelvis. Its position changes with the degree of fullness of the bladder and rectum. It can also be subdivided into several parts—the fundus, body, isthmus, and cervix (Fig. 20-2). The fundus is the rounded upper portion of the uterus. It is found above the line joining the entrance of the uterine tubes. The body of the uterus, a small triangular area between the uterine walls, extends down toward the isthmus. The body is the main portion of the uterus. Between the cervix and the body of the uterus lies the isthmus, a narrow, constricted, very short segment about 1 cm long. The cervix communicates with the vagina, and can be divided into a supravaginal and a vaginal part. The vaginal portion extends into the vagina, whereas the supravaginal part extends up to the isthmus.





INDICATIONS AND CONTRAINDICATIONS


Hysterosalpingography is a safe diagnostic and therapeutic tool in the diagnosis and treatment of the female genital organs. It has been used in the study of infertility to determine possible structural or functional defects not obvious by clinical examination. Many other abnormal gynecologic conditions have also been demonstrated by this procedure.


As a therapeutic tool, hysterosalpingography has been shown to be effective in some cases of infertility. The procedure has had success in restoring patency to occluded tubes, straightening kinks, stretching adhesions, and dilating narrowed tubes.


Other uses for the procedure are preoperative and postoperative evaluations of the genital organs; determination and location of ectopic, misplaced, or lost contraceptive devices; and determination of the cause for dysmenorrhea.


Ultrasound is commonly performed for diagnosis of pathologic processes of the female reproductive system; hysterosalpingography also plays a part as a diagnostic tool. The following list is a summary of the indications for hysterosalpingography and hysterosonography:




This list is by no means complete. The indications for any specialized procedure increase as its possibilities and limitations are evaluated.


Hysterosalpingography is contraindicated when an acute or subacute pelvic inflammation exists. In cases of vaginal or cervical infection accompanied by purulent discharge, the procedure is also contraindicated. The procedure is not advised during the immediate premenstrual or postmenstrual phase.


Active uterine bleeding also contraindicates hysterosalpingography. If the study were performed under these conditions, it would not be of diagnostic value, and there would always be the danger of seepage of the contrast medium into the general circulation.


Pregnancy is usually considered an absolute contraindication.



CONTRAST AGENTS


The contrast agents used to delineate anatomic structures during hysterosalpingography are divided into two groups—water-soluble and oily. All are organic iodine compounds, and each group has its advantages. The water-soluble contrast agents are absorbed quickly and do not leave a residue within the genital tract2; the ethiodized oils are extremely opaque and are well tolerated by the structures under study. The low-osmolality contrast agents offer a reduction in the burning sensation and pain experienced with the ionic water-soluble contrast agents. The choice of contrast agent is governed by physician preference and institutional protocol. The oily contrast agents are almost never used today because the water-soluble organic iodides have proved their effectiveness for this procedure. Reference to the oily contrast agents is included because they are still manufactured and occasionally used. Table 20-1 is a comparison of oily contrast media with water-soluble media.



TABLE 20-1


Comparison of Oily and Water-Soluble Contrast Media











































Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Feb 27, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Hysterosalpingography

Full access? Get Clinical Tree

Get Clinical Tree app for offline access
Characteristic Oil-Based Contrast Media* Water-Soluble Media
Viscosity High Low to moderate
Radiopacity Very good Moderate to satisfactory
Absorption rate Very slow; delayed for many months when large amounts are injected Prompt excretion through kidneys after 20–60 minutes; this can be a desirable trait
    In cases of hydrosalpinx, absorption is slower; contrast may persist for 24–48 hours
Toxicity Not observed unless decomposed oil is used. Rare
Allergic reactions Not observed Occasionally observed
Peritoneal reactions Only when large amounts are injected; not observed when small amounts are used Observed, mostly transient
Pain Not observed when small amounts are injected under low pressure; few complaints when pressures <200 mm Hg are used Nearly always present; may be transient or persist for several hours post procedure
Dangers Intravasation, pulmonary embolism