Hysterosalpingography (HSG) anatomy, imaging and

pathology revisited

Poster No.: C-335

Congress: ECR 2009
Type: Educational Exhibit
Topic: Genitourinary
Authors: A. M. Browne, E. DeLappe, H. Khosa, G. Colleran, K. Cronin, C.
Roche; Galway/IE
Keywords: uterus, Genitourinary, Hysterosalpingography, fallopian tubes
DOI: 10.1594/ecr2009/C-335

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Page 1 of 16
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
• 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
• 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
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
Fig.: Spot radiograph of HSG demonstrating an intrauterine pregnancy.

Page 6 of 16
Imaging findings OR Procedure details

Information obtained from HSG includes

• 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.
UTERUS

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
 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
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

• congenital
• due to spasm
• occlusion
• infection
Spasm

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
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
Images linked within the text of this section:

Fig.: Spot radiograph of HSG showing an anteverted uterus.

Page 11 of 16
Fig.: Spot radiograph of HSG showing a septate uterus.

Page 12 of 16
Fig.: Spot radiograph of HSG demonstrating a T shaped uterus.

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

Page 14 of 16
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; 26:419-431.

2) Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical
issues. Radiology. Oct 2004;23-34.

3) Ahmad G, Duffy J, Watson AJS. Pain relief in hysterosalpingography.

Cochrane Database Syst Rev 2007; CD006106.

4) 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;90-93.

5) Johnson N, Vandekerckhove P, Watson A, et al. Tubal flushing for

subfertility. Cochrane Database Syst Rev 2005; CD003718.

6) 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;12:261-6.

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