Hysterosalpingography

Hysterosalpingography - X-ray examination of the uterus and fallopian tubes when filling their cavities with contrast substances. The method is used in gynecological practice to establish patency of the fallopian tubes, revealing anatomical changes in the walls of the uterine cavity. Hysterosalpingography can detect signs of adhesive process in the pelvic area. Hysterosalpingography is performed using water-soluble radiocontrast agents (verotrast, urotrast, verographin, etc.). These substances, due to their characteristics, give a clearer picture of the cracks, lacunae, bulges and niches in the wall of the uterus, and also contrast the adhesions in the cavity of the small pelvis.

Hysterosalpingography to determine the patency of the fallopian tubes is more expedient to produce in the first phase of the menstrual cycle on the 5th-7th day. Of definite importance is hysterography in the diagnosis of sexual infantilism, anomalies of the development of the uterus. Normally, the ratio of the length of the cavity to the length of the cervical canal is 2: 1, with infantilism 1: 2 with a pronounced folding of the mucous membrane of the cervical canal.

Carrying out gelsterosalpingography is possible only in the absence of inflammatory diseases of the genital organs.

With hysteroscopy, it is sometimes difficult to assess the shape and size of the uterine cavity, the size and localization of intrauterine structures, and their relationships. Difficulties are possible in the diagnosis of pathological structures located outside the uterine cavity in the thickness of the myometrium, as well as with widespread intrauterine synechiae and some defects in the development of the uterus. In such cases, valuable additional information is provided by hysterography.

For many years, radiographic examination of the pelvic organs was the main method of diagnosing gynecological pathology. Hysterosalpingography was proposed in 1909. Nemenov, who recommended the insertion of Lugol's solution into the uterine cavity for contrasting the internal sexual organs of women. Rindfleisch in 1910 injected a solution of bismuth into the uterine cavity. Subsequently, oily and water-soluble contrast agents were proposed. Each of them has advantages and disadvantages. The physician conducting the research should know their properties, as this depends on the technology of the research and the correct interpretation of the images obtained. Water-soluble contrast agents pass through the uterine cavity and fallopian tubes faster, so more is needed. The study is best conducted under the control of the monitor, observing the passage of the contrast medium during its introduction. When using oil contrast agents, a small amount of the drug is required, a delayed (after 24 hours) study is needed to diagnose the peritubar adhesions.

For the introduction of a contrast agent, various cannulas are used, including those with vacuum caps. In 1988, Yoder suggested using a balloon injected through the cervical canal and inflated by injecting 2 ml of sterile solution or air into it. Such a probe is very convenient for research with the purpose of clarifying the state of the fallopian tubes, but at the same time, some pathology in the area of the lower segment of the uterus can be missed. Authors of the book use umbrella probes-manipulators of the firm "Karl Storz".

Before carrying out hysterosalpingography, it is necessary to study the smears taken from the cervical canal into the flora. III degree of cleanliness of smears is recognized as a contraindication for research.

To avoid false positive results (spasm of the proximal part of the fallopian tubes) 2 hours before the procedure, antispasmodics and sedatives are administered.

The timing of hysterosalpingography depends on the purpose of the study, but most often it is carried out on the 7-8th day of the menstrual cycle. For the diagnosis of ischemic-cervical insufficiency hysterography is performed before menstruation, when the expansion of the lower segment of the uterus is maximized.

The study is carried out in an equipped X-ray room, preferably under a monitor control. The patient is on the X-ray table with legs bent in the knee and hip joints.

After treating the vagina with alcohol, the cervix is fixed with bullet forceps, a cannula is placed in the cervical canal, then 10-20 ml of contrast medium is gradually introduced through it. Before its introduction, it is necessary to remove air bubbles from the cannula and to ensure a tight contact between the cannula and the cervix.

Under the control of the monitor, the passage of the contrast medium and the filling of the uterine cavity are monitored, and the most optimal moments for registration on the roentgenogram are selected. If there is no possibility of visual control over the passage of the contrast medium, a small amount of it (5-10 ml) is first introduced, an X-ray is taken, then a more tight filling of the uterine cavity with contrast medium (15-20 ml) is made and the X-ray is again taken.

When using a water-soluble contrast medium, it is desirable to fix the image on the roentgenogram at the time of administration, since it passes through the uterine tubes rapidly from the uterine cavity. An x-ray in the anteroposterior projection is necessary to determine the exact location of the filling defect. For the investigation of the cervical canal, it is advisable to make an additional X-ray image immediately after the cannula is removed. A delayed roentgenogram (after 20 minutes when using a water-soluble contrast medium and after a day using an oil contrast medium) is performed for infertile patients to assess the distribution of contrast in the small pelvis.

Normally, the uterine cavity has a triangular shape and smooth, even edges. The upper border (the bottom of the uterus) can be oval, concave or saddle-shaped, corners of the uterus - in the form of acute angles. The normal lower segment has smooth, even boundaries. If there is a Caesarean section in the history, it is possible to identify the cavities or diverticulums of the wedge shaped form in the scar area. If the pathology of the cervical canal is possible, filling defects, excessive expansion, the channel may have a serrated contour.

With intrauterine pathology on the hysterogram, the uterine shadow is deformed. There are direct and indirect signs of change.

To the direct include defects of filling and lawful shadows, to indirect - the curvature of the uterine cavity, its expansion or decrease in size. Careful analysis of these signs allows to determine the type of pathology with high accuracy.

Submucosal uterine myoma. Hysterography (metrography) for the diagnosis of submucosal uterine fibroids has been used by many researchers. According to their data, the coincidence of radiological and histological diagnoses varies with the frequency from 58 to 85%.

Radiographic signs of fibroids consider enlargement and curvature of the uterine shadow.

With submucous myomatous nodes, filling defects with clear contours are visible, more often on a broad base.

Most authors indicate that X-ray symptoms in submucosa are not pathognomonic, they are also found in other pathological processes in the uterus: large polyps of the endometrium, nodal form of adenomyosis, cancer of the uterus. To a certain extent, the diagnostic value of metrography reduces the inability to conduct it with prolonged bloody discharge. At present, in connection with the high level and capabilities of ultrasound equipment, as well as the wide introduction of hysteroscopy, metrography is rarely used to diagnose submucosal nodes.

Adenomyosis is radiographically represented by contiguous shadows, small cystic cavities. Some of them are connected to the uterine cavity by small passages. Sometimes these cavities are seen in the form of small cluster-shaped diverticula, ending in the contours of the uterus. In addition, adenomyosis is accompanied by muscular hypertrophy and fibrosis, leading to rigidity of the uterine wall, especially its angular contours, so they are enlarged in the picture, and the fallopian tubes are straightened.

The frequency of adenomyosis detection using metrography ranges from 33.14 to 80%. This is due to the fact that radiographically identify only the foci that communicate with the uterine cavity. X-ray diagnosis of the nodular form of adenomyosis is difficult; her, according to E.E. Rothkin (1967), T.V. Lopatina (1972), A.I. Volobueva (1972), observed in 5.3-8% of cases. The nodular form of adenomyosis has general radiologic symptoms with submucous myoma of the uterus.

Many specialists dealing with the diagnosis of adenomyosis noted that metrography is now one of the important methods for diagnosing adenomyosis in combination with ultrasound and hysteroscopy.

Polyps of the endometrium. In the 1960s and 1970s metrography was widely used for the diagnosis of endometrial hyperplastic processes. Endometrial polyps are radioliologically defined as defects of filling with a round or oval shape with distinct outlines; usually the uterine cavity is not curved or expanded. The mobility of the polyps can be detected with the help of successive radiographs. The presence of multiple defects of filling of different sizes with clear contours is typical for polypoid hyperplasia of the endometrium; while the contours of the uterus can be fuzzy due to the considerable thickness of the endometrium.

Endometrial cancer. X-ray diffraction patterns show defects in the filling of an inhomogeneous structure with irregular contours.

Currently, due to the extensive use of hysteroscopy, which provides a lot of information in the pathological processes of the endometrium, metrography for the diagnosis of hyperplastic processes in the endometrium is practically not used.

Intrauterine synechia. X-ray picture depends on the nature of synechia and their prevalence. Usually they appear as single or multiple filling defects, they have an irregular, lacunar shape and different sizes. Dense multiple synechia can divide the uterus cavity into a multitude of chambers of various sizes, interconnected by small ducts. Such a pathology of the uterus can not be detected in detail with hysteroscopy, which visualizes only the first few centimeters of the lower segment of the uterine cavity.

According to hysterography, it is possible to determine the classification characteristic of intrauterine synechia, to choose the tactics of management and the method of hysteroscopic surgery.

Malformations of the uterus. Metrography is of great value in diagnosing the developmental defects of the uterus. On the hysterogram, you can clearly define the dimensions (length, thickness) and length of the intrauterine partition; the size and location of each horn of the two-horned uterus; The presence of a rudimentary horn connected to the uterine cavity. It must be remembered that with a wide intramuscular septum it is possible to admit a diagnostic error in differentiation with a two-legged uterus. Hysteroscopy does not always provide exhaustive information in the diagnosis of this pathology.

To clarify the appearance of the development of the uterus before hysteroscopy, metrography is performed.

Siegler (1967) proposed hysterographic diagnostic criteria for developmental defects in the uterus.

• In the double-horned and doubled uterus, the halves of its cavities have an arched (convex) median wall, and the angle between them is usually more than 90 °.
• With the intrauterine partition, the median walls are straight (straight), and the angle between them is usually less than 90 °.

According to J. Burbot (1975), the diagnostic accuracy of uterine malformations with hysteroscopy is 86%, with hysterography - 50%.

In more difficult situations, it is possible to accurately diagnose the appearance of the uterine malformation, supplementing hysteroscopy with laparoscopy.

Scar on the uterus. Hysterography is a method of selecting an assessment of the scar's condition on the uterus after miomectomy, caesarean section and uterine perforation. Incompleteness of the scar is determined in the form of a contiguous saccular diverticula - a shadow that is open to the outside of the contour of the uterine cavity. Hysteroscopy allows you to determine only the condition of fresh scar on the uterus after cesarean section.

Thus, hysteroscopy and hysterography are complementary rather than competing methods of diagnosis. Hysterography is an additional method of investigation in cases when there is insufficient information hysteroscopy. Hysterography is necessary for infertility and evaluation of the scar's condition on the uterus. With intrauterine synechia, hysterography is additionally performed, when it is not possible to completely examine the uterine cavity during hysteroscopy. Infertility in combination with intrauterine synechia is also considered an indication for hysterography. If, with hysteroscopy, adenomyosis is detected or suspected, it is desirable to make metrography to clarify the diagnosis. Suspicion of the developmental defects of the uterus also requires hysterography.

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