Hysterosalpingography

Hysterosalpingography is an X-ray examination of the uterus and fallopian tubes when their cavities are filled with contrast agents. The method is used in gynecological practice to establish the patency of the fallopian tubes, to identify anatomical changes in the walls of the uterine cavity. Hysterosalpingography allows you to detect signs of adhesions in the pelvic area. Water-soluble radiopaque agents (verotrast, urotrast, verografin, etc.) are used to perform hysterosalpingography. Due to their properties, these substances provide a clearer image of cracks, lacunae, bulges and niches in the uterine wall, and also contrast adhesions in the pelvic cavity.

Hysterosalpingography for determining the patency of the fallopian tubes is best performed in the first phase of the menstrual cycle on the 5th-7th day. Hysterography has a certain value in the diagnosis of sexual infantilism, anomalies in the development of the uterus. Normally, the ratio of the length of the cavity to the length of the cervical canal is 2:1, in infantilism 1:2 with pronounced folding of the mucous membrane of the cervical canal.

Glosterosalpingography can only be performed in the absence of inflammatory diseases of the genital organs.

During hysteroscopy, it is sometimes difficult to assess the shape and size of the uterine cavity, the size and location of intrauterine structures, and their relationships. There may be difficulties in diagnosing pathological structures located outside the uterine cavity in the thickness of the myometrium, as well as in the case of widespread intrauterine adhesions and some malformations of the uterus. In such cases, hysterography provides valuable additional information.

For many years, X-ray examination of the pelvic organs was the main method for diagnosing gynecological pathology. Hysterosalpingography was proposed in 1909 by N.M. Nemenov, who recommended introducing Lugol's solution into the uterine cavity to contrast the internal genital organs of women. Rindfleisch introduced a bismuth solution into the uterine cavity in 1910. Oil and water-soluble contrast agents were subsequently proposed. Each of them has its own advantages and disadvantages. The doctor conducting the examination must know their properties, since the technology of the examination and the correct interpretation of the images obtained depend on this. Water-soluble contrast agents pass through the uterine cavity and fallopian tubes faster, so a larger amount of the drug is needed. The examination is best carried out under the control of a monitor, observing the passage of the contrast agent during its introduction. When using oil contrast agents, a small amount of the drug is required; for the diagnosis of peritubal adhesions, a delayed (after 24 hours) examination is necessary.

Various cannulas, including those with vacuum caps, are used to introduce the contrast agent. In 1988, Yoder proposed using a balloon inserted through the cervical canal and inflated by introducing 2 ml of sterile solution or air into it. Such a probe is very convenient for examination to clarify the condition of the fallopian tubes, but at the same time, some pathology in the lower uterine segment may be missed. The authors of the book use uterine probes-manipulators from the company "Karl Storz".

Before performing hysterosalpingography, it is necessary to examine smears taken from the cervical canal for flora. III degree of smear purity is recognized as a contraindication for the study.

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

The time of hysterosalpingography depends on the purpose of the study, but most often it is performed on the 7th-8th day of the menstrual cycle. To diagnose isthmic-cervical insufficiency, hysterography is performed before menstruation, when the expansion of the lower segment of the uterus is maximal.

The examination is carried out in an equipped X-ray room, preferably under monitor control. The patient is on the X-ray table with her legs bent at the knees 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 agent is gradually introduced through it. Before its introduction, it is necessary to remove air bubbles from the cannula and ensure hermetic contact between the cannula and the cervix.

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

When using a water-soluble contrast agent, it is advisable to record the image on the radiograph at the time of administration, since it quickly flows out of the uterine cavity if the fallopian tubes are passable. An anteroposterior projection radiograph is necessary to determine the exact location of the filling defect. To examine the cervical canal, it is advisable to take an additional radiograph immediately after removing the cannula. A delayed radiograph (after 20 minutes when using a water-soluble contrast agent and after 24 hours when using an oil contrast agent) is performed on infertile patients to assess the distribution of the 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, the corners of the uterus are in the form of acute angles. The normal lower segment has smooth, even borders. If there is a history of cesarean section, it is possible to detect encapsulated cavities or wedge-shaped diverticula in the area of the scar. In case of pathology of the cervical canal, filling defects, its excessive expansion are possible, the canal can have a serrated contour.

In case of intrauterine pathology, the uterine shadow on the hysterogram is deformed. Direct and indirect signs of changes are distinguished.

Direct ones include filling defects and contour shadows, indirect ones include curvature of the uterine cavity, its expansion or reduction in size. A thorough analysis of these signs allows us to determine the type of pathology with high accuracy.

Submucous uterine myoma. Hysterography (metrography) has been used by many researchers to diagnose submucous uterine myoma. According to their data, the coincidence of radiological and histological diagnoses fluctuates with a frequency of 58 to 85%.

Radiological signs of fibroids include expansion and curvature of the uterine shadow.

In submucous myomatous nodes, filling defects with clear contours are visible, often on a wide base.

Most authors indicate that radiographic symptoms of submucous myoma are not pathognomonic, they are also found in other pathological processes in the uterus: large endometrial polyps, nodular adenomyosis, uterine cancer. To a certain extent, the diagnostic value of metrography is reduced by the impossibility of its implementation in case of prolonged bloody discharge. Currently, due to the high level and capabilities of ultrasound equipment, as well as the widespread introduction of hysteroscopy, metrography is rarely used to diagnose submucous nodes.

Adenomyosis is radiologically represented by contour shadows, small cystic cavities. Some of them are connected to the uterine cavity by small passages. Sometimes these cavities are visible as small grape-like diverticula ending at 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 dilated in the image, and the fallopian tubes are straightened.

The frequency of detection of adenomyosis by metrography fluctuates between 33.14 and 80%. This is due to the fact that only foci communicating with the uterine cavity are detected radiologically. Radiological diagnostics of the nodular form of adenomyosis is difficult; according to E.E. Rotkina (1967), T.V. Lopatina (1972), A.I. Volobuev (1972), it is observed in 5.3-8% of cases. The nodular form of adenomyosis has common radiological symptoms with submucous uterine myoma.

Many specialists involved in the problem of diagnosing adenomyosis have noted that even today, metrography is one of the important methods for diagnosing adenomyosis in combination with ultrasound and hysteroscopy.

Endometrial polyps. In the 1960s and 1970s, metrography was widely used to diagnose endometrial hyperplastic processes. Endometrial polyps are radiographically defined as filling defects of a round or oval shape with clear contours; usually, the uterine cavity is not curved or dilated. The mobility of polyps can be detected using successive radiographs. The presence of multiple filling defects of varying sizes with clear contours is characteristic of polypoid endometrial hyperplasia; in this case, the contours of the uterus may be unclear due to the significant thickness of the endometrium.

Endometrial cancer. Radiographs show filling defects of non-uniform structure with irregular contours.

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

Intrauterine adhesions. The radiographic picture depends on the nature of the adhesions and their prevalence. They usually appear as single or multiple filling defects, have an irregular, lacuna-like shape and vary in size. Dense multiple adhesions can divide the uterine cavity into many chambers of various sizes, connected by small ducts. Such uterine pathology cannot be identified in detail by hysteroscopy, which visualizes only the first few centimeters of the lower segment of the uterine cavity.

Based on hysterography data, it is possible to determine the classification characteristics of intrauterine adhesions, select the management tactics and the method of hysteroscopic surgery.

Uterine malformations. Metrography is of great value in diagnosing uterine malformations. A hysterogram can clearly determine the size (length, thickness) and length of the intrauterine septum; the size and location of each horn of a bicornuate uterus; the presence of a rudimentary horn connected to the uterine cavity. It is important to remember that with a wide intrauterine septum, a diagnostic error can be made in differentiating with a bicornuate uterus. Hysteroscopy does not always provide comprehensive information in diagnosing this pathology.

To determine the type of uterine malformation, a metrography is performed before hysteroscopy.

Siegler (1967) proposed hysterographic diagnostic criteria for uterine malformations.

• In a bicornuate and double uterus, the halves of its cavities have an arcuate (convex) middle wall, and the angle between them is usually more than 90°.
• With an intrauterine septum, the median walls are straightened (straight), and the angle between them is usually less than 90°.

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

In more complex situations, it is possible to accurately diagnose the type of uterine malformation by supplementing hysteroscopy with laparoscopy.

Uterine scar. Hysterography is the method of choice for assessing the condition of the uterine scar after myomectomy, cesarean section and uterine perforation. Scar inadequacy is determined as a contour saccular diverticulum - a shadow open outward from the contour of the uterine cavity. Hysteroscopy allows determining only the condition of a fresh uterine scar after cesarean section.

Thus, hysteroscopy and hysterography are complementary, not competing, diagnostic methods. Hysterography is an additional method of examination in cases where hysteroscopy is not informative enough. Hysterography is mandatory in cases of infertility and assessment of the condition of the uterine scar. In case of intrauterine adhesions, hysterography is additionally performed when it is impossible to fully examine the uterine cavity during hysteroscopy. Infertility combined with intrauterine adhesions is also considered an indication for hysterography. If adenomyosis is detected or suspected during hysteroscopy, it is advisable to perform metrography to clarify the diagnosis. Suspicion of a uterine malformation also requires hysterography.

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