GYNECOLOGICAL RADIOLOGY & IMAGING

1. Hysterosalpingography
Definition:
? Radiography of the uterus and fallopian tubes after the injection of rad
iopaque material
? Diatrizoate sodium is used as a radiographic contrast medium
? Hysterosalpingography is used mainly to determine the patency of the fal
lopian tubes and to visualize uterine and tubal cavities in the evaluation of ab
normal conditions of the uterus and fallopian tubes (e.g. tumors).
? The patient should empty her bladder prior to the examination.
? The injection is instilled slowly into the uterus in fractional doses of
approximately 1 mL, preferably using fluoroscopy to monitor the instillation.
? Usually, 4 mL of the injection is sufficient to visualize a normal uteru
s; an additional 3-4 mL may be used to visualize the fallopian tubes.
? Fluoroscopic spot films or radiographs are taken after each instillation
of 1 mL of the injection or as necessary during fluoroscopic monitoring until t
he examination is completed.
Procedure:
? The contrast medium first used for salpingography was Lipiodol, an iodis
ed oil.
? This was superseded by the newer less viscous aqueous contrast media suc
h as Endografin, or Diaginol Viscous.
? With iodised oil it was necessary to take a film twenty-four hours after
the injection of the contrast medium to demonstrate whether or not there had be
en peritoneal spill.
? With the newer contrast media the spill can be observed immediately by s
creening the salpingogram during injection.
? The radiologist observes the injection on an image intensifier and takes
any appropriate pictures necessary.
? The normal hysterosalpingogram shows the uterus as inverted triangular s
hadow and the tubes as fine sinuous lines extending out from the cornual angles.
? In cases of sterility normal appearances may be shown with a free spill
into the peritoneum and a local mechanical cause may thus be excluded.
? In these normal cases the prognosis is fair and in one series about a th
ird of the patients subsequently became pregnant.
? However salpingography is no longer used in the investigation of pelvic
masses or cysts in the female since ultrasound is both more accurate and non-inv
asive
? CT is also of great value particularly in the assessment and staging of
pelvic malignant tumours
Indications:
1. Sterility
? Hysterosalpingography is most widely used in the investigation of steril
ity
? The salpingogram may show a definite cause for sterility such as blockag
e of both tubes or the presence of bilateral hydrosalpinx.
? It has even been postulated that salpingography had a therapeutic effect
in some of these patients by clearing adhesions.
2. Tumours
? It has also been used in the investigation of uterine hemorrhage and pel
vic tumours.
? The HSG has been considered the gold standard in the imaging of the uter
ine corpus for benign disorders (submucous myomas, submucous polyps, localizatio
n of tubal occlusion, and evaluation of mullerian fusion defects) and malignant
(endometrial carcinoma).
? In the case of ovarian cysts or masses, or of pelvic tumours, there may
be an appreciable displacement of the uterus and of one tube enabling the lesion
to be accurately localised to the ovary or broad ligaments
3. Congenital anomalies
? Congenital anomalies of the uterus such as bicornuate or infantile uteru
s may be seen, or grosser anomalies such as uterus didelphys may be diagnosed
Contraindications:
1. pregnancy,
2. severe hemorrhage
3. active infection
4. allergy to contrast
5. menstrual period
2. Ultrasonography
Introduction:
? Generally, the scan is performed with the bladder full; this elevates th
e uterus out of the pelvis, displaces air-filled loops of bowel, and provides th
e operator with an index of density-a sonographic "window" differentiating the p
elvic organs.
Indications:
? Ultrasonography can be helpful in the diagnosis of almost any pelvic abn
ormality, since all structures, normal and abnormal, can usually be demonstrated
1. Foreign body:
? Ultrasonography may be used to locate a lost intrauterine device or a fo
reign body in the vagina of a child.
2. Congenital malformations
? Congenital malformations such as a bicornuate uterus or vaginal agenesis
are sometimes, but not always, detected
3. Adjuvant to gynecological procedures
? Ultrasound examination is useful in the placement of uterine tandems for
radiation therapy for endometrial cancer and for guidance during second-trimest
er abortion procedures.
? The vaginal scan is used very often to determine follicular size with in
vitro fertilization and to predict the best time for ovum retrieval.
4. Tumours
? One of the more common uses for ultrasonography is the diagnosis of pelv
ic masses.
? Often because of their location, attachment, and density, myomas can be
diagnosed without too much difficulty
? Pelvic ultrasonography plays a significant role in the diagnosis of uter
ine leiomyomas (submucous, intramural, and subserosal) and polyps.
? These may be detected by irregularities in the endometrial stripe or by
sonohysterography (SHG).
? Adnexal masses can also be found with relative ease by ultrasonography,
although an accurate diagnosis is more difficult because of the various types of
adnexal masses that can be found
5. Cysts
? Cystic and solid structures of the ovary are now better evaluated by tra
nsabdominal ultrasonography (TAUS), transvaginal ultrasonography (TVUS)
? Ovarian cysts can be described as being unilocular or multilocular, tota
lly fluid-filled or partially solid. A very common adnexal mass, a dermoid cyst,
can have characteristic ultrasound findings because of fat tissue and bone dens
ities seen in these cysts
? Trans-vaginal ultrasonography is commonly used to diagnose ovarian cysts
, especially in obese patients in whom abdominal scans are of limited use.
6. Pelvic infections
? Pelvic abscesses can be diagnosed by ultrasonography, especially if ther
e is a well-encapsulated large abscess pocket.
3. CT
? CT may be useful for staging ovarian cancer preoperatively or for planni
ng second-look procedures. In patients with benign-appearing adnexal masses (ova
rian cysts or tubo-ovarian abscesses), CT may be very useful for biopsy and drai
nage.
4. MRI
? MRI can accurately measure the volume of the myoma.
? This is an aid in determining whether medical management of myomas has r
esulted in shrinkage or if conservatively treated myomas are growing.
? Malignant degeneration of myomas visualized by MRI allows for early and
appropriate intervention.
? MRI also may be useful in the differential diagnosis of myomas and adeno
myosis, benign and malignant ovarian pathology, pelvic kidney, and pelvic absces
s.
? Its main use in gynecology appears to be for staging and following up pe
lvic cancers.
? Other potential uses of MRI include evaluation of placental blood flow a
nd accurately performing pelvimetry

<PIXTEL_MMI_EBOOK_2005>7</PIXTEL_MMI_EBOOK_2005>