The uterine cavity and the lumens of the oviducts can be outlined by instillation of contrast medium through the cervix, followed by fluoroscope observations or film.
· Infertility: to demonstrate normal patency of the Fallopian tubes and their communication with the peritoneal cavity.
· Recurrent Abortion: to demonstrate congenital abnormalities of the uterine cavity or incompetence of the internal os the uterus.
· To Monitor The Effects of Tubal Surgery: e.g. occlusion in a sterilization procedure; or to demonstrate patency after a sterilization reversal, or after surgical intervention to restore patency of pathologically obstructed tubes.
The examination is best performed at about the middle of the menstrual cycle. Patients should be advised to abstain from intercourse, or to use some contraceptive method, in the interval from the last menstrual period up to the examination to avoid the possibility of irradiating an early pregnancy.
The patient is placed in the lithotomy position at the end of the screening table. A speculum is introduced into the vagina and the cannula (or small self-retaining catheter) is introduced into the cervix. The speculum is then removed and the patient carefully moved up the table so that she lies in a supine position, and the contrast medium is injected while the radiologist screens the procedure. This allows films to be taken at the most opportune time or to note if any contrast medium is refluxing into the vagina due to a poor seal between the injecting device and the cervical canal. One or two films may be necessary to show the cervical canal the body of the uterus, the Fallopian tubes and the spread of contrast medium on to the peritoneum. Any water-soluble contrast medium otherwise used for intravenous urography is satisfactory in this context.
· Pain: Two types of pain can occur. The first type is a hypogastric colic and is probably related to distension of the uterus. The second is more continuous generalized lower abdominal pain, most likely due to peritoneal irritation. Both are transient and usually of nuisance value only.
·Venous Intravasation: The contrast medium is accidentally injected through the endometrium and taken up by the interstitial veins which the outline the thickness of the uterine wall and are seen draining through the iliac and ovarian veins. Intravasation is said to occur: due to excessive injection pressure;due to traumatization of the endometrium by the tip of the cannula;and if the examination is performed when the endometrium is deficient as after curettage or menstruation.
·Exacerbation of Pelvic Infection: Care should be taken not to perform the examination in the presence of any active inflammation process. It is considered advisable to give prophylactic antibiotics in a patient with chronic pelvic infection.
The normal uterine cavity is approximately triangular, with sides of 3,7 cm. The cervical canal has a length of about 2,5 cm or less. The cornua of the uterus are often seen to have a constriction, possibly a sphincter, at each cornotubal junction. When the spill occurs the contrast takes on an amorphous shape around the end of the tube. The pouch of Douglas is often identifiable and the elliptical outlines of the ovaries can sometimes be distinguished. Care should be taken not to confuse residual contrast medium lying the vaginal fornices.
Failure of contrast medium to pass through the tubes to the peritoneum may occasionally be due to cornual tubal spasm. Gentle injection pressure and patience, giving the spasm time to relax, are probably the most important factors in overcoming the tubal spasm. I.v. Buscopan and inhalation of amyl nitrate may be used to relieve the spasm, but its effect is dubious.
Congenital anomalies of the uterus
Varying degrees of failure of fusion of the Müllerian ducts lead to a corresponding series of congenital abnormalities of the uterus (see bellow fig. 2).
{Fig. 2}
When it becomes anteflexed or retroflexed it is seen radiographically in almost axial projection on the PA film and the cavity presents an elliptical shape. The uterus may be displaced laterally by tumor masses or adhesions.
The hysterographic appearances will be affected by the situation of the fibroids, whether submucous, interstitial or subserous. Although isolated tumors may give characteristic appearances, it must be remembered that fibroids are often multiple and generally enlarge and distort the whole uterine cavity.
Submucous fibroids will appear as sessile or polypoid filling defects in the contrast-filled cavity. It may be impossible to differentiate them from other smooth masses in the cavity such as mucosal polyps or an early pregnancy. Interstitial fibroids cause a general enlargement or distortion of the uterine cavity. The effect of subserous fibroids depends on their position. One at the fundus may cause little or no abnormality or merely cause the uterus to lie an abnormal position. If situated laterally in the parametrium, the mass will deflect the uterus to the opposite side and the ipsilateral tube will be stretched over the mass.
·Salpingitis/hydrosalpinx: The examination is contraindicated in acute infection. In some cases previous infection results in blockage of the tube, but in others contrast medium will enter the distended hydrosalpinx and reveal its extent(see fig. 3).
{Fig. 3}
·Tuberculous Salpingitis-: Tuberculoses of the Fallopian tubes usually results in obstruction of their distal ends, but the tubes may fill and then tuberculous infection is characterized by the irregular calibre of the tubes with small filling defects an some dilatation of their peripheries parts. Occasionally calcification is seen in a tuberculous pyosalpinx. When the uterine cavity is involved in a tuberculous endometritis the results may be a very small irregular contracted uterine cavity.
·Salpingitis Isthmica Nodosa: Sometimes tiny falseness of contrast medium are seen apparently lying outside the lumen of the isthmic part of the tubes. This condition of salpingitis isthmica nodosa is uncommon. It is due to small tubal diverticula and may be related to endometrosis.
· Tubal Blockage: The commonest abnormality found on salpingography in cases of the infertility is tubal blockage, with no evidence of contrast medium being spilt on the peritoneum. The obstruction, real or apparent, may be due to a number causes. They are:
· Poor operative technique
· Tubal spasm
· Obstruction following tubal infection or operation
· Fimbrial adhesions
· Tubal pregnancy, tumors, etc
· Sterilization procedures
The cervical canal is best shown when the contrast medium is injected through a suction cap device rather than with olive-tipped cannula. The cervical canal extends upwards 1-2cm from the external os to the internal os, above with there is a short narrow isthmus which then opens into the general uterine cavity. The width of the cervical canal varies with the menstrual cycle, being wider in the proliferative than in the secretory phase. Distensibility of the canal is of importance in cases of habitual midterm abortion (incompetent cervix).
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