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DOI: 10.1148/rg.262055109
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Hysterosalpingography: A Reemerging Study1

William L. Simpson, Jr, MD, Laura G. Beitia, MD and Jolinda Mester, MD

1 From the Department of Radiology, Mount Sinai Medical Center, Box 1234, 1 Gustave L. Levy Place, New York, NY 10029. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received May 4, 2005; revision requested June 3 and received July 28; accepted July 29. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  (a) Spot radiograph obtained during the early filling stage of the uterus. Small filling defects are best seen at this stage. (b) On a radiograph obtained with the uterus fully distended with contrast material, portions of both fallopian tubes are opacified. Like images obtained during the early filling stage of the uterus, images obtained at full uterine distention allow evaluation for filling defects and contour abnormalities. However, small filling defects may be obscured when the uterus is well opacified. (c) Spot radiograph clearly depicts the interstitial, isthmic, and ampullary portions of both fallopian tubes. (d) Spot radiograph shows intraperitoneal contrast material spillage from the fallopian tubes. In this case, the spillage outlines the convexity of the uterine fundus (arrow).

 

Figure 1
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  		Figure 1b.  (a) Spot radiograph obtained during the early filling stage of the uterus. Small filling defects are best seen at this stage. (b) On a radiograph obtained with the uterus fully distended with contrast material, portions of both fallopian tubes are opacified. Like images obtained during the early filling stage of the uterus, images obtained at full uterine distention allow evaluation for filling defects and contour abnormalities. However, small filling defects may be obscured when the uterus is well opacified. (c) Spot radiograph clearly depicts the interstitial, isthmic, and ampullary portions of both fallopian tubes. (d) Spot radiograph shows intraperitoneal contrast material spillage from the fallopian tubes. In this case, the spillage outlines the convexity of the uterine fundus (arrow).

 

Figure 1
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  		Figure 1c.  (a) Spot radiograph obtained during the early filling stage of the uterus. Small filling defects are best seen at this stage. (b) On a radiograph obtained with the uterus fully distended with contrast material, portions of both fallopian tubes are opacified. Like images obtained during the early filling stage of the uterus, images obtained at full uterine distention allow evaluation for filling defects and contour abnormalities. However, small filling defects may be obscured when the uterus is well opacified. (c) Spot radiograph clearly depicts the interstitial, isthmic, and ampullary portions of both fallopian tubes. (d) Spot radiograph shows intraperitoneal contrast material spillage from the fallopian tubes. In this case, the spillage outlines the convexity of the uterine fundus (arrow).

 

Figure 1
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  		Figure 1d.  (a) Spot radiograph obtained during the early filling stage of the uterus. Small filling defects are best seen at this stage. (b) On a radiograph obtained with the uterus fully distended with contrast material, portions of both fallopian tubes are opacified. Like images obtained during the early filling stage of the uterus, images obtained at full uterine distention allow evaluation for filling defects and contour abnormalities. However, small filling defects may be obscured when the uterus is well opacified. (c) Spot radiograph clearly depicts the interstitial, isthmic, and ampullary portions of both fallopian tubes. (d) Spot radiograph shows intraperitoneal contrast material spillage from the fallopian tubes. In this case, the spillage outlines the convexity of the uterine fundus (arrow).

 

Figure 2
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  		Figure 2.  Unicornuate uterus. Spot radiograph demonstrates a single uterine horn with an irregular medial contour. A single fallopian tube is also visualized.

 

Figure 3
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  		Figure 3.  Bicornuate uterus. Spot radiograph shows two markedly splayed uterine horns. The fallopian tubes are not visualized at this imaging stage.

 

Figure 4
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  		Figure 4.  Septate and arcuate uterus. Spot radiograph demonstrates a depression of the uterine fundus, a finding that may represent a short septum or an arcuate deformity.

 

Figure 5
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  		Figure 5a.  Air bubbles. (a) Spot radiograph shows air bubbles (arrow) in the left side of the uterus. (b) Spot radiograph no longer depicts the air bubbles seen in the left cornua of the uterus in a. Air bubbles are often mobile or transient when they are expelled into the fallopian tubes.

 

Figure 5
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  		Figure 5b.  Air bubbles. (a) Spot radiograph shows air bubbles (arrow) in the left side of the uterus. (b) Spot radiograph no longer depicts the air bubbles seen in the left cornua of the uterus in a. Air bubbles are often mobile or transient when they are expelled into the fallopian tubes.

 

Figure 6
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  		Figure 6.  Uterine folds. HSG spot radiograph demonstrates uterine folds (arrows) as linear filling defects that parallel the longitudinal axis of the uterus. Uterine folds are normal findings that are occasionally seen at HSG.

 

Figure 7
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  		Figure 7a.  Synechiae. (a) Spot radiograph shows a central oval filling defect within the uterus, a finding that represents a synechia. (b) Spot radiograph obtained in a different patient demonstrates a short linear defect (arrow) along the inferior left side near the uterine isthmus.

 

Figure 7
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  		Figure 7b.  Synechiae. (a) Spot radiograph shows a central oval filling defect within the uterus, a finding that represents a synechia. (b) Spot radiograph obtained in a different patient demonstrates a short linear defect (arrow) along the inferior left side near the uterine isthmus.

 

Figure 8
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  		Figure 8.  Endometrial polyp. Sagittal sonohysterogram shows a large, well-defined mass in the fundus arising from the anterior aspect of the endometrium. Note the cystic area in the lower portion of the polyp.

 

Figure 9
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  		Figure 9a.  Leiomyomas. (a) Spot radiograph obtained during the early filling stage shows a well-defined filling defect (arrow) in the fundus. (b) On a spot radiograph obtained with the uterus more distended with contrast material, the fibroid (arrow) is less apparent. (c) Spot radiograph obtained in a different patient reveals a large leiomyoma distorting the endometrial cavity as it drapes over a mass in the left myometrium. (d) Sonohysterogram obtained in a third patient shows a retroverted uterus with fluid outlining a submucosal mass in the fundus. The balloon of an HSG catheter (arrow) is seen in the lower uterine segment.

 

Figure 9
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  		Figure 9b.  Leiomyomas. (a) Spot radiograph obtained during the early filling stage shows a well-defined filling defect (arrow) in the fundus. (b) On a spot radiograph obtained with the uterus more distended with contrast material, the fibroid (arrow) is less apparent. (c) Spot radiograph obtained in a different patient reveals a large leiomyoma distorting the endometrial cavity as it drapes over a mass in the left myometrium. (d) Sonohysterogram obtained in a third patient shows a retroverted uterus with fluid outlining a submucosal mass in the fundus. The balloon of an HSG catheter (arrow) is seen in the lower uterine segment.

 

Figure 9
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  		Figure 9c.  Leiomyomas. (a) Spot radiograph obtained during the early filling stage shows a well-defined filling defect (arrow) in the fundus. (b) On a spot radiograph obtained with the uterus more distended with contrast material, the fibroid (arrow) is less apparent. (c) Spot radiograph obtained in a different patient reveals a large leiomyoma distorting the endometrial cavity as it drapes over a mass in the left myometrium. (d) Sonohysterogram obtained in a third patient shows a retroverted uterus with fluid outlining a submucosal mass in the fundus. The balloon of an HSG catheter (arrow) is seen in the lower uterine segment.

 

Figure 9
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  		Figure 9d.  Leiomyomas. (a) Spot radiograph obtained during the early filling stage shows a well-defined filling defect (arrow) in the fundus. (b) On a spot radiograph obtained with the uterus more distended with contrast material, the fibroid (arrow) is less apparent. (c) Spot radiograph obtained in a different patient reveals a large leiomyoma distorting the endometrial cavity as it drapes over a mass in the left myometrium. (d) Sonohysterogram obtained in a third patient shows a retroverted uterus with fluid outlining a submucosal mass in the fundus. The balloon of an HSG catheter (arrow) is seen in the lower uterine segment.

 

Figure 10
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  		Figure 10a.  (a, b) Diffuse adenomyosis. (a) Spot radiograph shows irregularity of the uterine contour with small outpouchings of contrast material, findings that represent diffuse adenomyosis. (b) Sagittal T2-weighted MR image shows thickening of the junctional zone to more than 1 cm, especially in the anterior fundus. (c, d) Focal adenomyosis. (c) Spot radiograph demonstrates an irregular mass-like filling defect in the fundus with small contrast material–filled diverticula, findings that represent focal adenomyosis. (d) Transabdominal US image shows thickening of the posterior uterine fundus with a heterogeneous echotexture in the area of focal adenomyosis (cf c).

 

Figure 10
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  		Figure 10b.  (a, b) Diffuse adenomyosis. (a) Spot radiograph shows irregularity of the uterine contour with small outpouchings of contrast material, findings that represent diffuse adenomyosis. (b) Sagittal T2-weighted MR image shows thickening of the junctional zone to more than 1 cm, especially in the anterior fundus. (c, d) Focal adenomyosis. (c) Spot radiograph demonstrates an irregular mass-like filling defect in the fundus with small contrast material–filled diverticula, findings that represent focal adenomyosis. (d) Transabdominal US image shows thickening of the posterior uterine fundus with a heterogeneous echotexture in the area of focal adenomyosis (cf c).

 

Figure 10
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  		Figure 10c.  (a, b) Diffuse adenomyosis. (a) Spot radiograph shows irregularity of the uterine contour with small outpouchings of contrast material, findings that represent diffuse adenomyosis. (b) Sagittal T2-weighted MR image shows thickening of the junctional zone to more than 1 cm, especially in the anterior fundus. (c, d) Focal adenomyosis. (c) Spot radiograph demonstrates an irregular mass-like filling defect in the fundus with small contrast material–filled diverticula, findings that represent focal adenomyosis. (d) Transabdominal US image shows thickening of the posterior uterine fundus with a heterogeneous echotexture in the area of focal adenomyosis (cf c).

 

Figure 10
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  		Figure 10d.  (a, b) Diffuse adenomyosis. (a) Spot radiograph shows irregularity of the uterine contour with small outpouchings of contrast material, findings that represent diffuse adenomyosis. (b) Sagittal T2-weighted MR image shows thickening of the junctional zone to more than 1 cm, especially in the anterior fundus. (c, d) Focal adenomyosis. (c) Spot radiograph demonstrates an irregular mass-like filling defect in the fundus with small contrast material–filled diverticula, findings that represent focal adenomyosis. (d) Transabdominal US image shows thickening of the posterior uterine fundus with a heterogeneous echotexture in the area of focal adenomyosis (cf c).

 

Figure 11
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  		Figure 11.  Cesarean section scar. Spot radiograph shows the uterine incision from a cesarean section (arrows) in the typical location (ie, oriented transverse in the lower uterine segment in the region of the isthmus). At HSG, a cesarean section scar can have a linear appearance (as in this case) or can occasionally manifest as a wedge-shaped outpouching or diverticulum.

 

Figure 12
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  		Figure 12.  SIN. Spot radiograph demonstrates SIN as small outpouchings or diverticula from the isthmic portion of the fallopian tubes. SIN can be either unilateral or (as in this case) bilateral.

 

Figure 13
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  		Figure 13a.  Cornual spasm. (a) On an HSG spot radiograph obtained during the early filling stage of the uterus, the right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the pelvis. These calcifications were also present on the scout image (not shown). (b) On a spot radiograph obtained after the instillation of additional contrast material, the right fallopian tube opacifies to the ampullary portion. Right-sided SIN and a left-sided hydrosalpinx are also noted. Amorphous calcifications (arrowheads) are again seen on the right side of the pelvis.

 

Figure 13
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  		Figure 13b.  Cornual spasm. (a) On an HSG spot radiograph obtained during the early filling stage of the uterus, the right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the pelvis. These calcifications were also present on the scout image (not shown). (b) On a spot radiograph obtained after the instillation of additional contrast material, the right fallopian tube opacifies to the ampullary portion. Right-sided SIN and a left-sided hydrosalpinx are also noted. Amorphous calcifications (arrowheads) are again seen on the right side of the pelvis.

 

Figure 14
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  		Figure 14a.  Tubal occlusion. (a) Spot radiograph demonstrates abrupt cutoff of the left fallopian tube. (b) Spot radiograph demonstrates cutoff of contrast material in the isthmic portions of both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen with postsurgical occlusion (eg, following tubal ligation).

 

Figure 14
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  		Figure 14b.  Tubal occlusion. (a) Spot radiograph demonstrates abrupt cutoff of the left fallopian tube. (b) Spot radiograph demonstrates cutoff of contrast material in the isthmic portions of both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen with postsurgical occlusion (eg, following tubal ligation).

 

Figure 15
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  		Figure 15a.  Hydrosalpinx. (a) Steep right oblique spot radiograph shows dilatation of the ampullary portion of the right fallopian tube (arrow). The left fallopian tube is normal in caliber. Mucosal folds are visible in the ampullary portions of both fallopian tubes, a finding that helps confirm the presence of contrast material within the tubes. (b) Spot radiograph shows dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is abruptly cut off, a finding that is consistent with previous tubal ligation.

 

Figure 15
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  		Figure 15b.  Hydrosalpinx. (a) Steep right oblique spot radiograph shows dilatation of the ampullary portion of the right fallopian tube (arrow). The left fallopian tube is normal in caliber. Mucosal folds are visible in the ampullary portions of both fallopian tubes, a finding that helps confirm the presence of contrast material within the tubes. (b) Spot radiograph shows dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is abruptly cut off, a finding that is consistent with previous tubal ligation.

 

Figure 16
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  		Figure 16.  Peritubal adhesions. Spot radiograph demonstrates a round collection of contrast material adjacent to the left fallopian tube, a finding that suggests peritubal adhesions. Note the free contrast material spillage on the right side.

 

Figure 17
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  		Figure 17a.  Irreversible tubal occlusion with a microinsert. (a) Scout radiograph obtained prior to the instillation of contrast material shows a microinsert that has been placed hysteroscopically into the proximal fallopian tube. (b) Radiograph obtained after instillation shows no contrast material filling of the fallopian tube beyond the microinsert, a finding that helps document tubal occlusion.

 

Figure 17
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  		Figure 17b.  Irreversible tubal occlusion with a microinsert. (a) Scout radiograph obtained prior to the instillation of contrast material shows a microinsert that has been placed hysteroscopically into the proximal fallopian tube. (b) Radiograph obtained after instillation shows no contrast material filling of the fallopian tube beyond the microinsert, a finding that helps document tubal occlusion.

 

Figure 18
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  		Figure 18.  Tubal polyp. Spot radiograph shows a small filling defect (arrow) in the proximal left fallopian tube, a finding that typically represents a tubal polyp.

 




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