Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Hydrosalpinx TERMINOLOGY Definitions • Fluid-filled dilatation of fallopian tubes resulting from tubal obstruction • Must be distinguished from pyosalpinx or hematosalpinx based on tubal content and clinical picture • May /be isolated finding or bilateral or part of a complex adnexal pathologic process IMAGING General Features • Best diagnostic clue ○ Dilated tubular structure in adnexa separate from uterus and ovaries containing incomplete septa, which are due to dilated tube folding upon itself • Location ○ Adnexal but separate from ovary • Morphology ○ Cystic pelvic mass or complex fluid collection ○ Oval ○ Pear shaped ○ Convoluted or S-shaped, dilated tubular structure ○ More dilated at fimbriated end ○ Content anechoic or may contain low-level echoes (debris) Ultrasonographic Findings • Thin-walled distended tube ○ Tube wall < 3 mm ○ Walls well defined and echogenic ○ Wall could be thicker in setting of chronic dilation (due to fibrotic changes) • Waist sign: Indentation of opposing walls of dilated tubal structure, resulting in appearance of a waist • Thin endosalpingeal folds ○ "Beads on a string" sign: Small hyperechoic mural nodules on transverse imaging ○ ~ 2-3 mm in size ○ Form due to flattened and fibrotic tubal folds as result of progressive (and chronic) dilation ○ Folds could also be flattened and effaced, resulting in smooth appearance of wall – Difficult to distinguish from other pelvic cystic masses • Thicker endosalpingeal folds produce cogwheel sign in acute PID ○ Cogwheels represent thickened longitudinal folds of dilated tube • Incomplete septa ○ Short linear echogenic projections into lumen from tubal kinking • Fluid in tube and cul-de-sac is anechoic ○ Debris or echoes suggest PID • Separate and distinguishable normal ovary and uterus ○ If extensive pelvic adhesions are present, dilated tube can be deformed and simulate other pelvic masses • Doppler findings ○ High resistance flow in wall of hydrosalpinx – Resistive index (RI): ≥ 0.7 – Higher resistance than acute PID ○ No flow in endosalpingeal folds • Adnexal torsion is complication Imaging Recommendations • Best imaging tool ○ Transvaginal ultrasound • Protocol advice ○ Look for intact separate ovary ○ Use high gain settings to look for echoes in fluid ○ Cine clips can be very helpful to confirm tortuous folded tube ○ 3D-rendered US can help see tortuous structure, which is difficult to follow with 2D imaging • Inconclusive findings can be better assessed with MR • Hysterosalpingogram (HSG) is mainstay of tubal patency evaluation MR Findings • If ultrasound findings are atypical, incompletely evaluated or another associated adnexal mass is seen, proceed to MR ○ T1WI – Tubular dilated structure separate from ovaries and uterus – Tube content has low SI if simple fluid – Proteinaceous or hemorrhagic fluid is intermediate to high signal intensity depending on content of tube – High SI is correlated to pelvic and tubal endometriosis ○ T2WI – Tube content is high SI – Incomplete septa are of low SI – T2* helpful in identifying hemorrhagic content – Heavily T2 FSE (long effective echo time of 250-350 msec) result in significantly hyperintense simple fluid, while layering debris or clot will appear low SI within fluid content ○ T1WI with contrast material – Mild enhancement of tubal wall and septa, which could also be thickened – Significant enhancement suggestive of active inflammatory process • MR hysterosalpingography has been reported in literature ○ Diluted contrast agent instilled into uterine cavity via a cannula followed by multiplanar imaging Fluoroscopic Findings • HSG • Dilated fallopian tube without spillage of contrast material into peritoneal cavity from fimbriated end • Can be bilateral DIFFERENTIAL DIAGNOSIS Pyosalpinx (Acute PID) • Tube distended with echogenic material • Tube wall > 5 mm and thick endosalpingeal folds ○ Hypervascular on Doppler imaging • Low resistive flow in walls and folds (RI ≤ 0.5) • Patient is symptomatic with tenderness during transvaginal exam • May be accompanied with adnexal inflammatory changes, ovarian enlargement, endometritis, and parovarian fluid collections Diagnoses: Female Pelvis 831

Hydrosalpinx Diagnoses: Female Pelvis Tubo-Ovarian Complex • More severe manifestation of PID • Pyosalpinx adherent to ovary Paraovarian Cyst • Unilocular anechoic broad ligament cyst • More round than hydrosalpinx and thin walled Ectopic Tubal Pregnancy • Echogenic ring in adnexa with ↑ flow • Cul-de-sac fluid contains echoes if bleeding/rupture Cystic Ovarian Neoplasm • Usually not tubular; associated with ovary ○ Exception: High-grade serous ovarian carcinomas now believed to arise from distal tube • May have papillary projections of variable sizes and locations • May have multiple septations of various locations and thickness • May have variable degree of internal debris and echogenic fluid and ovarian enlargement Dilated Bowel • Distinct bowel wall layers with peristalsis seen during imaging Peritoneal Inclusion Cyst • Pseudocyst formed by entrapped peritoneal fluid by peritoneal adhesions without true walls • Ovary is entrapped by cystic structure, which may be surrounded by complete septations Acute Appendicitis • Thicker wall with gut signature • Appendicolith, surrounding echogenic fat • Traced to cecum PATHOLOGY General Features • Etiology ○ Tube obstruction from PID ○ Usually at ampullary or infundibular segments due to adhesions ○ Most common pathogens: Chlamydia trachomatis, Neisseria gonorrhoeae ○ Also associated with endometriosis, appendicitis, or post pelvic surgery • Associated abnormalities ○ Infertility ○ Ectopic pregnancy ○ Endometriosis and chronic pelvic pain Microscopic Features • Chronic salpingitis • Fibrotic thickened endosalpingeal folds, small lumen ○ Can present with lower abdominal or pelvic pain • Other signs/symptoms ○ Acute pain if adnexal torsion – Isolated tubal torsion is rare ○ Can be discovered during work-up for infertility Demographics • Age ○ Any age Treatment • None necessary if asymptomatic • For those with infertility, recommended treatment by American Society for Reproductive Medicine is salpingectomy or proximal tubal occlusion DIAGNOSTIC CHECKLIST Image Interpretation Pearls • Tubular fluid-filled structure with incomplete septa and mural nodules separate from uterus and ovaries • Look for signs of acute PID SELECTED REFERENCES 1. Kaproth-Joslin K et al: Imaging of female infertility: a pictorial guide to the hysterosalpingography, ultrasonography, and magnetic resonance imaging findings of the congenital and acquired causes of female infertility. Radiol Clin North Am. 51(6):967-81, 2013 2. Matorras R et al: Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated. Eur J Obstet Gynecol Reprod Biol. 169(1):54-9, 2013 3. Ma L et al: Fallopian tubal patency diagnosed by magnetic resonance hysterosalpingography. J Reprod Med. 57(9-10):435-40, 2012 4. Rezvani M et al: Fallopian tube disease in the nonpregnant patient. Radiographics. 31(2):527-48, 2011 5. Carrascosa PM et al: Virtual hysterosalpingography: a new multidetector CT technique for evaluating the female reproductive system. Radiographics. 30(3):643-61, 2010 6. Moyle PL et al: Nonovarian cystic lesions of the pelvis. Radiographics. 30(4):921-38, 2010 7. Timor-Tritsch IE et al: Three-dimensional ultrasound inversion rendering technique facilitates the diagnosis of hydrosalpinx. J Clin Ultrasound. 38(7):372-6, 2010 8. Kim MY et al: MR Imaging findings of hydrosalpinx: a comprehensive review. Radiographics. 29(2):495-507, 2009 9. Potter AW et al: US and CT evaluation of acute pelvic pain of gynecologic origin in nonpregnant premenopausal patients. Radiographics. 28(6):1645- 59, 2008 10. Bontis JN et al: Laparoscopic management of hydrosalpinx. Ann N Y Acad Sci. 1092:199-210, 2006 11. Patel MD et al: Likelihood ratio of sonographic findings in discriminating hydrosalpinx from other adnexal masses. AJR. 186:1033-8, 2006 12. Simpson WL Jr et al: Hysterosalpingography: a reemerging study. Radiographics. 26(2):419-31, 2006 13. Benjaminov O et al: Sonography of the abnormal fallopian tube. AJR Am J Roentgenol. 183(3):737-42, 2004 14. Dohke M et al: Comprehensive MR imaging of acute gynecologic diseases. Radiographics. 20:1551-66, 2000 832 CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Commonly asymptomatic

Hydrosalpinx<br />

Diagnoses: Female <strong>Pelvis</strong><br />

Tubo-Ovarian Complex<br />

• More severe manifestation of PID<br />

• Pyosalpinx adherent to ovary<br />

Paraovarian Cyst<br />

• Unilocular anechoic broad ligament cyst<br />

• More round than hydrosalpinx <strong>and</strong> thin walled<br />

Ectopic Tubal Pregnancy<br />

• Echogenic ring in adnexa with ↑ flow<br />

• Cul-de-sac fluid contains echoes if bleeding/rupture<br />

Cystic Ovarian Neoplasm<br />

• Usually not tubular; associated with ovary<br />

○ Exception: High-grade serous ovarian carcinomas now<br />

believed to arise from distal tube<br />

• May have papillary projections of variable sizes <strong>and</strong><br />

locations<br />

• May have multiple septations of various locations <strong>and</strong><br />

thickness<br />

• May have variable degree of internal debris <strong>and</strong> echogenic<br />

fluid <strong>and</strong> ovarian enlargement<br />

Dilated Bowel<br />

• Distinct bowel wall layers with peristalsis seen during<br />

imaging<br />

Peritoneal Inclusion Cyst<br />

• Pseudocyst formed by entrapped peritoneal fluid by<br />

peritoneal adhesions without true walls<br />

• Ovary is entrapped by cystic structure, which may be<br />

surrounded by complete septations<br />

Acute Appendicitis<br />

• Thicker wall with gut signature<br />

• Appendicolith, surrounding echogenic fat<br />

• Traced to cecum<br />

PATHOLOGY<br />

General Features<br />

• Etiology<br />

○ Tube obstruction from PID<br />

○ Usually at ampullary or infundibular segments due to<br />

adhesions<br />

○ Most common pathogens: Chlamydia trachomatis,<br />

Neisseria gonorrhoeae<br />

○ Also associated with endometriosis, appendicitis, or post<br />

pelvic surgery<br />

• Associated abnormalities<br />

○ Infertility<br />

○ Ectopic pregnancy<br />

○ Endometriosis <strong>and</strong> chronic pelvic pain<br />

Microscopic Features<br />

• Chronic salpingitis<br />

• Fibrotic thickened endosalpingeal folds, small lumen<br />

○ Can present with lower abdominal or pelvic pain<br />

• Other signs/symptoms<br />

○ Acute pain if adnexal torsion<br />

– Isolated tubal torsion is rare<br />

○ Can be discovered during work-up for infertility<br />

Demographics<br />

• Age<br />

○ Any age<br />

Treatment<br />

• None necessary if asymptomatic<br />

• For those with infertility, recommended treatment by<br />

American Society for Reproductive Medicine is<br />

salpingectomy or proximal tubal occlusion<br />

DIAGNOSTIC CHECKLIST<br />

Image Interpretation Pearls<br />

• Tubular fluid-filled structure with incomplete septa <strong>and</strong><br />

mural nodules separate from uterus <strong>and</strong> ovaries<br />

• Look for signs of acute PID<br />

SELECTED REFERENCES<br />

1. Kaproth-Joslin K et al: Imaging of female infertility: a pictorial guide to the<br />

hysterosalpingography, ultrasonography, <strong>and</strong> magnetic resonance imaging<br />

findings of the congenital <strong>and</strong> acquired causes of female infertility. Radiol<br />

Clin North Am. 51(6):967-81, 2013<br />

2. Matorras R et al: Hysteroscopic hydrosalpinx occlusion with Essure device in<br />

IVF patients when salpingectomy or laparoscopy is contraindicated. Eur J<br />

Obstet Gynecol Reprod Biol. 169(1):54-9, 2013<br />

3. Ma L et al: Fallopian tubal patency diagnosed by magnetic resonance<br />

hysterosalpingography. J Reprod Med. 57(9-10):435-40, 2012<br />

4. Rezvani M et al: Fallopian tube disease in the nonpregnant patient.<br />

Radiographics. 31(2):527-48, 2011<br />

5. Carrascosa PM et al: Virtual hysterosalpingography: a new multidetector CT<br />

technique for evaluating the female reproductive system. Radiographics.<br />

30(3):643-61, 2010<br />

6. Moyle PL et al: Nonovarian cystic lesions of the pelvis. Radiographics.<br />

30(4):921-38, 2010<br />

7. Timor-Tritsch IE et al: Three-dimensional ultrasound inversion rendering<br />

technique facilitates the diagnosis of hydrosalpinx. J Clin <strong>Ultrasound</strong>.<br />

38(7):372-6, 2010<br />

8. Kim MY et al: MR Imaging findings of hydrosalpinx: a comprehensive review.<br />

Radiographics. 29(2):495-507, 2009<br />

9. Potter AW et al: US <strong>and</strong> CT evaluation of acute pelvic pain of gynecologic<br />

origin in nonpregnant premenopausal patients. Radiographics. 28(6):1645-<br />

59, 2008<br />

10. Bontis JN et al: Laparoscopic management of hydrosalpinx. Ann N Y Acad<br />

Sci. 1092:199-210, 2006<br />

11. Patel MD et al: Likelihood ratio of sonographic findings in discriminating<br />

hydrosalpinx from other adnexal masses. AJR. 186:1033-8, 2006<br />

12. Simpson WL Jr et al: Hysterosalpingography: a reemerging study.<br />

Radiographics. 26(2):419-31, 2006<br />

13. Benjaminov O et al: Sonography of the abnormal fallopian tube. AJR Am J<br />

Roentgenol. 183(3):737-42, 2004<br />

14. Dohke M et al: Comprehensive MR imaging of acute gynecologic diseases.<br />

Radiographics. 20:1551-66, 2000<br />

832<br />

CLINICAL ISSUES<br />

Presentation<br />

• Most common signs/symptoms<br />

○ Commonly asymptomatic

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