uterography


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uterography

 [u″ter-og´rah-fe]
x-ray examination of the uterus; hysterography.

hysterosalpingography

A method for evaluating uterine tubal pathology, in which radiocontrast is instilled transcervically into the endometrial cavity and fallopian tubes, followed by fluoroscopy or taking plain films, as a way of defining the uterine cavity and tube.

Uses
Evaluation of infertility (e.g., to determine fallopian tube patency), uterine-cavity (e.g., submucosal) leiomyomas, endocervical and endometrial polyps, pelvic tuberculosis, intrauterine adhesion-synequiae, endometrial cancer, congenital malformations (e.g., müllerian duct abnormalities), bicornuate uterus, septate uterus, uterus didelphys, uterine hypoplasia, and DES-induced defects.

Hysterosalpingography has waned in popularity, due to high false-positivity and false-negativity.

Hysterosalpingography

Synonym/acronym: Hysterogram, uterography, uterosalpingography.

Common use

To visualize and assess the uterus and fallopian tubes to assess for obstruction, adhesions, malformations, or injuries that may be related to infertility.

Area of application

Uterus and fallopian tubes.

Contrast

Iodinated contrast medium.

Description

Hysterosalpingography (HSG) is performed as part of an infertility study to identify anatomical abnormalities of the uterus or occlusion of the fallopian tubes. The procedure allows visualization of the uterine cavity, fallopian tubes, and peritubal area after the injection of contrast medium into the cervix. The contrast medium should flow through the uterine cavity, through the fallopian tubes, and into the peritoneal cavity, where it is absorbed if no obstruction exists. The procedure has therapeutic indications in that passage of the contrast medium through the tubes may clear mucous plugs, straighten kinked tubes, or break up adhesions, thus restoring fertility. This procedure is also used to evaluate the fallopian tubes after tubal ligation and to evaluate the results of reconstructive surgery.

This procedure is contraindicated for

  • high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alert Conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
  • high alert Conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycocides and NSAIDs) because iodinated contrast is nephrotoxic.
  • high alert Elderly and compromised patients who are chronically dehydrated before the test, because of their risk of contrast-induced renal failure.
  • high alert Patients with bleeding disorders, because the puncture site may not stop bleeding.
  • high alert Patients with menses, undiagnosed vaginal bleeding, or pelvic inflammatory disease.

Indications

  • Assist in the investigation of abnormal uterine bleeding, amenorrhea, or recurrent abortion.
  • Confirm the presence of fistulas, adhesions, polyps, or pelvic masses.
  • Confirm tubal abnormalities such as adhesions and occlusions; evaluate the patency of the tubes.
  • Confirm uterine abnormalities such as congenital malformation, traumatic injuries, missing or ectopic contraceptive devices, or indicate the presence of foreign bodies.
  • Detect bicornate uterus.
  • Evaluate adequacy of surgical tubal ligation and reconstructive surgery.

Potential diagnosis

Normal findings

  • Contrast medium flowing freely into the fallopian tubes and from the uterus into the peritoneal cavity
  • Normal position, shape, and size of the uterine cavity

Abnormal findings related to

  • Bicornate uterus
  • Developmental abnormalities
  • Extrauterine pregnancy
  • Internal scarring
  • Kinking of the fallopian tubes due to adhesions
  • Partial or complete blockage of fallopian tube(s)
  • Tumors
  • Uterine cavity anomalies
  • Uterine fistulas
  • Uterine masses or foreign body
  • Uterine fibroid tumors (leiomyomas)

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
    • Retained barium from a previous radiological procedure.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
    • Insufficient injection of contrast medium.
    • Excessive traction during the test or tubal spasm, which may cause the appearance of a stricture in an otherwise normal fallopian tube.
  • Other considerations

    • Excessive traction during the test may displace adhesions, making the fallopian tubes appear normal.
    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • Failure to follow pretesting preparations may cause the procedure to be canceled or repeated.
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the uterus and fallopian tubes.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent barium or other radiological contrast procedures. Ensure that barium studies were performed more than 4 days before the hysterosalpingography.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect coagulation (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
  • Note that if iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort. Explain to the patient that she may feel temporary sensations of nausea, dizziness, slow heartbeat, and menstrual-like cramping during the procedure, as well as shoulder pain from subphrenic irritation from the contrast medium as it spills into the peritoneal cavity. Inform the patient that the procedure is performed in a radiology department by a health-care provider (HCP), with support staff, and takes approximately 30 to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during and after the procedure.
  • Instruct the patient to take a laxative or a cathartic, as ordered, on the evening before the examination.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction or department protocol.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:
  • Risks from HSG can include uterine perforation, exposure to radiation, infection, allergic reaction to contrast medium, heavy vaginal bleeding, uterine perforation, severe abdominal pain or cramping, pelvic infection (uterine or of the fallopian tubes), and pulmonary embolism.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure the patient has complied with pretesting preparations prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Assess for completion of bowel preparation according to the institution’s procedure. Administer enemas or suppositories on the morning of the test, as ordered.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Place the patient in a lithotomy position on the fluoroscopy table.
  • A kidney, ureter, and bladder film is taken to ensure that no stool, gas, or barium will obscure visualization of the uterus and fallopian tubes.
  • A speculum is inserted into the vagina, and contrast medium is introduced into the uterus through the cervix via a cannula, after which both fluoroscopic and radiographic images are taken.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual medications and activity, as directed by the HCP.
  • Observe for delayed reaction to iodinated contrast medium, including rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Inform the patient that a vaginal discharge is common and that it may be bloody, lasting 1 to 2 days after the test.
  • Inform the patient that dizziness and cramping may follow this procedure, and that analgesia may be given if there is persistent cramping. Instruct the patient to contact the HCP in the event of severe cramping or profuse bleeding.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include CT abdomen, laparoscopy gynecological, MRI abdomen, US obstetric, US pelvis, and uterine fibroid embolization.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.

uterography

radiographic examination of the uterus; hysterography.
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