Tuberculous salpingitis (HSG)

Tuberculous Salpingitis – Hysterosalpingography

Tuberculous salpingitis is a form of genital tuberculosis and represents one of the most common causes of tubal factor infertility in endemic regions. The fallopian tubes are usually affected bilaterally, leading to fibrosis, strictures, and obliteration of the tubal lumen. On hysterosalpingography (HSG), characteristic features include tubal beading, rigid “pipe-stem” appearance, multiple strictures, and absent peritoneal spill.

Fig-1

Fig. 1—Hysterosalpingogram showing tuberculous salpingitis. The fallopian tubes appear rigid with multiple constrictions and segmental narrowing, producing a beaded appearance, with no free peritoneal spill (arrows).

Findings: The uterine cavity may be normal or show irregularity depending on endometrial involvement. Both fallopian tubes demonstrate irregular outlines with alternating dilatation and narrowing, distal obstruction, and absence of free intraperitoneal contrast spill.

Conclusion: Hysterosalpingographic features are consistent with tuberculous salpingitis.

Patient Symptoms

Patients commonly present with primary or secondary infertility. Other symptoms may include chronic pelvic pain, menstrual irregularities, low-grade fever, weight loss, or a past history of tuberculosis.

Procedure (Hysterosalpingography)

HSG is performed during the early proliferative phase of the menstrual cycle. Gentle, low-pressure contrast injection is essential due to friable and fibrotic tubal walls.

Contrast Medium & Administration

A water-soluble iodinated contrast medium such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position, and approximately 5–8 mL of contrast is injected slowly under fluoroscopic control.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided to prevent tubal rupture or intravasation. Active pelvic infection is a contraindication. Adequate infection screening is recommended before the procedure.

Related Conditions

Differential diagnoses include chronic pelvic inflammatory disease, hydrosalpinx, salpingitis isthmica nodosa, post-surgical tubal scarring, and tubo-ovarian adhesions. Correlation with ultrasound, MRI, and microbiological tests is advised.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved.

Salpingitis isthmica nodosa (HSG)

Salpingitis Isthmica Nodosa – Hysterosalpingography

Salpingitis isthmica nodosa (SIN) is a chronic tubal disorder characterized by multiple epithelial-lined diverticula arising from the isthmic portion of the fallopian tube. It is strongly associated with infertility and ectopic pregnancy. On hysterosalpingography (HSG), SIN classically demonstrates multiple small, rounded contrast-filled outpouchings along the isthmus, producing a characteristic beaded or nodular appearance.

Fig-1

Fig. 1—Hysterosalpingogram demonstrating salpingitis isthmica nodosa. Multiple small, round, contrast-filled outpouchings are seen arising from the isthmic segment of the fallopian tube, giving a nodular appearance (arrows).

Findings: The uterine cavity is normal in size and contour. One or both fallopian tubes show clusters of tiny diverticular outpouchings along the isthmic portion. Tubal lumen may appear narrowed with delayed or absent peritoneal spill.

Conclusion: Hysterosalpingographic features are characteristic of salpingitis isthmica nodosa.

Patient Symptoms

Most patients present with primary or secondary infertility. Some may have a history of ectopic pregnancy, chronic pelvic pain, or previous pelvic inflammatory disease.

Procedure (Hysterosalpingography)

The study is performed in the early proliferative phase of the menstrual cycle. Slow, controlled contrast injection is important to avoid tubal spasm and to clearly delineate the diverticula.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position, and 5–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided, as it may exaggerate tubal diverticula or cause intravasation. Active pelvic infection is a contraindication.

Related Conditions

Differential diagnoses include tubal diverticulosis, genital tuberculosis, hydrosalpinx, cornual spasm, and post-inflammatory tubal scarring. Laparoscopy may be required for definitive assessment.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved.

Hematosalpinx (HSG)

Hematosalpinx – Hysterosalpingography

Hematosalpinx refers to accumulation of blood within the fallopian tube, most commonly associated with endometriosis, ectopic pregnancy, pelvic inflammatory disease, or post-procedural causes. On hysterosalpingography (HSG), hematosalpinx appears as a dilated fallopian tube with incomplete or absent peritoneal spill, often showing irregular or interrupted contrast column due to intraluminal blood products.

Fig-1

Fig. 1—Hysterosalpingogram showing hematosalpinx. The affected fallopian tube is dilated with irregular opacification and absence of free peritoneal spill (arrow).

Findings: The uterine cavity is normal in size and contour. One fallopian tube shows fusiform dilatation with interrupted or irregular contrast filling. The distal end appears obstructed with no free intraperitoneal spill, consistent with retained blood within the tube.

Conclusion: Hysterosalpingographic features are suggestive of hematosalpinx.

Patient Symptoms

Patients may present with infertility, chronic pelvic pain, dysmenorrhea, history of endometriosis, or prior pelvic infection. Acute symptoms are uncommon unless associated with recent hemorrhage.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Gentle contrast injection is essential to avoid rupture of a distended tube.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is placed in the lithotomy position, and 5–8 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided due to risk of tubal rupture. HSG is contraindicated in suspected ectopic pregnancy or active pelvic infection.

Related Conditions

Differential diagnoses include hydrosalpinx, pyosalpinx, tubo-ovarian abscess, salpingitis isthmica nodosa, and tubal endometriosis. Correlation with ultrasound or MRI may aid diagnosis.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved.

Tubal Polyps (HSG)

Tubal Polyp – Hysterosalpingography

Tubal polyp represents a benign intraluminal lesion of the fallopian tube, commonly arising from the mucosal folds. It may cause partial or intermittent tubal obstruction and is a recognized cause of infertility. On hysterosalpingography (HSG), a tubal polyp typically appears as a smooth, well-defined intraluminal filling defect within an otherwise opacified fallopian tube, with delayed or reduced peritoneal spill.

Fig-1

Fig. 1—Hysterosalpingogram demonstrating a tubal polyp. A smooth intraluminal filling defect is seen within the fallopian tube, surrounded by contrast, with mild delay in distal contrast passage (arrow).

Findings: The uterine cavity appears normal in size and contour. One fallopian tube shows a well-circumscribed intraluminal filling defect with preserved tubal outline. Partial contrast passage beyond the lesion is noted with reduced or delayed peritoneal spill.

Conclusion: Hysterosalpingographic features are suggestive of a tubal polyp.

Patient Symptoms

Patients may be asymptomatic or present with primary or secondary infertility. Some may report intermittent pelvic discomfort. Menstrual history is usually normal.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Slow, controlled contrast injection helps in accurate visualization of intraluminal tubal abnormalities.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position, and 5–10 mL of contrast is injected gradually under fluoroscopic control.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided to prevent tubal spasm or rupture. Active pelvic infection is a contraindication for HSG.

Related Conditions

Differential diagnoses include tubal mucus plugs, air bubbles, salpingitis isthmica nodosa, tubal adhesions, and early hydrosalpinx. Confirmation may require hysteroscopy, laparoscopy, or salpingoscopy.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been maintained.

Pyosalpinx (HSG)

Right Cornual Block with Left Pyosalpinx – Hysterosalpingography

This represents a mixed proximal–distal tubal pathology, with obstruction at the right uterotubal junction (cornual block) and inflammatory dilatation of the left fallopian tube (pyosalpinx). Pyosalpinx refers to accumulation of pus within an obstructed fallopian tube, usually secondary to pelvic inflammatory disease or genital tuberculosis. On hysterosalpingography (HSG), asymmetric tubal findings are seen with non-opacification of the right tube and a dilated, irregular left tube without free peritoneal spill (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing right cornual block with left pyosalpinx. The right fallopian tube fails to opacify beyond the uterine cornu, while the left tube is dilated, irregular, and tortuous with no peritoneal spill (arrows).

Findings: The uterine cavity is normal in size and contour. On the right side, contrast terminates abruptly at the cornual region with no tubal visualization. On the left side, the fallopian tube is dilated with irregular walls and a clubbed distal end, consistent with pyosalpinx. No free intraperitoneal spill is seen.

Conclusion: Hysterosalpingographic features are consistent with right cornual block and left pyosalpinx.

Patient Symptoms

Patients may present with primary or secondary infertility, chronic pelvic pain, fever, lower abdominal pain, abnormal vaginal discharge, or a prior history of pelvic inflammatory disease. Acute symptoms may be absent in chronic pyosalpinx.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Careful low-pressure contrast injection is essential, especially when an infected or inflamed tube is suspected.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. A limited volume (5–8 mL) is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

HSG should be performed cautiously in suspected active infection. Excessive injection pressure must be avoided to prevent tubal rupture or dissemination of infection. Active pelvic infection is a relative contraindication.

Related Conditions

Differential diagnoses include right cornual spasm, left hydrosalpinx, tubo-ovarian abscess, genital tuberculosis, and severe peritubal adhesions. Ultrasound, MRI, or laparoscopy may be required for confirmation and management.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Hydrosalpinx (HSG)

Bilateral Hydrosalpinx – Hysterosalpingography

Bilateral hydrosalpinx refers to dilatation of both fallopian tubes due to distal tubal obstruction, most commonly at the fimbrial ends, resulting in accumulation of serous fluid. It is usually secondary to pelvic inflammatory disease, genital tuberculosis, endometriosis, or post-surgical adhesions. On hysterosalpingography (HSG), both tubes appear dilated, elongated, and tortuous with clubbed distal ends and absence of free peritoneal spill on either side (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing bilateral hydrosalpinx. Both fallopian tubes are dilated, elongated, and tortuous with clubbed distal ends and no free intraperitoneal spill (arrows).

Findings: The uterine cavity is normal in size and contour. Both fallopian tubes demonstrate marked dilatation with serpiginous configuration and blind-ending distal segments. No intraperitoneal contrast spill is seen bilaterally. Delayed images may show contrast retention within both tubes.

Conclusion: Hysterosalpingographic features are consistent with bilateral hydrosalpinx.

Patient Symptoms

Patients commonly present with primary or secondary infertility. Some may have chronic pelvic pain, dyspareunia, or a prior history of pelvic infection. Bilateral hydrosalpinx is strongly associated with reduced fertility.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Delayed images are helpful to demonstrate contrast retention within the dilated tubes, confirming distal tubal obstruction.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided to prevent tubal rupture or intravasation. Bilateral hydrosalpinx should be clearly reported due to its significant negative impact on natural conception and assisted reproductive outcomes.

Related Conditions

Differential diagnoses include distal tubal block without dilatation, peritubal adhesions, pyosalpinx, and tubo-ovarian masses. Laparoscopy or pelvic MRI may be required for definitive diagnosis and treatment planning.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Hydrosalpinx with fimbrial block

Left Hydrosalpinx with Fimbrial Block – Hysterosalpingography

Left hydrosalpinx with fimbrial block refers to distal obstruction of the left fallopian tube at the fimbrial end, resulting in dilatation of the tube with accumulation of fluid. It is commonly caused by pelvic inflammatory disease, genital tuberculosis, endometriosis, or post-surgical adhesions. On hysterosalpingography (HSG), the affected tube appears dilated, elongated, and tortuous with clubbing of the fimbrial end and absence of free peritoneal spill (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing left hydrosalpinx with fimbrial block. The left fallopian tube is markedly dilated and tortuous with a clubbed distal end and no peritoneal spill (arrow). The right tube shows normal opacification and free spill.

Findings: The uterine cavity is normal in size and contour. The left fallopian tube is dilated, elongated, and serpiginous, terminating in a blind, club-shaped distal end. No free intraperitoneal contrast spill is seen on the left. The right fallopian tube is patent with free spill.

Conclusion: Hysterosalpingographic features are consistent with left hydrosalpinx with fimbrial block.

Patient Symptoms

Patients may present with primary or secondary infertility, chronic pelvic pain, dyspareunia, or a history of pelvic infection. Some cases are asymptomatic and detected during infertility evaluation.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Delayed images may demonstrate contrast retention within the dilated tube, helping to confirm fimbrial occlusion.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided to prevent tubal rupture or intravasation. Hydrosalpinx should be reported carefully due to its negative impact on fertility outcomes.

Related Conditions

Differential diagnoses include distal tubal block without dilatation, peritubal adhesions, pyosalpinx, and tubo-ovarian mass. Laparoscopy or pelvic MRI may be required for confirmation and management planning.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Isthmic & Interstitial Portion Block (HSG)

Right Isthmic & Left Interstitial Portion Block – Hysterosalpingography

This pattern represents asymmetric proximal tubal obstruction, with blockage at the isthmic portion of the right fallopian tube and at the interstitial (cornual) portion of the left fallopian tube. Such mixed-level tubal block may be functional (tubal spasm, mucus plugging) or organic, commonly related to pelvic inflammatory disease, genital tuberculosis, endometriosis, or post-surgical fibrosis. On hysterosalpingography (HSG), contrast shows differential termination at the two tubal levels with no peritoneal spill (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing asymmetric tubal block. The right fallopian tube opacifies up to the isthmic segment with abrupt cutoff, while the left tube shows contrast arrest at the interstitial (cornual) portion (arrows). No free peritoneal spill is seen.

Findings: The uterine cavity is normal in size and contour. On the right side, the tube fills proximally and terminates abruptly at the isthmus. On the left side, contrast fails to progress beyond the uterotubal junction. Intraperitoneal spill is absent bilaterally.

Conclusion: Hysterosalpingographic findings are consistent with right isthmic tubal block and left interstitial (cornual) tubal block.

Patient Symptoms

Patients usually present with primary or secondary infertility. Menstrual cycles are typically normal unless associated pelvic pathology is present.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Delayed images, patient repositioning, and gentle repeat injection may help differentiate transient tubal spasm from true organic obstruction.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive injection pressure should be avoided to prevent tubal rupture or intravasation. Asymmetric tubal non-filling should be interpreted cautiously, as spasm can occur at different tubal segments.

Related Conditions

Differential diagnoses include bilateral tubal spasm, proximal tubal block, genital tuberculosis, endometriosis-related fibrosis, and post-surgical tubal occlusion. Selective salpingography or laparoscopy may be required for confirmation.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Tubal Block (Bilateral)

Tubal Block (Bilateral) – Hysterosalpingography

Bilateral tubal block refers to obstruction of both fallopian tubes, resulting in complete absence of peritoneal spill on hysterosalpingography (HSG). The level of obstruction may be proximal (cornual or isthmic) or distal, and may be functional (tubal spasm, mucus plugging) or organic due to pelvic inflammatory disease, genital tuberculosis, endometriosis, prior surgery, or post-inflammatory fibrosis. On HSG, the uterine cavity opacifies normally, but contrast fails to traverse both tubes with no intraperitoneal spill (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing bilateral tubal block. The uterine cavity is well opacified, but both fallopian tubes fail to show distal opacification or peritoneal spill (arrows).

Findings: Normal uterine cavity outline is seen. Both fallopian tubes show non-opacification beyond the site of obstruction. No free intraperitoneal contrast spill is demonstrated on either side.

Conclusion: Hysterosalpingographic findings are consistent with bilateral tubal block.

Patient Symptoms

Patients typically present with primary or secondary infertility. Menstrual cycles are usually normal unless associated pelvic pathology is present. Bilateral tubal block represents a major cause of tubal factor infertility.

Procedure (Hysterosalpingography)

The study is performed during the early proliferative phase of the menstrual cycle. Delayed images and gentle repeat contrast injection may help exclude transient tubal spasm before labeling true bilateral tubal occlusion.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

High-pressure injection should be avoided to prevent tubal rupture or intravasation. Apparent bilateral block should be interpreted cautiously, especially in anxious patients where tubal spasm is common.

Related Conditions

Differential diagnoses include bilateral cornual block, bilateral isthmic block, distal tubal block, hydrosalpinx, peritubal adhesions, and genital tuberculosis. Laparoscopy remains the gold standard for confirmation.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Bilateral Cornual block (HSG)

Bilateral Cornual Block – Hysterosalpingography

Bilateral cornual block refers to obstruction at both uterotubal junctions (cornual regions), resulting in failure of contrast to enter either fallopian tube. The obstruction may be functional—most commonly due to bilateral tubal spasm or mucus plugging—or organic, secondary to fibrosis, infection (including genital tuberculosis), endometriosis, or prior uterine surgery. On hysterosalpingography (HSG), bilateral cornual block is characterized by opacification of the uterine cavity without visualization of either fallopian tube (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing bilateral cornual block. Contrast opacifies the uterine cavity but fails to progress beyond both cornual regions (arrows), with no tubal visualization or peritoneal spill.

Findings: The uterine cavity is normal in size and contour. Both cornual regions show abrupt termination of contrast with non-opacification of the fallopian tubes. No intraperitoneal spill is seen.

Conclusion: Hysterosalpingographic findings are consistent with bilateral cornual block.

Patient Symptoms

Patients usually present with primary or secondary infertility. Menstrual history is often normal. Bilateral cornual block is a significant cause of tubal factor infertility.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. When bilateral non-filling is seen, delayed images, gentle repeat injection, or antispasmodic administration may help differentiate transient tubal spasm from true organic obstruction.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

High injection pressure should be avoided to prevent tubal rupture or intravasation. Apparent bilateral cornual block should be interpreted with caution, as bilateral tubal spasm is relatively common.

Related Conditions

Differential diagnoses include bilateral tubal spasm, proximal tubal block, genital tuberculosis, severe peritubal adhesions, and post-surgical fibrosis. Selective salpingography or laparoscopy may be required for confirmation.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Unilateral Cornual block (HSG)

Unilateral Cornual Block – Hysterosalpingography

Unilateral cornual block refers to obstruction at the uterine end (cornua) of one fallopian tube, preventing passage of contrast into that tube. It may be due to transient causes such as tubal spasm or mucus plugging, or true pathology including inflammation, fibrosis, endometriosis, or previous infection. On hysterosalpingography (HSG), the affected side shows non-opacification of the fallopian tube with a normal appearance of the opposite tube (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing unilateral cornual block. One fallopian tube fails to opacify beyond the uterine cornua, while the contralateral tube shows normal filling and free peritoneal spill (arrows).

Findings: The uterine cavity is normal in shape and size. Contrast fills one fallopian tube with free peritoneal spill, while the opposite tube shows abrupt termination at the cornual region with no distal opacification.

Conclusion: Hysterosalpingographic findings are consistent with a unilateral cornual block. Tubal spasm should be considered.

Patient Symptoms

Patients may be asymptomatic or present with primary or secondary infertility. Unilateral cornual block may still allow conception if the opposite tube is patent.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. If unilateral non-filling is observed, delayed images or gentle repeat injection may help differentiate true block from transient cornual spasm.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is injected slowly under fluoroscopic guidance.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Forceful injection should be avoided to prevent tubal rupture or false passage. Pregnancy and active pelvic infection must be excluded. Apparent cornual block should always be interpreted with caution.

Related Conditions

Differential diagnoses include bilateral cornual block, tubal spasm, proximal tubal occlusion due to pelvic inflammatory disease, genital tuberculosis, and endometriosis. Selective salpingography or hysteroscopy may help confirm true obstruction.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Mucus plugging in the cervical canal (HSG)

Mucus Plugging in the Cervical Canal – Hysterosalpingography

Mucus plugging of the cervical canal refers to transient obstruction of the canal by thick cervical mucus. It is a benign and functional condition, commonly seen during certain phases of the menstrual cycle, in chronic cervicitis, or due to inadequate cervical preparation before hysterosalpingography (HSG). On HSG, mucus plugging is suggested by temporary filling defects or complete non-opacification of the uterine cavity that resolves after gentle flushing or repeat injection (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing mucus plugging of the cervical canal. An amorphous, smooth filling defect is seen within the cervical canal with transient obstruction to contrast flow (arrow), which may clear on repeat injection.

Findings: The cervical canal shows partial or complete blockage by a smooth, non-fixed filling defect. The defect may change shape or disappear with gentle contrast injection. Subsequent opacification of the uterine cavity and fallopian tubes is usually normal.

Conclusion: Hysterosalpingographic appearance is consistent with mucus plugging of the cervical canal.

Patient Symptoms

Most patients are asymptomatic. Some may have a history of chronic vaginal discharge, cervicitis, or prior inconclusive HSG due to difficult contrast passage.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. If resistance is encountered, gentle flushing, slight repositioning of the cannula, or repeat injection may help clear the mucus plug and allow completion of the study.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Typically 5–8 mL of contrast is injected slowly under low pressure.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive force should be avoided to prevent cervical trauma or false passage. Pregnancy and active pelvic infection must be excluded. Repeat imaging after clearing the mucus plug helps avoid false-positive diagnoses.

Related Conditions

Differential diagnoses include cervical stenosis, cervical synechiae, cervical polyp, and cervical malignancy. Resolution after repeat injection favors mucus plugging.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Cervical synechiae (HSG)

Cervical Synechiae – Hysterosalpingography

Cervical synechiae refer to fibrous adhesions within the cervical canal resulting in partial narrowing or irregularity of the canal. They are usually acquired and commonly follow cervical instrumentation, surgery, infection, radiotherapy, or postpartum trauma. On hysterosalpingography (HSG), cervical synechiae appear as thin linear or band-like filling defects traversing the cervical canal, often causing irregular contrast flow or partial obstruction (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram demonstrating cervical synechiae. Thin linear filling defects are seen crossing the cervical canal with irregular contrast passage (arrows).

Findings: The cervical canal shows irregular narrowing with fine contrast-negative bands representing adhesions. Contrast passage into the uterine cavity may be delayed but is usually achievable. The uterine cavity and fallopian tubes are often normal.

Conclusion: Hysterosalpingographic features are consistent with cervical synechiae.

Patient Symptoms

Patients may be asymptomatic or present with infertility, dysmenorrhea, hypomenorrhea, post-procedural difficulty in cervical access, or pelvic pain.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Cannulation may be mildly difficult. A fine cannula or balloon catheter is preferred, and contrast is injected slowly under fluoroscopic guidance.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. A small volume (4–7 mL) is usually sufficient.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Fine balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Gentle cannulation and low-pressure contrast injection are essential to avoid cervical trauma or creation of a false passage. Pregnancy and active pelvic infection must be excluded prior to the procedure.

Related Conditions

Differential diagnoses include cervical stenosis, cervical diverticulum, post-radiation fibrosis, and severe intrauterine adhesions extending into the cervix. Hysteroscopy provides definitive diagnosis and treatment.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Cervical stalked polyp (HSG)

Cervical Stalked Polyp – Hysterosalpingography

A cervical stalked polyp is a benign pedunculated growth arising from the endocervical mucosa. It is commonly associated with chronic inflammation, hormonal factors, or local irritation. On hysterosalpingography (HSG), a cervical stalked polyp appears as a smooth, well-defined intraluminal filling defect attached to the cervical wall by a narrow stalk, often surrounded by contrast (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing a cervical stalked polyp. A smooth, oval filling defect is seen within the cervical canal, attached to the wall by a narrow pedicle (arrow), with free contrast flow around it.

Findings: A solitary, well-circumscribed intraluminal filling defect is noted within the cervical canal. The lesion shows smooth margins and may change position slightly with patient movement or contrast flow. The uterine cavity and fallopian tubes are otherwise normal.

Conclusion: Hysterosalpingographic appearance is consistent with a cervical stalked polyp.

Patient Symptoms

Many patients are asymptomatic. Symptomatic patients may present with postcoital bleeding, intermenstrual spotting, vaginal discharge, or infertility.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. A cervical cannula or balloon catheter is placed carefully to avoid trauma to the polyp, and water-soluble contrast is injected under fluoroscopic guidance.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 5–8 mL of contrast is injected slowly.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Gentle cannulation and contrast injection are essential to avoid bleeding from the polyp. Pregnancy and active pelvic infection must be excluded prior to the procedure.

Related Conditions

Differential diagnoses include endometrial polyp prolapsing into the cervix, submucosal fibroid, cervical cancer, and cervical diverticulum. Hysteroscopy allows definitive diagnosis and removal.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Prominent Cervical Glands (HSG)

Prominent Cervical Glands – Hysterosalpingography

Prominent cervical glands represent dilatation of endocervical glands, most commonly due to chronic cervicitis or mucus retention. These glands may be seen incidentally on hysterosalpingography (HSG) as benign findings. On HSG, they appear as multiple small, smooth, contrast-filled outpouchings arising from the cervical canal, typically symmetric and without associated canal distortion (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing prominent cervical glands. Multiple small, smooth, contrast-filled sacculations are seen along the cervical canal (arrows), giving a beaded appearance.

Findings: The cervical canal is patent and of normal caliber. Numerous tiny, rounded contrast collections project from the canal walls. The uterine cavity and fallopian tubes are normal with free peritoneal spill.

Conclusion: Hysterosalpingographic appearance is consistent with prominent cervical glands, a benign finding.

Patient Symptoms

Most patients are asymptomatic. Some may have a history of chronic cervicitis, vaginal discharge, or mild postcoital spotting.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. A cervical cannula or balloon catheter is placed, and water-soluble contrast is injected gently under fluoroscopic guidance to outline the cervical canal, uterine cavity, and fallopian tubes.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 5–8 mL of contrast is sufficient.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Gentle injection is recommended to avoid excessive filling of glands, which may mimic cervical diverticula. Pregnancy and active pelvic infection must be excluded.

Related Conditions

Differential diagnoses include cervical diverticulum, nabothian cysts (non-communicating), chronic cervicitis, and cervical fistula. Clinical correlation is usually sufficient.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Cervical diverticulum (HSG)

Cervical Diverticulum – Hysterosalpingography

Cervical diverticulum is a rare benign outpouching of the cervical canal wall. It may be congenital or acquired, commonly related to trauma, infection, prior cervical surgery, or obstetric injury. On hysterosalpingography (HSG), cervical diverticulum appears as a contrast-filled saccular or tubular outpouching arising from the cervical canal, which may retain contrast on delayed images (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram demonstrating cervical diverticulum. A well-defined contrast-filled outpouching is seen arising from the cervical canal (arrow), with delayed emptying on subsequent images.

Findings: A localized saccular contrast collection communicates with the cervical canal through a narrow neck. The main cervical canal and uterine cavity are otherwise normal. Contrast retention within the diverticulum may be seen on delayed films.

Conclusion: Hysterosalpingographic features are consistent with a cervical diverticulum.

Patient Symptoms

Many patients are asymptomatic. Symptomatic patients may present with infertility, postcoital bleeding, chronic vaginal discharge, dyspareunia, or recurrent cervicitis due to retention of secretions within the diverticulum.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. A cervical cannula or balloon catheter is inserted, and water-soluble contrast is injected slowly under fluoroscopic guidance to delineate the cervical canal, uterine cavity, and fallopian tubes.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 5–8 mL of contrast is usually sufficient, injected gently to avoid false passage or extravasation.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Uterine tenaculum (if required)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Care should be taken to avoid overfilling the diverticulum, which may cause pain or mimic extravasation. Pregnancy and active pelvic infection must be excluded prior to the procedure.

Related Conditions

Differential diagnoses include cervical fistula, cervical duplication, post-surgical sinus tract, and nabothian cyst (non-communicating). MRI or hysteroscopy can help confirm the diagnosis and guide management.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Cervical cancer (HSG)

Cervical Cancer – Hysterosalpingography

Cervical cancer is a malignant tumor arising from the epithelial lining of the cervix, most commonly squamous cell carcinoma. It is a leading cause of gynecologic cancer morbidity in developing countries. Hysterosalpingography (HSG) is not a diagnostic or staging modality for cervical cancer; however, abnormal findings may be encountered incidentally when the study is performed for infertility or other indications. On HSG, cervical cancer may be suggested by irregular cervical canal narrowing, rigidity, shouldering, or complete obstruction to contrast passage (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing abnormal cervical canal. The cervical canal appears irregular, narrowed, and rigid with shouldered margins and incomplete passage of contrast into the uterine cavity (arrows).

Findings: The cervical canal demonstrates irregular narrowing with mucosal destruction and poor distensibility. Contrast passage may be delayed or completely obstructed. Uterine cavity opacification is often incomplete.

Conclusion: Hysterosalpingographic appearance is suspicious for cervical pathology. Malignancy must be excluded with clinical examination and biopsy.

Patient Symptoms

Patients commonly present with postcoital bleeding, irregular vaginal bleeding, foul-smelling vaginal discharge, pelvic pain, or dyspareunia. Advanced disease may cause urinary or rectal symptoms.

Procedure (Hysterosalpingography)

HSG is contraindicated when cervical cancer is clinically suspected. If performed inadvertently, cannulation is often difficult due to cervical rigidity or friability, and the study should be terminated at the first sign of abnormal resistance or bleeding.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) may be used incidentally. The patient is positioned in the lithotomy position. Only minimal contrast (2–4 mL) should be injected gently if abnormal cervical resistance is encountered.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Fine HSG balloon catheter
• Leech–Wilkinson cannula (with caution)
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

HSG should be avoided in suspected cervical cancer due to the risk of bleeding, infection, and tumor dissemination. Any abnormal cervical appearance during cannulation mandates immediate termination of the procedure and gynecologic referral.

Related Conditions

Differential diagnoses include cervical stenosis, chronic cervicitis, post-radiation fibrosis, and benign cervical polyps. Diagnosis and staging rely on Pap smear, colposcopy, biopsy, MRI, and clinical examination.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Cervical stenosis (HSG)

Cervical Stenosis – Hysterosalpingography

Cervical stenosis refers to partial or complete narrowing of the cervical canal, which may be congenital or acquired. Acquired causes include prior cervical surgery, radiotherapy, infection, postmenopausal atrophy, or scarring following instrumentation. On hysterosalpingography (HSG), cervical stenosis is suggested by difficulty in cannulation, delayed or minimal passage of contrast through the cervical canal, and poor or absent opacification of the uterine cavity (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram showing cervical stenosis. Marked narrowing of the cervical canal is seen with delayed or minimal passage of contrast into the uterine cavity (arrows).

Findings: Contrast outlines a narrowed, elongated cervical canal with resistance to flow. Uterine cavity opacification is delayed or incomplete. Tubal assessment may be limited due to inadequate contrast passage.

Conclusion: Hysterosalpingographic findings are suggestive of cervical stenosis.

Patient Symptoms

Patients may present with infertility, dysmenorrhea, hypomenorrhea or amenorrhea, difficulty during cervical procedures, or cyclic pelvic pain due to obstructed menstrual outflow.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. Cannulation may be technically challenging, often requiring gentle cervical dilatation or the use of a fine balloon catheter. Contrast is injected slowly under fluoroscopic guidance.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. A small volume (3–6 mL) is injected slowly due to increased resistance at the cervix.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Uterine tenaculum
• Leech–Wilkinson cannula
• Rubin cannula
• Fine balloon HSG catheter
• Cervical dilators (if required)
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Excessive force during cannulation or contrast injection should be avoided to prevent cervical injury or uterine perforation. Pregnancy and active pelvic infection must be excluded prior to the procedure.

Related Conditions

Differential diagnoses include cervical atresia, severe intrauterine adhesions, and uterine hypoplasia. Hysteroscopy allows direct visualization and therapeutic dilatation when indicated.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.

Endometrial carcinoma (HSG)

Endometrial Carcinoma – Hysterosalpingography

Endometrial carcinoma is a malignant neoplasm arising from the endometrial lining of the uterus and is the most common gynecologic malignancy. It typically presents in peri- or postmenopausal women with abnormal uterine bleeding. Although hysterosalpingography (HSG) is not routinely performed for diagnosis, characteristic abnormal cavity findings may be encountered incidentally. On HSG, endometrial carcinoma is suggested by irregular, ill-defined filling defects, cavity destruction, and rigidity of the uterine walls (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram suggestive of endometrial carcinoma. The uterine cavity shows irregular, ragged margins with an ill-defined filling defect and partial obliteration of the cavity (arrows).

Findings: The uterine cavity is distorted with irregular outlines and non-uniform contrast coating. Large, poorly marginated filling defects are seen, sometimes associated with reduced cavity distensibility. Tubal opacification may be absent or incomplete.

Conclusion: Hysterosalpingographic findings are suspicious for endometrial carcinoma. Histopathological correlation is mandatory.

Patient Symptoms

Patients commonly present with postmenopausal bleeding, menorrhagia, intermenstrual bleeding, pelvic pain, or abnormal vaginal discharge. Advanced disease may present with weight loss or anemia.

Procedure (Hysterosalpingography)

HSG is rarely indicated when malignancy is suspected. If performed incidentally, it is done during the early proliferative phase of the menstrual cycle using minimal contrast under fluoroscopic guidance.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Only a small volume (4–6 mL) of contrast is injected gently to outline the cavity.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Uterine tenaculum (if required)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

HSG should be avoided when endometrial carcinoma is clinically suspected due to the risk of tumor dissemination. Endometrial biopsy or hysteroscopy is preferred for diagnosis.

Related Conditions

Differential diagnoses include endometrial hyperplasia, large endometrial polyp, submucosal fibroid, and chronic endometritis. Transvaginal ultrasound, MRI, and histopathological examination are essential for definitive diagnosis and staging.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.