Lymphatic Intravasation (HSG)

Lymphatic Intravasation (Hysterosalpingography)

Lymphatic intravasation during hysterosalpingography refers to the entry of contrast medium into the uterine lymphatic channels due to increased intrauterine pressure or disruption of the endometrial–myometrial interface. It is a benign and usually transient phenomenon, commonly observed in association with uterine inflammation, recent instrumentation, or forceful contrast injection. Recognition of this entity is essential to avoid misdiagnosis as tubal patency or peritoneal spill (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram demonstrating lymphatic intravasation. Fine, reticular, beaded channels are seen extending from the uterine wall, following lymphatic drainage pathways rather than the expected course of the fallopian tubes (arrows).

Findings: Delayed appearance of multiple thin, non-branching, reticular channels radiating from the uterine cavity is observed. The pattern does not conform to tubal anatomy and shows no free intraperitoneal spill.

Conclusion: Imaging features are consistent with lymphatic intravasation during hysterosalpingography.

Patient Symptoms

Most patients are asymptomatic. Mild pelvic discomfort or cramping may occur during contrast injection. Lymphatic intravasation is often associated with prior uterine surgery, endometritis, or repeated uterine instrumentation.

Procedure (Hysterosalpingography)

The study is performed in the early proliferative phase of the menstrual cycle. Following sterile preparation, a cervical cannula or balloon catheter is placed. Contrast is injected slowly under fluoroscopic monitoring. If lymphatic filling is identified, injection pressure should be reduced.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used with the patient in the lithotomy position. Contrast volume typically ranges from 8–12 mL, administered gradually to avoid excessive intrauterine pressure.

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

Water-soluble contrast agents must be used exclusively. Gentle injection techniques reduce the risk of lymphatic intravasation. The procedure should be deferred in the presence of active pelvic infection or suspected pregnancy.

Related Conditions

Lymphatic intravasation may be associated with chronic endometritis, post-surgical uterine scarring, adenomyosis, or recent dilation and curettage. Differentiation from venous intravasation is based on delayed appearance, finer reticular pattern, and lack of rapid systemic washout.

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Declaration

This case is presented for educational purposes only. Patient identity has been anonymized, and ethical standards for anonymized imaging data have been maintained.