Fact-sheet: Hydrosalpinx - Hematosalpinx - Pyosalpinx
Updated on 09/17/2021 at 12:16 PM
View all RADEOS cases associated with this fact-sheet
Definition
Hematosalpinx: Dilated fallopian tube(s) with blood-containing content.
Salpingitis: inflammation of the fallopian tubes falling within the spectrum of pelvic inflammatory disease (PID).
Acute salpingitis results from an ascending infection by organisms originating from the uterine cavity (frequently associated with endometritis), which may be complicated by pyosalpinx (pus within the tubal lumen), tubo-ovarian abscess, or acute peritonitis.
Hydrosalpinx: Dilated tube containing purely serous fluid (as opposed to hematosalpinx and pyosalpinx, which contain blood and pus, respectively)
Clinical features
The clinical presentation of hematosalpinx varies depending on the cause: tubal ectopic pregnancy, pelvic inflammatory disease, endometriosis, iatrogenic causes (surgery, IUD, etc.), congenital malformation (unicornuate uterus), etc.
Salpingitis - Pyosalpinx: More common in premenopausal women, multiple partners, IUD use, history of PID.
Pelvic or even abdominal pain, guarding, fever, foul vaginal discharge, mass or induration on palpation and/or pelvic examination.
Hydrosalpinx: Usually asymptomatic. Infertility.
History of pelvic inflammatory disease: endometritis, salpingitis, tubo-ovarian abscess.
Laboratory findings
Hematosalpinx: Beta HCG +++ to rule out ectopic pregnancy
Salpingitis - Pyosalpinx:
- Inflammatory syndrome with PMN leukocytosis.
- Mainly Gonococcus and Chlamydia trachomatis, polymicrobial in 30%
Radiography
Salpingitis: Above all, no Hysterosalpingography (HSG) if there is doubt about untreated upper genital tract infection! Useful in the absence of infectious signs to look for sequelae of PID, particularly in an infertility workup.
Hydrosalpinx: Dilated tubal lumina with distal tubal obstruction and absence of peritoneal spillage on Hysterosalpingography (HSG). Risk of iatrogenic tubal reinfection during the procedure (antibiotic prophylaxis or even discussion of the value of this examination versus laparoscopy).
Ultrasound
Via suprapubic AND transvaginal approach.
HEMATOSALPINX: Dilated adnexal structure with heterogeneous fluid content, unilateral or bilateral. Depending on the clinical context, look for an associated adnexal mass (tubal ectopic pregnancy?) and hemoperitoneum.
SALPINGITIS - PYOSALPINX: Examination is often normal in early salpingitis (a negative ultrasound does not rule out the diagnosis and should not lead to avoiding exploratory laparoscopy).
May initially show a tube with thickened wall and hypervascularity on color Doppler, better seen when there is peritubal effusion.
The tubal lumen can then fill with echogenic fluid pus (pyosalpinx) with persistent posterior enhancement unless gas is present. The elongated shape of this collection, its progressively increasing diameter, its posteroinferior orientation relative to the uterus, and the presence of septa (rather than a complete septum) allow it to be differentiated from other pelvic collections.
Hyperechoic infiltration of the peripheral pelvic fat.
May be associated with:
- Oophoritis: enlarged ovary
- Endometritis: intracavitary gas (attenuating hyperechoic bubbles)
- Fitz-Hugh-Curtis perihepatitis: perihepatic intraperitoneal fluid (Morrison's pouch) +/- adhesions, thickened Glisson's capsule
HYDROSALPINX: Dilated adnexal structure with anechoic fluid content (or scant echoes), unilateral or bilateral.
Its elongated shape, progressively increasing diameter, posteroinferior orientation relative to the uterus, and the presence of septa (rather than complete septations within the fluid) confirm its tubal origin.
Characteristic "cogwheel" appearance of the tubal folds on cross-section.
Normal, well-visualized ovary (to differentiate from an Ovarian cyst).
Should be differentiated from normal or pathologic venous structures (varix) using color Doppler.
CT
Hematosalpinx: Spontaneously hyperdense adnexal mass, with heterogeneous contrast enhancement +/- hemoperitoneum.
Salpingitis - Pyosalpinx: Often normal.
May show dilated tubes with fluid content, thick walls with strong contrast enhancement, most often bilateral. The presence of intratubal air is pathognomonic of pyosalpinx (in the absence of recent endocavitary manipulation). Infiltration of the adjacent fat.
Hydrosalpinx: Often bilateral adnexal structure, with hypodense, serpiginous tubular fluid content, of increasing diameter as it approaches the ovary (the latter being normal). Thin walls with mild enhancement.
MRI
Hematosalpinx: Same as CT
Salpingitis - Pyosalpinx: If fluid content, T1 hypointense to intermediate signal, T2 intermediate to hyperintense signal. Thickened wall with strong enhancement.
If associated oophoritis: enlarged ovary with heterogeneous signal and enhancement.
Hydrosalpinx: Fluid content:
- pure: T1 hypointense, T2 hyperintense
- proteinaceous: intermediate or T1 hyperintense, intermediate or T2 hyperintense.
Thin walls with septa mimicking septations: analysis of the different T2 slices in the three planes shows there is no true complete septum and that it is the lumen of a single structure (unlike a septated multilocular cystic lesion).
Management
Salpingitis - Pyosalpinx:
- IUD removal.
- Antibiotic therapy.
- Surgical or percutaneous drainage (provided there is no doubt about an associated gynecologic cancer in postmenopausal women) if an associated abscess is present.
- Follow-up and infertility workup if necessary
Hydrosalpinx: Surgery if infertility.
Differential diagnosis
Paratubal (or paraovarian) cyst
Peritoneal inclusion cyst
Ectopic pregnancy
Adnexal torsion
Hemorrhagic Ovarian cyst
Perisigmoid abscess or other origin
Actinomycosis
Endometrioma
Acute pelvic Appendicitis
pelvic varices
