Radiology related to female fallopian tube- anatomy and pathology

1. Dr. Sumit Sharma (PG)
Dept. of Radiodiagnosis
SLIMS, Puducherry
Female Genital System-
The Fallopian Tubes

2. Fallopian Tube
 The eponymous name, the Fallopian tube, is
named after Gabriel Fallopius. He was
Italian anatomist (1523-62), the same
anatomist who gave his name to the
Fallopian ligament and the Fallopian canal.

3. Fallopian Tube - Introduction
 The uterine tube, also known as Fallopian tube, is
approximately 10-12 cm long and 1-4 mm in
diameter. It bridges the gap between the ovary
laterally, and the uterus medially. Through it, the
ovum passes into the uterine cavity. If conception
occurs, it does so within the tube. The peritoneal
reflection draping over the salpinges forms the
mesosalpinx.

4. The Female Reproductive System

5. Development of the Reproductive
Systems
Like the kidney apparatus:
•the gonads develop in a RETROPERITONEAL position
next to the dorsal body wall.
•they are derived from intermediate mesoderm.

6. In the Developing Human
Female:
A specialized collecting tube
runs from the ovary to the
embryonic cloaca.
•It is plastered over the ovary
so that when an egg is shed
from the ovary, it doesn’t
escape into the coelom.
•This collecting tube – the
PARAMESONEPHRIC
DUCT -- is positioned just
lateral to the mesonephric
duct of the developing
kidney.

8. Developing Human Female (Continued):
•The caudal ends of the right and left paramesonephric
ducts fuse near their entrance into the embryonic
cloaca to become the UTERUS AND VAGINA.
•The remaining unfused parts are then known as the
UTERINE TUBES, or more commonly the FALLOPIAN
TUBES.

9. Gross Anatomy and Relations
 A uterine tube is divided into several anatomic
segments (from lateral to medial):
 fimbriae: these drape over the ovary and are
composed of ~25 finger like projections
 infundibulum: funnel-shaped lateral part that drapes
over the ovary with the fimbriae:
– it opens into the peritoneal cavity at the abdominal ostium
 ampulla: the widest and longest section forming over
half the entire length
 isthmus: immediately lateral to the uterus, is as the
name suggests, the narrowest segment
 interstitial or intramural segment: section within
the myometrium

11. The Ovaries and Their Relationships to
the Uterine Tube and Uterus

12. SUPPORTING LIGAMENTS OF THE OVARY
AND UTERUS
BROAD LIGAMENT – Sheet of connective tissue
supporting uterus laterally, as well as fallopian tube and
ovary out to lateral body wall.
OVARIAN LIGAMENT – connective tissue strap/band
anchoring ovary to lateral uterine wall.
MESOSALPINX – connective tissue sheet spanning
distance between ovarian ligament and fallopian tube.

13. Ovarian ligament
Broad ligament
Mesosalpinx

14. Blood supply
 arterial supply: tubal branch of the
ovarian artery and terminal (tubal)
branch of the uterine artery
 venous drainage: similarly named
veins

15. Lymphatic supply
 Lymph drainage is predominantly laterally
and up to the para-aortic lymph nodes
(like the ovaries).

16. The Uterus

17. Nerve supply
 ovarian and uterine plexuses (from T11
- L1)

18. Histology
 Like many other muscular hollow tubes it has
two layers of muscle (inner circular, outer
longitudinal), and is lined by
columnar epithelium, a mixture of ciliated and
non ciliated. It is the former that 'beat' the
ovum towards the uterus.

19. The Uterine Tubes

20. Radiological appearance
 The normal uterine tubes are not visualized at
cross-sectional imaging unless they are
outlined by fluid.
 In the presence of peritoneal fluid or contrast
material, the uterine tubes appear as paired,
thin, serpentine juxta-uterine structures
extending either anteriorly or posteriorly into
the cul-de-sac.

21. Plain films
 Contrast studies can be completed by
performing a hysterosalpingogram (HSG)

22. Diseases of the Fallopian Tubes
 inborn – malformations:
– aplasia (Müllerian duct disorders)
bilateral incl. uterus & vagina
unilateral incl. kidney
– partial atresia
 acquired

23. Diseases of the Fallopian Tubes
 inborn
 acquired
– non neoplastic : atrophy, infection – pyosalpinx,
hydrosalpinx, tbc salpingitis, synechiae
– salpingitis isthmica nodosa
– pseudotumours – cysts, ectopic pregnancy.
– neoplastic: adenocarcinoma

24. Diseases of the Fallopian Tubes & Ovaries
 PID – pelvic inflammatory disease (chronic
salpingooophoritis)
 tubal sterility

25. Hysterosalpingogram

26.  Hysterosalpingogram (HSG) is a
fluoroscopic examination of the uterus and
the Fallopian tubes, most commonly used in
the investigation of infertility or recurrent
spontaneous abortions.

27. Technique
 the procedure should be performed during the
proliferative phase of the patient’s menstrual cycle
(days 6-12), when the endometrium is thinnest
– this improves visualisation of the uterine cavity, and also
minimises the possibility that the patient may be pregnant
– if there is any uncertainty about the patient’s pregnancy
status, a bHCG is warranted prior to commencing.

28.  After an antiseptic clean of the external genital area,
a vaginal speculum is inserted with the patient in the
lithotomy position ; the cervix is cleaned with an
aseptic solution.
 Catheterisation of the cervix is then performed ; the
type of device used depends on local practice
preferences
– e.g. 6 Fr Foley catheter with balloon inflation, or
– any one of a range of available HSG catheters or metal
cannulas

29.  water soluble iodinated contrast is subsequently
injected slowly under fluoroscopic guidance
 A typical fluoroscopic examination includes
preliminary frontal view of the pelvis, as well as
subsequent spot images that demonstrate uterine
endometrial contour, filled fallopian tubes and
bilateral intraperitoneal spill of contrast, to establish
tubal patency

30. Normal Hysterosalpingogram

31. Contraindications and Complications
Contraindications
pregnancy
active pelvic infection
recent uterine or tubal surgery
Complications
Common but self limiting
abdominal cramping
PV spotting
Rare but serious
pelvic infection
contrast reaction

32. Detectable pathology
Conditions which may be detected with HSG include
 Tubal
 obliteration of fallopian tubes : usually secondary to previous
pelvic inflammation. It must be differentiated from incomplete
tubal opacification due to tubal spasm, or underfilling of the
uterus with contrast
 tubal polyps
 tubal malignancy
 hydrosalpinx
 salpingitis isthmica nodosa (SIN)
 tubal spasm can be physiological

33. Fallopian tube polyp
 A Fallopian tube polyp refers to a small focal lesion of ectopic
endometrial tissue located at the intramural portion of the
fallopian tube.
Epidemiology
 The reported incidence is 1- 2.5% on hysterosalpingograms
performed for assessment of infertility 3
Clinical presentation
 Most patients with tubal polyps are asymptomatic and polyps
are usually an incidental finding at hysterosalpingography.

34.  Radiographic features
They can be unilateral or bilateral, and they usually measure less
than 1 cm in diameter.
 Hysterosalpingogram - HSG
Tubal polyps appear as smooth, rounded or oval filling defects
which are not associated to tubal dilatation or obstruction, with
free flow of contrast medium to the peritoneal cavity.

35. Tubal Polyp
Spot radiograph
shows a small filling
defect (arrow) in the
proximal left fallopian
tube, a finding that
typically represents a
tubal polyp.

36. Salpingitis isthmica nodosa
 Salpingitis isthmica nodosa (SIN) (sometimes also referred to
as perisalpingitis isthmica nodosa - PIN) refers to nodular
scarring of the fallopian tubes. In very early stages, the tubes
may appear almost normal. As scarring and nodularity
progresses, the changes become more radiographically
apparent.
Aetiology
 the aetiology of SIN has remained a matter of controversy since
its first description
 the prevailing theories include an inflammatory (salpingitis), a
congenital, and more recently an acquired (but not post-
inflammatory) aetiology
Location
 It can involve the entire fallopian tube, but usually involves the
proximal two-thirds of the fallopian tube.

37. Radiographic features
An accurate radiographic diagnosis is important due to its strong
association with infertility and ectopic pregnancy.
Hysterosalpingography (HSG)
A characteristic finding is multiple nodular diverticular spaces
involving the fallopian tubes (usually involving the proximal two-
thirds of the fallopian tubes).
HSG of the nodular area with severe SIN shows several pockets
(diverticulae) containing the introduced contrast material 5
.
It is observed that no dominant channel is seen as the contrast
flows through the tube. This means there appears to be no direct
pathway for sperm to travel which increases the chances of a tubal
pregnancy.

38. Salpingitis Isthmica Nodosa

39. Complications
increased risk of tubal ectopic pregnancy 4
Subfertility
Etymology
The term is derived from salpingitis for inflammation of the salpinx
(tube), isthmica for involvement of the proximal isthmic portion of
fallopian tube and nodosa for its nodular appearance
Differential diagnosis
Considerations include
tubal tuberculosis
often has multiple constrictions along the course of fallopian tube can form
because of scarring and give rise to "beaded" appearance to the tubes on
HSG can also have adnexal calcification

40. Hydrosalpinx
 Hydrosalpinx is a descriptive term and refers to a
fluid filled dilatation of the fallopian tube.
 Clinical presentation
 Patients may be asymptomatic or may present with
pelvic pain or infertility.
 Pathology
 One or both fallopian tubes may be affected. A
hydrosalpinx results from an accumulation of
secretions when the tube is occluded at its distal end
(obstruction of the ampullary segment) or both ends.
On rare occasions, transient distention of the fallopian
tubes occurs because of retrograde passage of blood
from the uterus without complete distal occlusion.

41. Causes
 endometriosis
 ovulation induction
 pelvic inflammatory disease (e.g chlamydial or gonococcal
infection): a hydrosalpinx is most commonly a sequela of
adhesions from pelvic inflammatory disease
 post hysterectomy (without salpingo-oophorectomy)
– unilateral or bilateral hydrosalpinx may also occur in women after
hysterectomy when only the fallopian tubes are left to protect the
blood supply to the ovary
– this is from accumulation of tubal secretions caused by surgical
blockage proximally and adhesion-related blockage distally
 tubal ligation
 tubal malignancy: primary or secondary tumours of the fallopian
tubes

42. Radiographic features
Ultrasound
 May be seen as a thin-or thick-walled (in chronic cases), elongated or
folded, tubular, C shaped or S shaped fluid-filled structure that
is distinct from the uterus and ovary.
 Longitudinal folds that are present in a normal fallopian tube may
become thickened in the presence of a hydrosalpinx.
 The folds may produce a characteristic “cogwheel” appearance when
imaged in cross section. These folds are pathognomonic of a
hydrosalpinx.
 Incomplete septae may also give a "beads on a string" sign.
 A significantly scarred hydrosalpinx may present as a multi-locular
cystic mass with multiple septa (often incomplete) creating multiple
compartments. These septa are generally incomplete, and the
compartments can be connected. However, with more pronounced
scarring, differentiation from an ovarian mass may not be possible.

43. Hysterosalpingogram
Will classically show a dilated fallopian tube filling with contrast
with absence of free spillage.
CT
A hydrosalpinx may be seen incidentally at CT as a fluid-
attenuation tubular juxta-uterine structure that is separate from the
ovary. A simple hydrosalpinx is not accompanied by pelvic
inflammation. The tubal wall may enhance following contrast.

44. Left Hydrosalpinx

45. MRI
 MR imaging is the modality of choice for the characterisation
and localisation of adnexal masses that are inadequately
evaluated with ultrasound. A dilated fallopian tube is interposed
between the uterus and ovary and demonstrates fluid signal
intensity. Incomplete septa or folds can be seen. The mucosal
plicae are usually effaced, and the tube wall is uniformly smooth
and thin.
 Signal characteristics of the dilated tube(s) include:
 T1: typically hypo-intense although can be hyper-intense if there
is proteinaceous fluid
 T1 C+ (Gd): the the mucosal plicae and the tube walls may
show mild enhancement
 T2: hyper-intense

46. Complications
tubal torsion: can be a late complication
Differential diagnosis
General imaging differential considerations include:
elongated para ovarian cyst
cystic ovarian neoplasm(s)
bowel obstruction
dilated pelvic veins
elongated pelvic perineural cyst

47. Fallopian tube spasm
 It is a transient functional anomaly that can mimic a
true mechanical tubal occlusion.
 At radiography, tubal spasm cannot be distinguished
from a tubal occlusion. Administration of spasmolytic
agents such as Glucagon can occasionally result in
uterine muscle relaxation and consequent tube
opacification, thereby helping differentiate a spasm
from true occlusion .
 Delayed radiography may also be performed to help
differentiate tubal spasm from a true tubal occlusion.

48. Fallopian Tube Spasm

49. Ectopic pregnancy
 Ectopic pregnancy refers to the implantation of a
fertilised ovum outside of the uterine cavity.
Epidemiology
The overall incidence has increased over the last few
decades and is currently thought to affect 1-2% of
pregnancies. There is an increased incidence in in-
vitro fertilisation pregnancies (IVF).
Clinical presentation
Presentation is often with abdominal pain or bleeding.
If unrecognised haemorrhage can be life
threatening.

50. Location of ectopics
 tubal ectopic: 93-97%
– ampullary ectopic: most common ~70% of tubal
ectopics and ~ 65% of all ectopics
– isthmal ectopic: ~12% of tubal ectopics and ~11%
of all ectopics
– fimbrial ectopic: ~11% of tubal ectopics and ~10%
of all ectopics

51. Sites of Ectopic Implantation

52. Markers
• serum beta HCG levels tend to increase at a
slower rate
• serum progesterone levels can be not as
elevated as for an intrauterine pregnancy; 5-
25 ng/ml range although not absolute

53. Radiographic features
 It is essential to know a quantitative beta
HCG prior to scanning as this will determine
what you expect to see. At levels below 1000
IU a normal early pregnancy may well not be
visible, and therefore should the scan prove
negative, a repeat scan in a couple of days
(along with a repeat beta HCG) is necessary
(beta HCG should normally double
approximately every two days).

54. Ultrasound
 tube and ovary
– simple adnexal cyst: 10% chance of an ectopic
– complex adnexal cyst/mass: 95% chance of an
tubal ectopic
– tubal ring sign
95% chance of an tubal ectopic if seen
described in 49% of ectopics and in 68% of unruptured
ectopics
– ring of fire sign: can be seen on colour Doppler in
a tubal ectopic
– live pregnancy: 100% specific, but only seen in a
minority of cases

55.  It is of utmost importance not to be reassured by the
presence of a live intrauterine pregnancy, as this may
delay the important diagnosis of a co-existing ectopic
pregnancy (i.e. heterotopic pregnancy).
 This life-threatening condition for both mother and
intrauterine child necessitates a high level of clinical
suspicion, especially in cases of assisted
reproduction (e.g. in-vitro fertilisation) or former tubal
surgery

56. TVS: Ectopic pregnancy
An off-midline sagittal
transvaginal
ultrasound image of
the uterus
demonstrates an
echogenic rounded
structure in the region
of the uterine cornu
(towards fundus and
eccentrically placed).

57. TVS: Tubal ring sign
Transvaginal gray-
scale US image of
the left adnexa
reveals an
extraovarian
adnexal mass with a
hyperechoic tubal
ring.

58. Colour Doppler: Ring of Fire
Sign
"ring of fire"
sign
(hypervascular
ring)

59. Ring of Fire Sign

60. Complications
 Complications somewhat depend on the type
of ectopic. General complications for a typical
(tubal) ectopic pregnancy include
 tubal rupture: 15-20%

61. Management
 In general the options are:
 Surgical: (in the case of tubal ectopics with open or
laparoscopic salpingectomy or salpingotomy)
 Medical:
– methotrexate (a folate antagonist) either administered
systemically or by direct ultrasound guided injection or
potassium chloride (direct injection only obviously)
– usually considered if size small (e.g <4 cm) and if no
complication
– the gestational mass can paradoxically increase in size
following methotrexate on subsequent scanning and does
not necessarily imply failure of methotrexate therapy

62. Management
 Conservative or expectant management is
being recognised as an option for those
ectopics where rupture has not occurred (i.e.
no haemoperitoneum ) and fetal demise has
already taken place.

63. Differential diagnosis
 The differential diagnosis of abdominal pain
in a pregnant patient is broad. An ectopic
pregnancy must be excluded with ultrasound.
Other common diagnoses in this setting
include:
 ruptured corpus luteum
 appendicitis