Fig. 3.1
A thick fallopian tube wall in case of acute tubal inflammatory disease
Fig. 3.2
Another thick fallopian tube wall in case of acute tubal inflammatory disease
“Cogwheel sign” (short-linear projections) (Fig. 3.3)
Fig. 3.3
A cogwheel sign (see arrow) in case of acute tubal inflammatory disease
Incomplete septa (septa that do not reach the opposite wall) with a tube filled by hypoechoic fluid (Fig. 3.4)
Fig. 3.4
An incomplete septum in case of acute tubal inflammatory disease with a tube filled by hypoechoic fluid
Fluid in the cul-de-sac
At ultrasound in chronic tubal inflammatory disease, the following findings can be present:
Thin fallopian tube wall (less than 5 mm) (Fig. 3.6).
Fig. 3.6
A thin fallopian tube wall (less than 5 mm) in case of chronic tubal inflammatory disease surrounding the ovary (see star)
“Beads on a string” (small hyperechoic mural nodules) (Fig. 3.7).
Fig. 3.7
The presence of beads on a string (small hyperechoic mural nodules) (see arrows)
Incomplete septa (Figs. 3.8 and 3.9) with a tube filled by anechoic fluid.
Fig. 3.8
An incomplete septum in case of hydrosalpinx
Fig. 3.9
Another incomplete septum in case of hydrosalpinx
Tubo-ovarian complex and fluid in the cul-de-sac are less present [10].
Patel et al. [28] suggest that an additional finding as the “waist sign” (defined as diametrically opposed indentations along the wall of the cystic mass) (Fig. 3.10) is a useful additional finding associated with the presence of hydrosalpinx.
Fig. 3.10
The “waist sign” (defined as diametrically opposed indentations along the wall of the cystic mass) described by Patel et al. [28]
Using these findings, the transvaginal ultrasonography [4, 5, 16, 29] shows a very good accuracy in the evaluation of hydrosalpinx with very good values of positive and negative likelihood ratios as it is shown in Table 3.1.
Guerriero et al. [16] evaluate the diagnostic power of transvaginal sonography in the differential diagnosis of hydrosalpinx in 239 premenopausal patients with 256 adnexal masses, reporting a sensitivity of 93.3 % and specificity of 99.6 %.
The role of ultrasonography seems crucial also because only hydrosalpinges visible on ultrasound are associated with reduced implantation and pregnancy rates after in vitro fertilization as previously described [30, 31]. In addition in case of visualization at ultrasound of findings related to the presence of acute tubal inflammatory disease, also when symptoms are not present, we should suggest to avoid tubal patency evaluations and/or hysteroscopy.
3.2.1 Differential Diagnosis
In the case of an acute inflammatory process, to differentiate tubal inflammatory disease from an ovarian tumor is relatively easy and is determined by the acute inflammatory features of the pelvic disease. More complicated is the differential diagnosis of chronic hydrosalpinx from benign or malignant ovarian tumors including endometriomas, benign and malignant cystadenomas, cystadenofibromas, and paraovarian cysts. Dilated hydroureters have been misdiagnosed as fluid-filled fallopian tubes. The question arises when it is necessary to differentiate the “beads-on-a-string” sign of chronic tubal disease from small internal papillations and septa of an ovarian cystic. But in the case of a chronic hydrosalpinx, the mural lesions (beads on a string) are small, almost equal in size, and are distributed around the thin wall. On the contrary the papillary formations of an ovarian tumor are usually dissimilar in size and located along the wall, which may show variable thickness with the presence of color Doppler signals inside. If the incomplete septa are present, these almost uniformly indicate the diagnosis of a fallopian tube since the true septa of ovarian tumors are very seldom, if ever, incomplete [1]. In some case the operator should also investigate the associated presence of deep endometriosis present in some cases.
3.3 Important Technical Tips
Tubal inflammatory disease can be identified by the following transvaginal sonographic technical aspects [1] (see videos):
The relationship with the ovary has to be evaluated pushing the tube with the vaginal probe and using the second hand that has to push on the pelvis (see videos 3.1, 3.2, 3.3, and 3.4).
Shape: when the mass has been identified, the rotation in the longitudinal section has to show a pear-shaped, ovoid, or retort-shaped structure (see videos 3.1, 3.2, 3.3, and 3.4).
Wall structure has to be evaluated by the rotation of the probe and following the enlarged tube for the presence of:
Incomplete septa: that is hyperechoic septa that originate from one of the walls, without reaching the opposite wall (see videos 3.1 and 2); in some cases the mass can appear as multilocular, but rotating the probe the incomplete septum is visualized in the majority of cases (Fig. 3.11a, b).
Fig. 3.11
This hydrosalpinx appears as multilocular (a), but rotating the probe in the incomplete septum is visualized in the majority of cases (b)
“Beads-on-a-string” sign, small hyperechoic mural nodules seen on the cross section of the fluid-filled distended structure (see video 3.3); rotating the probe these structures are usually linear.
“Cogwheel” sign, internal profile coded for sonolucent cogwheel-shaped structure visible in the cross section of the tube with thick walls.
Content: sonolucent or sometimes low-level echoes have to be searched.
Push and pull with the vaginal probe to verify if it evokes pain.
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