(1)
Department of Fetal Medicine and Obstetric & Gynecological Ultrasound, Manipal Hospital, Bangalore, Karnataka, India
9.1 Fallopian Tube
The fallopian tube is anatomically divided into four segments: the proximal interstitial part (which lies within the uterine myometrium), the isthmus (which has thicker walls), the ampulla (which is thin walled) and the infundibulum (which is the distal end of the fallopian tube), ending in the fimbriae. The fallopian tube is lined with ciliated epithelium.
The normal fallopian tube is difficult to visualise on ultrasound unless it is surrounded by fluid, as is often seen following ovulation. The normal fallopian tube appears as an elongated, undulating, isoechoic structure about 8–10 mm wide. Doppler flows can be seen in the normal fallopian tube and pulse Doppler tracing shows a protodiastolic notch (which is not seen in ovarian tissue), which may help in identifying the tube. The tube is generally located lateral to the ovary, between the ovary and the lateral pelvic wall. During ovulation, when free fluid is seen in the POD, fimbriae may be seen floating within the fluid in the POD. The lumen of the fallopian tube is not seen unless it is distended with fluid, and depending on the type of fluid within, possibilities include:
Hydrosalpinx – with clear (anechoic) fluid in its lumen, which may be the result of chronic infections, tubal ligation or tubal malignancy.
Pyosalpinx – with pus (turbid fluid) in its lumen seen in acute PID.
Hematosalpinx – with blood (turbid fluid) in its lumen. This may be seen in cases with tubal ectopic pregnancy, endometriosis, torsion of a hydrosalpinx or associated with hematometra.
A tubal mass when distended with fluid appears sausage shaped and shows incomplete septae, which is because of infolding of its walls, as the tube bends over itself. The incomplete septum, if seen, is specific of a cystic mass of tubal origin.
Tubal pathology includes infection, torsion, ectopic and neoplasia. Infection and neoplasia will be dealt with in this chapter. Ectopic pregnancy and torsion are dealt with in Chaps. 10 and 11, respectively. A tube may be twisted along with the ovary in about 60 % of cases of ovarian torsion. A diseased tube like one with a hydrosalpinx or a tubal ectopic can also undergo torsion independent of the ovary.
9.2 Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease is the infection and inflammation of the upper female genital tract. It is seen in women belonging to the reproductive age group and is more common in women with multiple sexual partners, women who use intrauterine contraceptive devices, post-abortal or puerperal women and in those who have undergone intrauterine procedures.
Pelvic infection primarily involves the fallopian tubes. However, the ovaries and the endometrium can also be involved. In PID, generally the involvement is bilateral. Infection of the endometrium is dealt with in Chap. 4.
Acute PID
Typical symptoms of acute PID are pelvic pain, fever, dyspareunia and vaginal discharge. Clinical examination may reveal tenderness or a pelvic mass.
In PID generally the adnexal involvement is bilateral. Acute PID may resolve or proceed to chronic PID.
The ultrasound findings in PID vary based on the severity and the organs involved. They include:
- 1.
Essentially normal – with just mild tenderness of adnexa and hazy margins of the ovary (Fig. 9.1).
Fig. 9.1
Ovaries showing slightly hazy margins in a patient with PID
- 2.
Tubal or a tubo–ovarian mass – when the tube is inflamed (salpingitis).
The tube appears thickened (more than 10 mm in diameter).
It shows increased vascularity. In acute infection, typically there are several, small vessels that run perpendicular to the long axis of the tube. The flow in these vessels is generally of low RI (>0.45).
Very often, the tubes and ovaries are adherent to each other forming a tubo-ovarian mass.
The mass is tender to touch.
Fig. 9.2
Tubo-ovarian mass. (a) Right adnexa shows the right ovary inferiorly and a complex elongated tubal mass (arrow) superiorly. (b) Left adnexal mass showing the left ovary with follicles and a solid tubal mass (arrow) posterolateral to the left ovary. (c) Left and right TO masses showing increased vascularity of the tubal components
Fig. 9.3
Left adnexal TO mass. (a) A complex TO mass with solid and cystic areas. It was composed of different adnexal components. (b) Left ovary that formed a part of the mass. (c) Left tubal mass with hydrosalpinx formed the second component. (d) PO cyst with turbid contents was another component of the TO mass. (e) Turbid fluid suggestive of pus surrounding the TO mass. (f) Scan following treatment with antibiotics shows a resolution of pathology. The left ovary shows hazy margins and the PO cyst shows fluid–fluid level, with the denser debris in its posterior dependent part. No obvious tubal mass was noted
Fig. 9.4
Salpingitis in a patient on treatment for tuberculosis. (a) Bilateral hypoechoic elongated masses showing high vascularity suggestive of bilateral inflamed tubal masses. (b) Minimal turbid fluid seen in the endometrial cavity suggestive of associated endometritis
- 3.
Pyosalpinx – this is nothing but an infected fallopian tube with pus in its lumen, typical of acute PID.
A pyosalpinx appears as a fluid-filled tubular, somewhat folded or undulated mass. At times, the pyosalpinx may appear like a typical tubal mass showing an incomplete septum.
It shows thick echogenic walls. A wall thickness of 5 mm or more implies acute PID.
The walls show increased vascularity. Flow indices typically show low resistance (RI >0.45), but very often it is not so. In addition, variable values may be obtained in a given case.
The lumen of the tube contains fluid showing low-grade internal echoes suggestive of turbid fluid (pus).
On cross section, the pyosalpinx shows a relatively anechoic or hypoechoic central lumen with thick walls and mucosal folds – the so-called‘cogwheel sign’ (because of its resemblance with a cogwheel). The cogwheel sign is pathognomonic of acute infection of the fallopian tube.
In acute PID, the pyosalpinx is typically tender to touch.
Fig. 9.5
Bilateral pyosalpinx. (a) Right fallopian tube with thick turbid contents. (b) Complex left adnexal tubal mass showing a cross section of the fallopian tube which shows thick, hyperechoic walls with prominent mucosal folds (cogwheel sign – outlined in image). (c) Cross section of the pyosalpinx showing increased flow in its walls. (d) Diagrammatic representation of a cogwheel
Fig. 9.6
Pyosalpinx – TS of the right adnexa showing a cross section of a pyosalpinx (arrow) with hyperechoic, swollen tubal walls and mucosa (cogwheel sign). LS showing thickened tubal walls with turbid fluid in its lumen (arrow). Increased vascularity is seen in the tubal walls
Fig. 9.7
Bilateral pyosalpinx. (a) Left pyosalpinx seen as a complex mass with an irregular elongated lumen showing turbid contents (pus) within (arrow). The walls of the lumen are thick and show increased vascularity. (b) Right pyosalpinx seen as an elongated mass with turbid contents (pus) in its lumen (arrow) and thick tubal walls surrounding the lumen
Fig. 9.8
Pyosalpinx. (a) Greyscale image showing a tubular undulating mass with dilated tubal lumen, which shows hypoechoic turbid contents suggestive of pus. (b) Increased flow in the walls of the pyosalpinx. (c) 3D rendered image showing the folded tubal mass with turbid contents within
Fig. 9.9
Bilateral pyosalpinx. (a) Greyscale image with right tube showing thick walls with pus within. Left adnexal tubal mass showing fluid only in some segments of the tube. (b) 3D rendered image showing swollen tubal mucosa and turbid contents, with few scattered debris within its lumen (arrow)
Fig. 9.10
Pyosalpinx – folded tube showing turbid contents suggestive of pus. The walls of the tube are thick and vascular. A thick incomplete septum is seen because of the folding of the tube on itself
Fig. 9.11
Unilateral pyosalpinx. (a) Showing incomplete septum (arrow), thick walls with high vascularity and turbid contents. (b) Section across the plane (long white line) shown in (a) resulting in two cross sections of the single pyosalpinx. (c) A small fimbrial cyst (arrow) is seen beside the pyosalpinx showing thick vascular walls. (d) Inflamed fimbrial cyst (arrow) attached to the pyosalpinx seen at laparoscopy
- 4.
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Tubo–ovarian abscess – in some cases, pus is seen both in the tube and the ovary, forming a tubo-ovarian abscess.
This could appear as a unilocular or multilocular thick-walled structure.
High vascularity is noted in its walls. Flow indices typically show low resistance (RI >0.45), but often it is not so.
The fluid within the cystic spaces is turbid (shows low-grade internal echoes). The relatively hyperechoic areas, seen at times within the hypoechoic purulent contents, usually appear as wavy/linear, stretchy (i.e., lengthen on pressure) bands.
It may be difficult to distinguish between the tubal and the ovarian components. Generally, the tubal component (pyosalpinx) has cystic spaces communicating with each other, whereas the ovarian component (abscess) has circumscribed collections which occasionally may communicate with the pyosalpinx. At times when there are multiple ovarian purulent collections, the intervening wall may undergo necrosis, and the cystic areas may communicate with each other through the breach in the intervening septum.
Very often, however, the tube cannot be differentiated from the ovary in a tubo-ovarian abscess.
The masses are usually very tender.
These masses are usually adherent to the uterine walls.
There may be pus seen in the POD and around the masses.
Fig. 9.12
Bilateral tubo-ovarian abscesses seen as multilocular, thick-walled masses. (a) Right adnexa (TO abscess) – showing a cystic area in right ovary with turbid contents (probably pus). Tubal component is seen with turbid contents in its lumen (arrows). (b) Transverse section showing left paraovarian cyst with a multilocular cystic mass (TO abscess) superior to it. (c) Moderate vascularity noted in the left adnexal mass. (d) Pus in the POD is seen as a hypoechoic area with linear hyperechoic strands within. (e,f) Thick hyperechoic bands suggestive of organised strands of pus seen between the posterior wall of the uterus and the right adnexal mass (arrow) and also between the two adnexal masses (arrow) in the POD
Fig. 9.13
TO abscess. (a) IUCD is seen in the endometrial cavity with a complex mass (the TO abscess) posterior to the uterus, in the POD. (b) Long section of the TO abscess showing a pyosalpinx anteriorly (short arrow) and pus collection posteriorly (long arrow)
Fig. 9.14
Bilateral TO abscess. (a) Left adnexa: complex left adnexal mass seen with some ovarian tissue in its inferior part. Hyperechoic scattered echoes seen within the mass. (b) Tubal component of the TO mass is seen with a linear arrangement of scattered hyperechoic foci suggestive of air within its lumen, secondary to infection by gas-producing organisms. (c) Multilocular right adnexal mass showing thick turbid contents suggestive of pus. (d) Locules are seen communicating with each other (arrow). 300 ml of pus was drained from the right TO mass
Fig. 9.15
Bilateral TO abscesses. (a) TAS – uterus seen anteriorly. Complex hypoechoic masses are seen behind the uterus bilaterally. On TAS, details cannot be assessed. (b) TVS – left-sided TO abscess seen. The tubal component (arrow) shows cystic irregular spaces with turbid fluid, communicating with each other. (c) Flow in the mass shows an RI of 0.5. (d) TVS – right adnexal mass showing a pyosalpinx (arrow), seen as a hyperechoic, thick, elongated mass with turbid contents within, which was placed over a large area with purulent (turbid) contents, probably an ovarian abscess. (e) The right pyosalpinx (arrow) shows thick vascular walls
Fig. 9.16
Acute superimposed on chronic PID. Patient who gave a past history of PID, presented with lower abdominal pain and fever. (a) Complex right adnexal mass showing cystic spaces with turbid contents communicating with each other, suggestive of a TO abscess. (b) Mass showed mild to moderate vascularity. (c) Minimal turbid collection seen in the endometrial cavity suggestive of associated endometritis
Fig. 9.17
TO mass with pyosalpinx. (a) Complex mass seen with solid and cystic areas. Tubal component identified by the presence of turbid fluid (arrows) within thick-walled structures that were communicating with each other on angulating the probe. (b) Increased vascularity noted in the tubal walls
Fig. 9.18
PID with right-sided tubo-ovarian mass. (a) Complex mass seen with no ovarian tissue identified. (b) In one section, the cogwheel pattern suggestive of a cross section of a pyosalpinx is seen (arrow). (c) IUCD is seen in the endometrial cavity. The right tubal mass was adherent to the posterior walls of the uterus. (d) Loculated area of pus collection is seen in the POD, showing fluid–fluid level
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