AJR 2000; 175:359-361
© American Roentgen Ray Society
Using the Uterine Push-Pull Technique to Outline the Fundal Contour on Hysterosalpingography
Amy S. Thurmond1,2,
Marla K. Jones3 and
Robert Matteri4
1
Department of Radiology, Legacy Meridian Park Hospital, 19300 S.W. 65th,
Tualatin, OR 97062.
2
Department of Obstetrics and Gynecology, Oregon Health Sciences University,
3181 S.W. Sam Jackson Park Rd., Portland, OR.
3
Department of Diagnostic Radiology, Kaiser Sunnyside Medical Center, 10180
S.E. Sunnyside Rd., Clackamas, OR 97015.
4
Department of Reproductive Endocrinology, Legacy Good Samaritan Medical
Center, 1015 N.W. 22nd Ave., Portland, OR 97210.
Received May 26, 1998;
accepted after revision January 14, 2000.
Presented at the annual meeting of the Society for Uroradiology, Palm
Beach, FL, January 1995.
Address correspondence to A. S. Thurmond.
Introduction
A double uterine cavity is often first detected at the time of
hysterosalpingography, a test that for more than 80 years has been a mainstay
in the evaluation of couples with fertility problems
[1]. Correct diagnosis of the
specific müllerian anomaly has required a view
of the external uterine fundus contour (Fig.
1A,1B,1C,1D,1E,1F,1G),
which is usually not provided by standard hysterosalpingography. We
hypothesized that three cycles of pushing and pulling on the uterus at the
time of hysterosalpingography would distribute the contrast agent around the
fundus and outline the fundal contour better than the absence of this
additional maneuver.
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Fig. 1A. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Fig. 1B. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Fig. 1C. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Fig. 1D. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Fig. 1E. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Fig. 1F. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Fig. 1G. —Classification of müllerian anomalies
of uterus. (Reprinted with permission from American Society for Reproductive
Medicine, Atlanta, GA) Drawings show hypoplasia and agenesis (A),
unicornuate (B), didelphic (C), bicornuate (D), septate
(E), arcuate (F), and diethylstilbesterol-related (G)
uterine anomalies.
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Subjects and Methods
One hundred forty consecutive patients referred for hysterosalpingography
were examined prospectively. Two techniques were used. If possible, a vacuum
cup cannula (Thurmond-Rösch Hysterocath; Cook,
Bloomington, IN) was applied to the external cervix. If the vacuum cup cannula
was not available or could not be used because of a cervical deformity, a
5-French balloon catheter (H/S; Ackrad Laboratories, Cranford, NJ) was
advanced into the uterine cavity for hysterosalpingography. Using fluoroscopic
guidance, 20 mL of a watersoluble contrast medium was instilled. Five routine
images were obtained: a scout radiograph, an early anteroposterior radiograph,
right and left shallow oblique radiographs, and a late anteroposterior
radiograph with traction applied to the cervix to straighten the uterus. At
the conclusion, in the patients in whom the cervical vacuum cup was used, an
additional maneuver was performed consisting of three cycles of traction on
the uterus followed by relaxation, creating a gentle push-pull in an attempt
to move the contrast agent around the uterus. The patient was then positioned
so that the X-ray beam was parallel to the short axis of the uterine fundus,
giving a tangential view of its contour, and a radiograph was obtained. The
push-pull maneuver was not performed in the women who underwent
hysterosalpingography with the balloon catheter because of inadequate ability
to place traction on the cervix with the balloon catheter. These patients
served as a control group. The push-pull maneuver was also not performed in
patients with tubal disease or technical problems that limited the flow of
contrast medium into the peritoneal cavity. The duration of fluoroscopy time
was recorded for all patients. Any occurrence of moderate to severe cramping
or vasovagal symptoms was recorded for all patients.
Results
One hundred forty consecutive hysterosalpingography examinations were
prospectively evaluated. In 61 (44%), the push-pull maneuver was not performed
because of the use of a balloon catheter (n = 27), cramps limiting
the volume of contrast medium instilled (n = 6), a poor cervical seal
that did not allow adequate volume to be instilled (n = 10), and
bilateral tubal occlusion (n = 18). The fundal serosal margin was
spontaneously outlined in one (4%) of the 27 women who underwent
hysterosalpingography performed with the balloon catheter.
The push-pull maneuver was performed in 79 women. In 33 (42%), the fundal
contour was seen despite unilateral tubal occlusion in three and peritubal
adhesions in two. In three of these patients, a septate uterus was diagnosed
(confirmed on sonography, MR imaging, or laparoscopy) (Fig.
2A,2B).
The uterine position was anteflexed in six, straight in eight, and retroflexed
in 19 patients.
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Fig. 2A. —Hysterosalpingograms of 32-year-old woman with septate uterus. After
instillation of 20 mL of contrast medium via cervical vacuum cup, traction
placed on cervix shows two widely spaced uterine cavities.
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Fig. 2B. —Hysterosalpingograms of 32-year-old woman with septate uterus. Three
cycles of gentle traction and relaxation on cervix (push-pull), followed by
imaging in push position, shows contrast medium around uterine fundus
(white arrowheads). Note broad-based uterine septum (black
arrowheads).
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In 46 women (58%), the fundus was not outlined. Uterine position was
anteflexed in 32, straight in 13, and retroflexed in one.
In 19 (95%) of the 20 women with retroflexed uteri, the fundal contour was
imaged; however, the fundal contour was identified in only 14 (24%) of the 59
women with anteflexed or straight uteri.
The average fluoroscopy time with the additional push-pull maneuver was 144
sec, compared with 150 sec for those who did not receive the additional
maneuver. With the addition of the push-pull maneuver, one patient (1%) of 79
experienced moderate or severe pain and three (4%) of 79 experienced
self-limited vasovagal symptoms during their examination. None of the 61
patients who underwent hysterosalpingography without the additional maneuver
experienced moderate or severe pain or vasovagal symptoms.
Discussion
Congenital uterine anomalies have been estimated to occur in as many as 9%
of women undergoing hysterosalpingography
[2,
3]. Anomalies are a result of
defects in paired müllerian duct development,
fusion, or resorption [3]. The
anomalies have been classified into seven groups on the basis of their
prognosis for future fertility and their surgical treatment
[4] (Fig.
1A,1B,1C,1D,1E,1F,1G).
A septate uterus results in spontaneous abortion in up to 90% of
pregnancies [5]. The septum can
be removed hysteroscopically, which results in an increase in live births
[4,
6]. A bicornuate uterus has a
lower rate of complications, requires laparotomy for repair, and therefore is
usually not treated [4]. Uterus
didelphys has a low risk for fertility complications and therefore is usually
not treated [4].
Findings at hysterosalpingography may be suggestive of the specific
müllerian anomaly. If the two uterine cavities
are widely spaced with an angle between them of greater than 105°, the
uterus is more likely to be bicornuate or didelphic than septate
[1,
6]. This is not a reliable
finding, however, and before surgical correction additional studies such as
sonography, MR imaging, and laparoscopy have been required to confirm the
diagnosis
[1,2,3,4,5,6,7,8].
The addition of the uterine push-pull technique to the standard
hysterosalpingography examination can outline the fundal contour in some women
in whom it is attempted. The maneuver requires at least one patent tube and a
hysterosalpingography device that allows adequate traction on the cervix. In
37 (26%) of our 140 patients, the cervical vacuum cup could not be used for
the examination because of cervical deformity (n = 27) or poor
cervical seal (n = 10). Since then we have discovered that this
technical limitation can be overcome by first applying the cervical vacuum cup
and then, if necessary, introducing the balloon catheter into the uterine
cavity through the cervical cannula. In this manner, adequate filling of the
tubes and the peritoneal cavity can be obtained via the balloon, and at the
same time adequate traction applied to the cervix via the vacuum cannula. Had
this been done, the push-pull maneuver could have been attempted in an
additional 37 women, leaving only 24 (17%) in whom the maneuver could not be
performed because of bilateral tubal disease (n = 18) or cramping
(n = 6).
The push-pull maneuver better defined the fundal contour in women with
retroflexed uteri (95%) than in women with anteflexed uteri (24%). This is
presumably because contrast medium naturally flows posteriorly into the
cul-de-sac and will outline a posteriorly placed fundus. The anteriorly placed
bladder prevents the contrast agent from pooling anteriorly; therefore, it is
more difficult to outline the anteriorly placed fundus.
The addition of the uterine push-pull maneuver to the hysterosalpingography
did not increase average fluoroscopy time and was well tolerated by the
patients. The maneuver did not require special equipment, and the additional
time required on the part of the radiologist was minimal. Because it helped to
show the fundal contour in almost half the patients in whom it was performed
and in 95% of women with retroflexed uteri, its use at the time of
hysterosalpingography when a double uterine cavity is identified is
recommended. Successful visualization of the fundal contour may obviate
sonography, MR imaging, or laparoscopy for this purpose. Other pelvic
disorders, including fundal myomas, adhesed loops of bowel, or endometriosis,
could interfere with fundal visualization. Until more experience is
accumulated, any equivocal cases should still be confirmed on MR imaging or
laparoscopy.
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Introduction
Subjects and Methods
