Hysterosonography Protocol

Contributions based upon the initial suggested protocol by: Sharon Durbin, RDMS

Policy

Physician to be assisted with procedure by sonographer.

Definition

Instillation of sterile saline, air, or other contrast medium through a catheter into the uterus under real-time vaginal transducer observation for enhancement and assessment of endometrial cavity. This procedure is done on day 3 - day 7, near end of menstrual bleeding, when endometrium is thin (Day 6 is generally the "ideal day.")

Equipment

1. Tray with barrier drape (approx. 16"x29")

2. Sterile container (i.e. sterile urine specimen container).

3. Hibiclens or betadine in specimen container

4. 60 cc syringe (some recommend 20 cc with a hysterosongram catheters with a balloon tip.)

5. Sterile saline solution (100 cc bag) (Warm the sterile saline before instillation to prevent cramping, and for patient comfort. Recommended technique is to place the sterile saline into a sterile disposable urine container, then place the closed sterile container into a thermal insulated coffee cup that has warm water in it. The water level goes up to near the top of the sterile container on the outside. It only takes a few minutes to warm the saline. This is a cost effective, easy technique that seems to be appreciated by the patients.)

6.  Three OB/GYN swabs

7.  Open-sided speculum

8.  KDF 2.3 intrauterine cannula or non-latex catheter

9.  Ring forceps

10. Tenaculum

11. Portable light source

12. Stool (for physician)

13. Catch basin positioned in leg rest on exam table.

Procedure

1. Explain procedure to patient to allay any anxiety. Have patient void to assure an empty bladder.

Be sure patient has taken Ibuprofen before coming to appointment. Take medical history and ask the patient if they have any allergies and specifically latex. Patient informed consent may be required by institutional protocol. Warn patients that have had a tubal ligation that they may experience slightly more cramping.

2. Set out sterile gloves for physician. Have flashlight or another light source available for use during procedure.

3. Arrange blue Chux (tripads) on both exam table and step.

4. Assist patient in assuming lithotomy position and follow procedure as described under endovaginal scans, obtaining views of cervix. Uterus, both ovaries and cul-de-sac. This is the baseline study; an unenhanced pre-instillation pre-evaluation.

5. Once physician is gloved, he/she draws the sterile saline solution into the 60 cc syringe, attaches the catheter and flushes saline solution through catheter. Syringe and catheter are set on sterile field.

6. Physician is ready to begin Sonohystrogram: Open-sided speculum is inserted.

7. Cervix is cleansed with a Betadine solution or chlorhexidine gluconate.

8. An intrauterine catheter is then threaded into the endometrium

9. Speculum is removed carefully so as not to dislodge the intrauterine catheter.

10. Vaginal transducer is re-inserted.

11. Using a 60 cc (or other) syringe, saline solution is instilled under direct real-time observation. (One should have had flushed the catheter prior to using it, to get rid of echogenic artifact.) There was an article in the past year either in the Journal of Diagnostic Medical Sonography or the Journal of Ultrasound in Medicine regarding use of sterile saline injection along with injecting air into the uterus for the visualization of tubal patency. Air has been reported to give good contrast in the tubes.

12. Obtain hard copy views from cornua to cornua, coronal plane; cervix to fundus. Continue obtaining views to reconstruct a 3-dimensional anatomy of the intrauterine cavity.

13. Have a sanitary napkin available for the patient's use, and warn them that they will probably have a brownish watery discharge, and that the discharge is due to the Betadine and the sterile saline.

Examples of Sonohysterogram images:

http://www.obgyn.net/us/gallery/Gyn_Abnormal_Polyp1_sm.jpg

http://www.obgyn.net/us/gallery/Gyn_Abnormal_Polyp2_sm.jpg

http://www.obgyn.net/us/gallery/Gyn_Abnormal_Endometrial_Polyp.jpg

Comments:

This procedure is useful in any case where better endometrial detail will be helpful. For example, to distinguish dysfunctional uterine bleeding from patients with myomas or polyps, thus dismissing or allowing appropriate surgical intervention. Infertility patients' endometrium can be evaluated for the presence of polyps. It does not replace the HSG, but the presence of free fluid in the cul-de-sac proves, at least, unilateral tubal patency. Sonohysterography is also useful in women on Tamoxifen therapy, especially if they have a history of vaginal bleeding. (Tamoxifen is used extensively in women with breast cancer, with reports of it causing hyperplasia or even adenocarcinoma of the endometrium).

Physician may give the Hysterosonogram results immediately to the patient, and explain the next course of action or treatment for the patient. The patient is told if she were to have any fever within the next 24 - 48 hours to contact us. There are some references that prescribe giving antibiotics previous to the exam, but our physicians do not feel that is required.

A bit from those with experience:

This is a suggested, abbreviated protocol:

Some comments on the protocol for sonohysterography that was submitted (above), as far as changes from it that I use. To outline my background, I am an OB/Gyn and MFM, and have practiced general OB/Gyn in the past, but now have a practice restricted to sonology in OB/Gyn. My partner and I do all our own scans in their entirety (at least at present). I have been doing sonohysterography for at least 4 or 5 years, and am currently doing about 15 to 20 of them each month on referral from other OB/Gyn physicians. For anyone who is not doing these procedures, you will be amazed at how often you find polyps (or less commonly submucous fibroids) in patients with recurrent intermenstrual bleeding, postmenopausal bleeding, or sometimes in patients just with menorrhagia and dysmenorrhea.

I agree with the timing of the procedure (I try for Day 4 to 7) but will do them at other times of the cycle on occasion. In my case it is the physician sonologist being assisted by a medical assistant.

Re equipment: I don't use a tray or barrier drape, and don't usually use a specimen container. I usually use a prepackaged Betadine swabstick, but always ask first if the patient is allergic to shellfish or Iodine. If they are I then use Zephiran (in a sterile specimen container). I use 20 cc syringes. Occasionally I'll need to use more than one syringe, but usually 20 cc is enough. I like to use the Ackrad H/S catheter, or alternatively the Cook Silicone Balloon HSG catheters. Both are latex-free. One nice thing about the Ackrad catheter is its introducer system and cover, which enhances the ease to maintain sterility and to introduce the catheter without needing ring forceps or a tenaculum. Indeed I don't use sterile gloves (just exam gloves -- as long as you maintain a no-touch technique, where the inserted part of the catheter is never touched, sterile gloves are not essential (similar to inserting an IUD or doing an endometrial biopsy). Side opening speculums make it easier, but in some patients I need to use the narrow Pederson speculums. I have ring forceps available, but only occasionally need them so I don't have them opened. I almost never need a tenaculum, but again have one available. I also have a # 1 / # 2 Hegar dilator available, for the occasional postmenopausal patient who needs some minimal dilation to be able to insert the (smaller) Cook catheter.

Re Procedure: As mentioned, I don't use sterile gloves, but regular exam gloves with a no-touch technique. I no longer have the patient take Ibuprofen before the procedure. I have found that patients rarely need to have it afterwards either, as long as (and this is key) the fluid is injected very slowly. If the fluid is injected quickly the rapid distension causes a lot of cramping. If it is injected slowly, they usually have minimal if any cramping.

My assistant draws up the sterile saline into a 20 cc syringe, and then passes the catheter to me once the speculum has been inserted and the cervix prepped, so no separate sterile field is required beyond the opened package. As mentioned, I use Betadine swabsticks or Zephiran solution, but any all-purpose antiseptic that can be used on skin and mucus membranes should be fine.

My goal is not to have the catheter in the endometrial cavity, but instead to have the balloon of the catheter within the cervix (which I usually inflate with about 1 cc of air). The advantage to inflating the balloon in the cervical canal is that you get a better seal (less leakage) and so need less fluid injection and get better images, and sometimes if the catheter has been inserted into the endometrial cavity you may lift up some endometrium with the tip of the catheter and have to decide if that it is tiny polyp of just from catheter tip trauma.

Other tips: In the past, some people have suggested that a sonohysterogram is unnecessary if the endometrial thickness is less than 4 mm. While pathology is unlikely at < 4mm, it can occur, so consider a patient's symptoms. I have found polyps of 2 mm thickness within a 3 mm endometrium.

In the uncommon situation that a patient does get cramping that isn't immediately relieved by removal of the catheter, check by ultrasound to see if the fluid has drained out. If not, the patient may have cervical stenosis, and you can relieve the cramping by opening the cervix with another catheter or a dilator to allow the fluid out.

If a patient has cervical stenosis with fluid retention, or if they have a hydrosalpinx, I give them 24 to 48 hours of prophylactic antibiotics following the procedure if I didn't already know about the situation. If I already knew about their problems then I give them one dose of antibiotic (e.g. doxycycline 200 mg) just before the procedure.

Simplistically, my protocol for Technique of Sonohysterography is:

Following a baseline transvaginal ultrasound:

*Cervix is visualized (and cleansed, e.g. with Betadine) using a speculum in the vagina - using a side opening speculum makes removal of the speculum (with the SHG catheter in place) easier

*Prefill the catheter with saline to lessen air bubbles

*The catheter is inserted through the cervix, so that the balloon will be able to inflate either within the cervix (my preference), or in the uterine cavity

*The catheter balloon is inflated with air (usually < 1 cc), the speculum is removed, and the transvaginal ultrasound probe (re)inserted

*Saline is then slowly injected through the catheter into the endometrial cavity (a 20 cc syringe is usually as much as or more than needed)

*The endometrial cavity is imaged in the longitudinal and transverse planes while the endometrial cavity is being distended

*Especially if the balloon is in the lower uterine segment, the balloon is deflated and removed under ultrasound observation"

More comments:

I use a Soules or Goldstein catheter, and reserve the far more expensive balloon catheter for those infrequent times when the fluid runs out as fast as you put it in and you cannot obtain any distension of the cavity. I agree that sometimes the catheter will undermine the fragile and delicate endometrium and then you have to decide if you are seeing a polyp or not.

I try to withdraw the fluid at the end of the procedure by aspirating with the syringe. Most of the time I can aspirate the fluid. Sometimes, when the tip of the catheter is under or against the endometrium, you are plugging up the tip when you aspirate, and then I slowly withdraw the catheter as I am gently aspirating. Usually you reach a point where the fluid will be withdrawn, before the catheter is out.

Other experienced comments:

"I have had one patient with an infection after a sonohysterogram. She returned within a 2 or 3 days of the procedure with abdominal pain and fever and with findings of uterine and cervical motion tenderness. She responded rapidly to oral antibiotics. At the time of sonohysterography, she had cervical stenosis and I had to dilate her cervix to 2 mm before being able to introduce the sonohysterogram catheter. She also had a history of infertility and with saline injection the uterine cavity filled, she got cramping, and then there was a sudden decrease of fluid in the uterus with relief of her cramping and appearance of fluid in the cul de sac. I suspect with her cervical stenosis and perhaps some tubal blockage (implying possible past tubal infection) that she may have retained some fluid within the endometrial cavity after the procedure, making her more susceptible to infection."

"Since then, I always make sure that the fluid empties from the endometrial cavity following balloon deflation, and if it doesn't I reinsert a catheter to help release the fluid, and in the presence of cervical stenosis and/or hydrosalpinx or history of PID I will then given them a couple of doses of Doxycycline following the procedure."

" I am in awe of what we can sometimes see once the saline is in the endometrial cavity."

Also - Anna Parsons MD has suggested manually retroverting the axially oriented uterus to eliminate the imaging difficulties associated with scanning "down the barrel" of this type of uterus.

Contributions based upon the initial suggested protocol by: Sharon Durbin, RDMS

Others contributing:

Kathleen Murphy, Program Director, GateWay Community College

Art Fougner, M.D., SonoScan/Genetic Sciences, 112-03 Queens Blvd., lab Forest Hills, N.Y. 11372 USA

Ruth A. King, RT, RDMS, Bayshore OB/GYN, Sandusky, Ohio

Eric Deigan, M.D., FACOG, FRCSC, Carolina Perinatal Associates, PLLC, Cary, NC, USA

Joseph A Worrall, MD RDMS, The Fairbanks Clinic, 1919 Lathrop Street, Suite 100, Fairbanks, AK 99701 USA

Terry J. DuBose, M.S., RDMS, APS, University of Arkansas for Medical Sciences, DMS Program, Little Rock, Arkansas USA

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