Abstract
Objective:
The aim of this study was to assess the role of 3D transvaginal sonography (3DTVS) in diagnosing hydrosalpinx, a common manifestation of pelvic inflammatory disease (PID). The PID is a complex inflammatory condition, in patients who can present with pelvic pain, infertility, or pelvic mass.
Materials and Methods:
This study was designed as a retrospective case series and conducted to ascertain the potential utility of sonographic identification of hydrosalpinx. The patient data, across a series of patient cases, were analyzed to investigate the diagnostic and surgical approaches received. This case series comprised of patients with specific conditions including deeply infiltrating endometriosis (DIE), as well as the utilization of the ovarian-adnexal radiological data-reporting system (O-RADS), for ovarian malignancy diagnosis.
Results:
Among the 42 patients diagnosed sonographically with hydrosalpinx and enrolled in the study, 19 underwent laparoscopic surgery to confirm the diagnoses through histopathology. Comparing sonographic findings with operative outcomes, the diagnostic accuracy in this case series revealed hydrosalpinx diagnosis was accurately established in 14 cases (74%) utilizing 3DTVS.
Conclusion:
In this group of patient cases, the use of noninvasive 3DTVS was found to be a valuable adjunct to conventional diagnostic methods for the diagnosis of hydrosalpinx and supplemented contemporary gynecologic practice.
Pelvic inflammatory disease (PID) is characterized by inflammation of a woman’s reproductive organs caused by infection of the upper reproductive tract. 1 It is a complication that often occurs from sexually transmitted infections most commonly from chlamydia and gonorrhea. 2 The clinical presentation of PID in women varies widely and can encompass a variety of signs and symptoms, spanning from subtle and mild to pronounced and severe, making prompt identification imperative for effective management. Given that certain instances of PID may manifest as a silent infection with limited symptoms, diagnosis is crucial because untreated PID can lead to complications such as female infertility, chronic pelvic pain, and the risk of ectopic pregnancy. 3
The diagnosis of PID involves a combination of clinical assessments, laboratory analyses, and imaging studies. Due to the critical nature of achieving early and precise PID diagnosis, radiologic examinations are frequently utilized to expedite identification. The diverse array of clinical and radiologic presentations, inherent in PID, necessitates a comprehensive reassessment of diagnostic approaches.
Hydrosalpinx (HS) is characterized by a fluid-filled fallopian tube leading to distal tubal occlusion. The PID is the most common cause of HS. Presently, there is substantial evidence supporting the notion that removal of the HS significantly improves the live birth rate in in vitro fertilization (IVF) procedures. 4 It is crucial that the removal procedure is conducted meticulously to avoid compromising the ovarian blood supply.
Previous studies have evaluated the use of 2D transvaginal sonography (2DTVS) in diagnosing HS. A recent systematic review and meta-analysis by Delgado-Morell et al. 5 evaluated the diagnostic accuracy of transvaginal ultrasound in diagnosing HS, considering a variety of statistical predictors. Despite the potential variability in diagnostic performance based on operator experience and the quality of ultrasound equipment systems, 3D transvaginal sonography (3DTVS) may have a greater diagnostic accuracy for HS identification, based on personal experience. As such, 3DTVS may be used as a primary diagnostic imaging technique in clinical settings for patients suspected of having HS, which was the aim of this study.
This study accentuates the expanding role of sonographic imaging as an adjunctive tool to surgical or medical intervention. Recognizing the frequent concurrence of PID and HS, it was important to investigate the diagnostic potential of 3DTVS. Augmenting the foundation laid by Timor-Tritsch, 6 the current study approach offers simplicity but enhanced diagnosis. Through two distinct case series involving deep invasive endometriosis (DIE) and the ovarian-adnexal radiological data-reporting system (O-RADS) application for ovarian malignancy diagnosis, 7 allowed for the creation of a unique data set to include only those specific cases which demonstrated possible HS. It also made it possible to expound upon the diagnostic accuracy of 3DTVS, in cases possibly linked to PID.
A case series was investigated for the possible diagnosis of DIE, for which patients presented with pelvic pain, infertility, and/or adnexal mass. A separate case series was investigated for the possible value of the O-RADS application for the diagnosis of ovarian malignancy. Since the sonographic diagnosis of HS was made in each data set, and some of those patients underwent laparoscopic surgery, the validity of the sonographic diagnosis could be calculated from this newly created data set. Given the overlapping symptoms of pelvic pain, infertility, and adnexal mass, which could also indicate possible PID, cases featuring HS were carefully evaluated for potential PID associations. The present investigation was performed to elucidate the value of 3D surface rendering imaging for diagnosing HS and to validate sonographic diagnoses through operative intervention and histologic confirmation.
Materials and Methods
A case series comprising a total of 42 patients (See Table 1), who presented with complaints of pelvic pain, infertility, or pelvic mass, underwent comprehensive evaluation using 3DTVS. All sonographic evaluations were conducted using the Voluson E8 equipment system (GE Healthcare Ultrasound, Milwaukee, Wisconsin) and was equipped with a transvaginal transducer operating at 5 to 9 MHz frequency. This equipment set-up allowed for volume acquisition and analysis. The recognition of HS via 2DTVS prompted the implementation of a specific 3DTVS surface rendering imaging procedure, which was consistently performed in each suspected case of HS.
The Descriptive Baseline Characteristics of Study Participants.
Of these 42 patients, 19 patients with positive 3DTVS findings for HS and subsequently underwent surgical intervention (See Table 2). The selection criteria for surgery were based on clinical indications and patient consent. The investigative period spanned from March 1, 2022 to May 31, 2023 and gained approval from the host institutions’ internal review board [IRB #45CFR46.104 (d)(4)] as well as receiving exempt status. The study method encompassed (1) precision 3D volume acquisition targeting the region of interest (suspected HS); (2) creation of a large 3D ultrasound rendering box to demonstrate the external surface of the resulting HS image; and (3) substantial manipulation of the ensuing 3D volume rendering image to produce optimal visual representation. The sonographic images provided clear and easily interpreted visual demonstrations of the tubal structure, facilitating the diagnosis of HS when present.
The Forty-Two Descriptive Patient Cases, Assessed Sonographically, for Hydrosalpinx (HS).
The standardized criteria for diagnosing HS was employed, based on the size, appearance, and structural characteristics of the fallopian tubes as visualized on 3DTVS. Hydrosalpinx was defined by the presence of tubular, fluid-filled structures with incomplete septations and thin walls. One experienced obstetrician and gynecologist (CMF), with 25 years of experience in gynecologic imaging and received training in ultrasonography through the American Institute of Ultrasound in Medicine (AIUM), was involved to ensure consistency and reliability in interpreting sonographic images.
Results
A total of 42 patients underwent the described rendering imaging with 3DTVS (See Figure 1), comparing the 2D and 3D rendering images. The image provided in Figure 2 reveals a case of HS, using 2DTVS, and Figure 3 is a sample image of the same case of HS, utilizing 3D surface rendering technology. Among all of these subjects, 19 (45%) also underwent laparoscopic surgery (See Figures 4 and 5), confirmed with histopathology. Out of these cases, 14 (74%) revealed histologic findings consistent with the presurgical sonographic diagnosis of HS.
An example transvaginal sonography image that combined 2D sonography (2DTVS) and 3D sonography (3DTVS) surface rendering of suspected right hydrosalpinx. (A) 2DTVS sagittal view demonstrating anechoic fluid-filled tubular structure and incomplete septation (arrows). (B) 3DTVS surface rendering of the suspected right HS demonstrating: tubular structure and an incomplete septation (arrows).
An example gray scale 2D sonogram that demonstrated a long axis of 7.6 × 3.7 cm, an echogenic fluid-filled tubular structure of right adnexal mass with positive incomplete septation, with positive endosalpingeal folds.
The same patient, as depicted in Figure 2, provided a long axis view of right adnexal mass using 3D sonographic live surface rendering. It also demonstrates the cut surfaces of a suspected right hydrosalpinx.
A laparoscopic view is provided of the left hydrosalpinx measuring 6.0 cm in length × 0.6 cm in diameter.
A laparoscopic view of the right hydrosalpinx measuring 7.5 cm in length × 0.6 cm in diameter.
Instances where initial sonographic images suggested HS, yet subsequent surgical intervention negated the diagnosis, included two cases of uncomplicated simple paratubal cyst, one case of cystadenofibroma, one instance of peritoneal pseudocyst, and one occurrence of ovarian serous cystadenoma. The remaining 14 cases, however, did visually confirm the diagnosis of HS (74%) and were subsequently confirmed histologically. The diagnostic interpretations of the images that resulted from this process of surface rendering perfectly identified HS, corroborated by the surgical/histologic findings.
All suspected HS were classified as O-RADS 2 using the O-RADS V2022 (Ovarian/Adnexal Reporting and Data System) 8 indicating an almost certainly benign condition (<1% risk of malignancy) and thus managed appropriately by a gynecologist, as needed for clinical issues.
Discussion
This case series underscores the clinical utility of 3DTVS in the diagnostic landscape of chronic PID as an adjunct in diagnosis leading to laparoscopic surgical investigation. Recognizing the frequent correlation between chronic PID and HS 9 while integrating the potential advantages of surgical intervention in managing subfertility 10 provides a valuable approach to the diagnosis and management of HS in PID. Although a direct value comparison of all of the different types of imaging tools that can be used for the diagnosis of HS could not be found at present, magnetic resonance imaging (MRI) has previously been widely used for this diagnosis, and examples of its use in comparable circumstances have been noted. 11 In addition, the cost differential between MRI and sonography should also be meaningfully noted. 12 In that reference, cost units for sonographic evaluation and MRI assessment were 47€ ($52) and 700€ ($775), respectively. This current sonographic technique is being described to add to the imaging armamentarium that is currently available.
The described imaging approach assumes a central role, strengthened by its alignment with surgical outcomes. The 3DTVS surface rendering can be considered as an important gynecologic diagnostic tool for HS. The rendered images increased the confidence in diagnosing HS in PID. Familiarity with the typical imitators of fallopian tube disease can significantly diminish the chances of misdiagnosis, delayed treatment, and unnecessary surgical interventions. Examples of other fallopian tube pathology can include endometriosis, pyosalpinx, tubo-ovarian abscess, ectopic pregnancy, paratubal cysts, and multiple types of neoplasms. 13 The following sonographic criteria for diagnosis of HS, according to O-RADS US, are anechoic fluid-filled tubular structures with possible incomplete septation and possible endosalpingeal folds (short round projections around the inner walls). Although, any form of imaging commonly requires surgical confirmation.
There are several strengths to this innovative study. First, the study employs 3DTVS as a diagnostic tool, offering a novel approach to diagnosing HS associated with PID. Given the significant impact of PID on female reproductive health, particularly infertility and ectopic pregnancy risk, the study addresses a clinically relevant topic with potential implications for patient management. The study conducts a comprehensive evaluation by combining sonographic diagnosis with surgical intervention, providing a broad understanding of the diagnostic accuracy of 3DTVS in identifying HS.
Limitations
The major study limitation is the research design and the small convenient sample size. These factors limit the generalizability of the findings and the ability to draw robust conclusions about the broader population of women with PID and HS. Being conducted in a single institution, may introduce bias, and limit the external validity of the results. The study’s inclusion criteria (e.g., patients presenting with pelvic pain, infertility, or pelvic mass) may introduce selection bias, as these symptoms could be indicative of various gynecologic conditions beyond PID and HS. Although the study focuses on the diagnostic accuracy of 3DTVS, it lacks comparison with other diagnostic modalities or techniques, which could provide additional context for interpreting the results and assessing the relative strengths and weaknesses of different approaches. In addition, since the primary focus of this investigation relates to the described sonographic diagnosis of HS, there was no exploration of infectious pathogens that resulted in its formation.
Conclusion
Future studies should be designed to include all subjects evaluated by the index test (3D transvaginal ultrasound [3DTVUS]) to undergo the reference standard to provide a more comprehensive assessment of diagnostic accuracy. In addition, incorporating a larger sample size and a prospective study design could help validate our findings and provide more robust conclusions.
The current implementation of this technique highlights its practicality in clinical settings. By confirming the diagnosis of chronic PID through sonographic examination, gynecologists can offer diverse treatment options and utilize a crucial diagnostic tool with confidence. As a result, 3DTVS surface rendering emerges as an indispensable diagnostic tool in gynecology, significantly improving diagnostic accuracy, especially in patients with PID.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval
Ethical approval for this study was waived by Advocate Aurora Institutional Review Board because it is exempt from IRB oversight as cited in 45CFR46.104(d)(4) on January 10, 2023.
Informed Consent
Informed consent was not sought because all case data were de-identified and/or aggregated and followed the ethics committee or IRB guidelines (also referred to as the Honest Broker System).
Animal Welfare
Guidelines for humane animal treatment did not apply to the present study because no animals were used during the study.
Trial Registration
Not applicable.
