What is hydrosalpinx?

Hydrosalpinx: Definition, Diagnosis, and Management

Hydrosalpinx is a distension or dilatation of the fallopian tube caused by distal tubal occlusion, resulting in fluid accumulation within the tube. It represents one of the most severe manifestations of tubal disease, accounting for 10-30% of tubal pathologies and approximately 25% of all infertility cases 1.

Etiology and Pathophysiology

• Primary cause: Pelvic inflammatory disease (PID), typically from prior infection 2, 1
• Secondary causes:
  • Endometriosis
  • Previous pelvic surgery
  • Adhesions from other pelvic pathologies
  • Incomplete salpingectomy during hysterectomy 3

The condition develops when inflammation causes scarring and occlusion of the distal (fimbrial) end of the fallopian tube, preventing fluid drainage and leading to progressive distension of the tube.

Clinical Presentation

• Often asymptomatic
• May present with:
  • Lower abdominal/pelvic pain (unilateral or bilateral)
  • Pelvic fullness or pressure
  • Infertility
  • Rarely, tubal torsion in cases of giant hydrosalpinx 4

Diagnostic Imaging

Transvaginal Ultrasound (TVUS)

• First-line imaging modality
• Sensitivity of 86% for detecting hydrosalpinx 2
• Typical findings:
  • Tubular anechoic or hypoechoic structure adjacent to ovary
  • Incomplete septa ("beads-on-a-string" sign) in chronic cases 2
  • Thin wall in chronic cases (97% of chronic cases) 2

Hysterosalpingography (HSG)

• Gold standard for evaluating tubal patency
• 65% sensitive and 85% specific compared to laparoscopy 2, 5
• Shows:
  • Dilated, fluid-filled fallopian tube
  • Absence of contrast spill into peritoneal cavity
  • May demonstrate other tubal abnormalities

MRI

• Useful when ultrasound findings are inconclusive
• 75.6% accurate in diagnosing hydrosalpinx in surgical cases 2
• Shows:
  • Dilated fluid-filled tube with variable signal intensity
  • T1: typically low signal intensity
  • T2: intermediate to high signal intensity 2

Hysterosalpingo-contrast Sonography (HyCoSy)

• Alternative to HSG, avoiding radiation exposure
• 91% accurate compared to laparoscopy 2, 5
• Real-time visualization of contrast in tubes

Differential Diagnosis

• Paraovarian cyst
• Ovarian cyst
• Tubo-ovarian abscess (TOA)
• Ectopic pregnancy (in reproductive-age women)
• Peritoneal inclusion cyst

Impact on Fertility

Hydrosalpinx significantly impacts fertility by:

• Physically blocking sperm-egg interaction
• Creating a hostile environment for embryo implantation through:
  • Mechanical disruption (hydrosalpingeal fluid reflux into uterine cavity)
  • Chemical/toxic effects on the endometrium 1, 6, 7

Management Options

For Women Seeking Pregnancy

1. Salpingectomy (surgical removal of the affected tube)

   • Preferred approach before IVF treatment 1
   • Improves IVF outcomes by eliminating toxic fluid reflux
   • Laparoscopic approach recommended when feasible

2. Salpingostomy (creating a new opening in the distal tube)

   • Option for women desiring natural conception
   • Higher risk of ectopic pregnancy (up to 10%) 1
   • Limited success rates

3. Proximal tubal occlusion

   • Alternative when salpingectomy is contraindicated
   • Can be performed hysteroscopically
   • Lower clinical pregnancy and live birth rates compared to salpingectomy 1, 6

For Women Not Seeking Pregnancy

• Observation if asymptomatic
• Salpingectomy for symptomatic cases or large hydrosalpinx
• Complete removal of fallopian tubes during hysterectomy to prevent post-hysterectomy hydrosalpinx 3

Special Considerations

• Giant hydrosalpinx: May require surgical intervention due to risk of torsion 4
• Post-hysterectomy hydrosalpinx: Can occur if fallopian tubes are incompletely removed during hysterectomy 3
• Bilateral hydrosalpinx: May significantly impact fertility prognosis

Prevention

• Early and appropriate treatment of pelvic inflammatory disease
• Complete removal of fallopian tubes during hysterectomy 3
• Consideration of prophylactic salpingectomy during pelvic surgery in women who have completed childbearing

Hydrosalpinx represents a significant cause of tubal infertility and requires appropriate diagnosis and management to optimize reproductive outcomes and prevent complications.