Ultrasound of Hydrosalpinx, Pyosalpinx & Tubo-ovarian Abscess

In this radiology lecture, we review the ultrasound appearance of hydrosalpinx, pyosalpinx and tubo-ovarian abscess!

Key teaching points include:

Hydrosalpinx = Fluid-filled, blocked fallopian tube
Hydrosalpinx causes: Pelvic inflammatory disease (most common), endometriosis, prior surgery, adhesions
Hydrosalpinx US: Thin-walled, tubular structure filled with anechoic simple fluid. Dilated tube may fold upon itself forming tubular C-shaped or S-shaped cystic mass. Incomplete septations common
With chronic hydrosalpinx, may see “beads-on-a-string” sign: Short, round, 2-3 mm projections seen along inner tubal walls in cross section = Flattened, fibrotic remnants of endosalpingeal folds. Don’t confuse with solid mural nodules
O-RADS US v2022 management of hydrosalpinx = Imaging: None. Clinical: Gynecologist
Pyosalpinx: Inflamed, blocked fallopian tube filled with purulent debris. Indicates pelvic inflammatory disease
Pyosalpinx US: Thick-walled tubal structure filled with complex fluid. Like hydrosalpinx, typically conforms to a C or S-shape
“Cogwheel” sign of pyosalpinx: Thickened endosalpingeal folds with surrounding tubal wall thickening. Typical of acute tubal inflammation
Tubal wall hyperemia more common with pyosalpinx than hydrosalpinx
Tubo-ovarian complex (TOC): With severe salpingo-oophoritis, ovary and tube adhere to each other. Can distinctly identify ovary from tube but cannot separate the two with transducer pressure. Tx: Antibiotics
Tubo-ovarian abscess (TOA): As pelvic inflammatory disease progresses, complete or near-complete loss of adnexal architecture with pockets of purulent fluid develop. Multiloculated mass with septations, irregular margins, may be bilateral. Tx: Antibiotics, percutaneous drainage, surgery