Hydrosalpinx

Hydrosalpinx is a fallopian tube blocked at the fimbrial end and distended with clear fluid.

• It is usually due to pelvic inflammatory disease, endometriosis, previous surgery or adhesions.
• It causes tubal infertility and reduces success of in vitro fertilisation.
• Treatment is by removing or blocking the tube.

Often none; chronic pelvic pain, watery vaginal discharge (hydrorrhoea), and infertility.

• Tender fixed adnexal mass in some women.
• Differential diagnosis: simple ovarian cyst, paratubal cyst, pyosalpinx, tubo-ovarian abscess, ectopic pregnancy, endometrioma.
• Complications: infertility, ectopic pregnancy, torsion, infection (pyosalpinx), reduced implantation in in vitro fertilisation.

Diagnosis is by ultrasound, confirmed by hysterosalpingography or laparoscopy.

• Transvaginal ultrasound: tubular or sausage-shaped anechoic structure with incomplete septa (cogwheel sign).
• Hysterosalpingography or sonosalpingography: distal tubal blockage with dilatation.
• Laparoscopy and dye test.
• Endocervical NAAT for chlamydia and gonorrhoea; HIV and syphilis tests; chlamydia antibodies where available.

Remove or occlude the affected tube before in vitro fertilisation, and treat any infection.

• Supportive: counselling on fertility options; analgesia; avoid intercourse around the procedure.
• Pharmacological: antibiotic cover at hysterosalpingography or tubal surgery: doxycycline 100 mg oral 12-hourly for 5 days. Pelvic pain: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours). Treat active infection: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days.
• Procedures: laparoscopic salpingectomy (preferred) or proximal tubal occlusion before in vitro fertilisation; laparoscopic salpingostomy only in young women with thin-walled tubes and healthy mucosa who want natural conception. Ultrasound-guided aspiration for women who cannot have surgery, with antibiotic cover.
• Special groups: in HIV infection, antiretroviral treatment is optimised before pregnancy. In women aged 35 or over move early to in vitro fertilisation.
• Red flags: fever with pain (pyosalpinx), sudden severe pain (torsion), pregnancy with abdominal pain (ectopic).
• Follow-up: review at 2 and 6 weeks after surgery; plan in vitro fertilisation within 3 to 6 months.