Use of spinal needle for transcervical saline infusion sonohysterography in presence of cervical stenosis

Abstract

Postmenopausal bleeding is a common problem in routine gynecologic practice. Although only 6% of these women have cancer, evaluation of the endometrial cavity is mandatory to rule out malignancy. Transvaginal ultrasound and endometrial biopsy or hysteroscopy and endometrial curettage are standard investigations performed to rule out significant endometrial pathology. However, cervical stenosis, which is commonly seen in postmenopausal women, can preclude access to the endometrial cavity. Here, we describe a new technique of performing saline infusion sonohysterography by insertion of a spinal needle through the cervix into the endometrial cavity. This technique allows ultrasound visualization of the endometrial cavity and aspiration of endometrial washings for cytological analysis. Mrs Pu, a 70-year-old G4P4, presented with one episode of postmenopausal bleeding. She had her menopause at the age of 47 years and her smear 6 months ago was normal. In April 2000, she had undergone Laser Cone Biopsy for CIN3. Ultrasound scan showed endometrial thickness of 19 mm. Outpatient endometrial biopsy was unsuccessful because of cervical stenosis. Hysteroscopy under general anesthesia was attempted. However, in spite of using small-sized dilators and probes under ultrasound guidance, the cervical canal could not be negotiated and a false passage was created. A size 20 spinal needle was then inserted through the cervix into the endometrial cavity under transvaginal ultrasound guidance. Twenty mL of normal saline was infused into the uterine cavity. An endometrial polyp was visualized on ultrasound (Fig. 1). Fluid from the endometrial cavity was aspirated for cytological analysis, which showed degenerative cells only with no evidence of malignancy. However, malignancy could not be completely excluded and Mrs Pu was advised to undergo a hysterectomy. Sonohysterograph showing an endometrial polyp. Postmenopausal bleeding can be a symptom of endometrial pathology. Endometrial cancer should be excluded in all such patients. Transvaginal scan and endometrial biopsy are considered adequate investigations to rule out endometrial carcinoma (1). In this case, transvaginal ultrasound showed thickened endometrium, and outpatient endometrial sampling was not successful as a result of cervical stenosis. Hysteroscopy under general anesthesia was also unsuccessful. Thus, satisfactory evaluation of the endometrial cavity using routine techniques was not possible. Saline infusion sonohysterography has a high sensitivity for investigation of abnormal uterine bleeding (2). This technique involves infusion of saline into the uterine cavity to aid visualization of endometrial pathology. A Foley's catheter is commonly used for this purpose. In our case, a Foley's catheter could not be used because of cervical stenosis. We introduced a spinal needle under transvaginal ultrasound guidance into the endometrial cavity and infused 20 mL of normal saline. This delineated the polyp inside the endometrial cavity. We also obtained endometrial washings for cytological analysis. The described method is safe, easy to use and effective in cases of cervical stenosis for evaluation of endometrial cavity. In this case, the procedure was carried out under a general anesthesia, but we believe that it can also be performed using a local anesthetic in outpatient settings.