Hysteroscopy

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Chapter 245 Hysteroscopy

DESCRIPTION

Hysteroscopy allows direct visual inspection of the uterine cavity. This may also serve as a portal for other diagnostic or therapeutic measures. (The hysteroscope may be used to perform vaginoscopy in young girls or infants. When used in this way, distending media are generally not required or indicated.)

INDICATIONS

Dysfunctional uterine bleeding, postmenopausal bleeding, menorrhagia, infertility (selected cases) or recurrent abortion, endometrial or pelvic infections (e.g., tuberculosis), missing intrauterine contraceptive device, or other situations where viewing the endometrial cavity can establish a diagnosis. Hysteroscopy may be used as the vehicle for transcervical sterilization, polypectomy, myomectomy, resection of intrauterine septa or adhesions, the retrieval of contraceptive devices, and other procedures.

CONTRAINDICATIONS

Acute bleeding (if carbon dioxide is used), acute pelvic infection, known uterine or cervical cancer, pregnancy (known or suspected), recent uterine perforation, uncooperative patient, vaginitis (relative).

REQUIRED EQUIPMENT

• Sterile gloves

• Operating vaginal speculum (open sided)

• Skin preparation materials (generally an iodine-based antibacterial solution such as Betadine)

• Single tooth tenaculum

• Blunt uterine sound (optional)

• Hysteroscope (flexible or rigid, 3 to 5 mm diameter, 0-, 12-, 30-, or 70-degree viewing angle; 10 mm or greater devices are available for operative procedures but are better suited to the ambulatory surgery setting)

• Insufflator (carbon dioxide, constant flow type) and light source (both compatible with the brand and type of hysteroscope chosen). (Other distending media, such as 32% dextran or 5% dextrose and water, may be used but CO₂ offers the most suitable medium for office use. Media such as dextran are preferred in the ambulatory surgery setting when operative procedures are likely to be performed.)

• Lidocaine (1%) without epinephrine, syringe and 22- to 25- gauge spinal (4″) needle or lidocaine spray

• Video or photographic equipment may be attached to the hysteroscope as desired (optional)

TECHNIQUE

Hysteroscopy is most easily performed during the early follicular phase when the endometrium is thinnest. Because of the nature and risks of hysteroscopy, informed consent should be obtained prior to initiating the procedure. The discomfort of hysteroscopy may be decreased by premedicating with a single oral dose of a nonsteroidal anti-inflammatory agent given in doses usually used to treat dysmenorrhea.

The patient should be placed in the dorsal lithotomy position, and a pelvic examination should be performed to determine the current size, shape, and position of the uterus. The vaginal speculum should be placed to allow clear access to the cervix. With the cervix in view, the cervix is disinfected with an appropriate antiseptic solution. If an anesthetic is to be used (generally advisable), a pericervical block should be placed or the anesthetic material applied at this time.

If the patient is parous and the cervical os is open, a tenaculum may not be required, although it is generally recommended. A uterine sound may be used to gently dilate the cervix or provide information about the axis and depth of the uterine cavity, if needed.

With the hysteroscope appropriately connected to the insufflator and light source, the tip of the hysteroscope is brought into contact with the external cervical os, and insufflation is begun (approximately 30 cc per minute). The hysteroscope is next advanced along the endocervical canal under direct vision, when a clear view ahead is available and resistance to advancement is minimal. When the body of the uterus is entered, carbon dioxide flow rates may have to be increased to provide adequate distention of the cavity, but intrauterine pressure should never be allowed to exceed 100 torr (mm Hg).

Inspection of the entire uterine cavity should be performed in a systematic way. The tubal ostia should be identified and the fundus of the uterus should be inspected. The endocervical canal should be inspected as the hysteroscope is withdrawn, if it was not evaluated at the beginning of the procedure.

If dextran has been used as the distending medium, it is imperative to clean the hysteroscope immediately after the completion of the procedure.

COMPLICATIONS

Uterine perforation, infection (endometrial, myometrial, pelvic). (Infection following hysteroscopy is rare, and prophylactic antibiotics are not recommended unless indicated by factors such as valvular heart disease.) Vasovagal syncope during the procedure may occur but is generally transient. Shoulder pain, unilateral or bilateral, is common if carbon dioxide is used. Gas embolism has rarely been reported. Fluid overload may occur when dextrose and water are used as the distending media.

FOLLOW-UP

Based on indications.

CPT CODE(S)

56350 Hysteroscopy, diagnostic (separate procedure)

56351 Hysteroscopy, surgical: with sampling (biopsy) of endometrium and/or polypectomy; with or without D&C

56355 Hysteroscopy, surgical: with removal of impacted foreign body

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