Chapter 17: Reproductive System

Detailed Chapter Overview

Chapter 17 provides a focused exploration of the radiographic procedures used to evaluate the reproductive systems of both females and males. While many conditions of these systems are now primarily assessed with ultrasound and MRI, specific radiographic examinations remain critical for answering certain clinical questions, particularly regarding infertility and breast pathology. The chapter dedicates significant attention to the anatomy of the female reproductive system, including the uterus, uterine (fallopian) tubes, and ovaries, as this is foundational for understanding the chapter's keystone procedure: hysterosalpingography (HSG). A central theme is the HSG's unique ability to assess the patency of the uterine tubes, a crucial factor in female fertility. The text meticulously details the procedural steps, from patient scheduling and sterile technique to the specific role of the radiographer in assisting the physician during this fluoroscopic examination. Another major component of the chapter is an introduction to mammography, the single most important imaging modality for the detection of breast cancer. It covers the specialized equipment, compression techniques, and the standard projections required for both screening and diagnostic studies. The male reproductive system is also covered, though it is noted that radiography plays a more limited role, with procedures like urethrography offering some insight. For every procedure, the chapter emphasizes patient care, radiation protection, and the rigorous evaluation criteria needed to ensure diagnostically valuable images are produced.

In-Depth Study Guide

Anatomy of the Female Reproductive System

The female reproductive system is a complex system of internal and external organs responsible for ovulation, fertilization, fetal development, and childbirth.

Internal Genitalia:

• Ovaries: The primary female gonads, analogous to the male testes. These two almond-shaped organs are responsible for producing ova (eggs) and secreting female sex hormones (estrogen and progesterone).
• Uterine (Fallopian) Tubes: Two muscular tubes, about 10-12 cm long, that extend from the superolateral aspect of the uterus. They are not directly attached to the ovaries.
  • Infundibulum: The distal, funnel-shaped end of the tube, which has finger-like projections called **fimbriae**. The fimbriae capture the ovum after its release from the ovary.
  • Ampulla: The central and longest portion of the tube. This is the most common site of **fertilization**.
  • Isthmus: The narrow, proximal portion that connects to the uterus.
• Uterus: A pear-shaped, muscular organ located in the pelvic cavity between the bladder and rectum. It is responsible for nurturing the fertilized ovum and carrying the fetus to term.
  • Fundus: The dome-shaped superior portion.
  • Body (Corpus): The main central portion.
  • Isthmus: A narrow, constricted area between the body and the cervix.
  • Cervix: The inferior, neck-like portion that projects into the vagina.
• Vagina: A muscular tube that connects the cervix to the exterior of the body.

Radiographic Procedures of the Female Reproductive System

Hysterosalpingography (HSG)

Purpose and Clinical Indications:

• Primary Purpose: HSG is a diagnostic fluoroscopic procedure designed to assess the anatomy and function of the uterus and uterine tubes. Its most important function is determining the **patency (openness) of the uterine tubes**, which is a primary investigation in cases of female infertility. Blocked tubes can prevent the sperm and egg from meeting or prevent a fertilized egg from reaching the uterus.
• Other Indications: It can also demonstrate the size, shape, and position of the uterus, and detect structural abnormalities such as uterine fibroids, polyps, or congenital defects.

Procedure and Patient Care:

• Scheduling: The exam must be scheduled within 10 days following the onset of menstruation. This timing ensures that the patient is not pregnant and that the endometrium (uterine lining) is at its thinnest, which is ideal for the procedure.
• Patient Prep: The patient should abstain from intercourse and may be instructed to take a mild laxative or cleansing enema to clear any gas or feces that could obscure the anatomy. An over-the-counter pain reliever may be recommended before the exam to reduce cramping.
• Sterile Technique: This is an invasive procedure, so strict sterile technique is required. The radiographer prepares a sterile tray with drapes, speculum, antiseptic solution, cannula or catheter, and contrast media.
• Contrast Injection: After a preliminary scout image, the physician places a speculum into the vagina to visualize the cervix. The cervix is cleaned, and a cannula or balloon catheter is inserted into the cervical canal. A water-soluble, iodinated contrast medium is then slowly injected under fluoroscopic guidance.

Radiographer's Role and Image Evaluation:

• The radiographer's role is to prepare the room and sterile tray, explain the procedure to the patient, obtain a patient history, assist the physician during the procedure, and operate the fluoroscopy unit. After the fluoroscopy, the radiographer may take overhead images.
• Image Interpretation: The radiologist watches the flow of contrast in real-time. A normal HSG will show the contrast filling the uterine cavity and then flowing through the entire length of both uterine tubes. The most critical part of the evaluation is observing the **intraperitoneal spill**—the contrast medium spilling out of the distal (fimbriated) end of the tubes into the peritoneal cavity. This spill confirms that the tubes are patent. If one or both tubes are blocked, the contrast will not spill out.

Mammography

• Purpose: The gold standard for breast cancer screening and diagnosis. Mammography uses specialized, low-dose x-ray equipment to produce high-contrast, high-resolution images of the breast tissue.
• Anatomy: The breast is composed of three types of tissue: glandular tissue (lobes and ducts), fibrous or connective tissue, and adipose (fatty) tissue.
• Compression: Firm compression of the breast is essential for a quality mammogram. Compression spreads the tissue out, reduces the thickness (lowering the radiation dose), decreases motion, and improves image sharpness.
• Routine Projections:
  • Craniocaudal (CC): The x-ray beam is directed from superior to inferior (head-to-foot). Provides a view of the medial and central portions of the breast.
  • Mediolateral Oblique (MLO): The x-ray beam is directed from the medial aspect to the lateral aspect, angled at 45-60 degrees. This is the single most important view as it demonstrates the most breast tissue, including the **axillary tail** (tail of Spence), a common site for cancer development.

Anatomy and Radiography of the Male Reproductive System

Anatomy:

• Testes: The primary male gonads, responsible for producing sperm (spermatogenesis) and testosterone.
• Duct System: A series of ducts that transport sperm, including the **epididymis** (where sperm mature), the **ductus deferens (vas deferens)**, and the ejaculatory duct.
• Accessory Glands: The **seminal vesicles**, **prostate gland**, and **bulbourethral glands** produce seminal fluid, which mixes with sperm to form semen. The prostate gland is a clinically significant structure that surrounds the proximal male urethra.

Radiographic Procedures:

Radiography of the male reproductive system is limited, as ultrasound is the primary imaging modality for structures like the testes and prostate.

• Retrograde Urethrography: While technically a urinary system procedure, it is used to visualize the male urethra. Contrast is injected directly into the distal urethra. It can be used to investigate strictures, trauma, or other urethral abnormalities.