Definition/General

Introduction:
-Hydrosalpinx is a condition characterized by dilatation of the fallopian tube filled with serous fluid
-It results from distal tubal obstruction with preserved proximal patency
-It represents the end-stage sequela of chronic salpingitis
-It is a major cause of tubal factor infertility.
Origin:
-Develops as a consequence of acute salpingitis
-Results from fimbrial end obstruction due to inflammatory adhesions
-Ciliary dysfunction impairs normal tubal transport
-Progressive accumulation of tubal secretions leads to dilatation
-May also result from congenital tubal abnormalities or endometriosis.
Classification:
-Classified as simple hydrosalpinx (single chamber)
-Complex hydrosalpinx (multiple chambers/septations)
-Can be unilateral or bilateral
-Severity graded as mild, moderate, or severe based on degree of dilatation
-May be associated with tubo-ovarian complex.
Epidemiology:
-Affects approximately 10-20% of infertile women
-More common in developing countries due to higher rates of PID
-Peak incidence in reproductive age group (25-35 years)
-Bilateral involvement in 50-70% of cases
-Associated with significantly reduced fertility rates (pregnancy rate <10% per cycle).

Clinical Features

Presentation:
-Often asymptomatic until infertility evaluation
-Chronic pelvic pain (30-40% cases)
-Intermittent watery vaginal discharge (due to tube spilling)
-Dysmenorrhea and menstrual irregularities
-Dyspareunia (painful intercourse)
-Recurrent pelvic infections.
Symptoms:
-Infertility (primary presenting complaint in 80% cases)
-Chronic pelvic pain (dull, aching)
-Intermittent hydrosalpinx (cyclical symptoms)
-Postcoital spotting
-Secondary dysmenorrhea
-Feeling of pelvic fullness or pressure
-May be completely asymptomatic in early stages.
Risk Factors:
-Previous history of pelvic inflammatory disease
-Sexually transmitted infections (Chlamydia, Gonorrhea)
-Previous pelvic surgery
-Endometriosis
-History of ectopic pregnancy
-Appendicitis with perforation
-Intrauterine device use
-Multiple sexual partners.
Screening:
-Transvaginal ultrasonography (first-line imaging)
-Hysterosalpingography (HSG) (shows characteristic appearance)
-MRI pelvis (detailed anatomy evaluation)
-Laparoscopy (gold standard for diagnosis and treatment)
-Saline infusion sonohysterography
-CT scan in complex cases.

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Gross Description

Appearance:
-Dilated, fluid-filled fallopian tube with smooth external surface
-Fimbrial end sealed with club-shaped appearance
-Tube appears sausage-shaped or retort-shaped
-Contains clear to turbid serous fluid
-Wall appears thin and translucent due to chronic distension.
Characteristics:
-Tube wall shows chronic thickening with fibrotic changes
-Loss of normal plicae architecture
-Fimbrial end shows complete obliteration with dense adhesions
-Surface may show adhesions to surrounding structures
-Smooth muscle atrophy in chronically distended areas.
Size Location:
-Diameter typically 2-10 cm (can be larger)
-Length may be normal or increased
-Ampullary dilatation most prominent
-Bilateral involvement in 50-70% cases
-May extend to form hydrosalpinx-ovarian complex
-Isthmic portion usually maintains normal caliber.
Multifocality:
-Bilateral disease common but not universal
-May have varying degrees of involvement on each side
-Can be associated with peritubal and periovarian adhesions
-May have septations creating multiple chambers
-Associated with chronic endometritis in many cases.

Microscopic Description

Histological Features:
-Chronic inflammatory changes with lymphocytic infiltrate
-Epithelial atrophy and loss of ciliated cells
-Plicae flattening and fusion
-Muscular wall shows fibrosis and atrophy
-Vascular sclerosis and chronic congestion.
Cellular Characteristics:
-Tubal epithelium shows marked atrophy with loss of normal architecture
-Absence of ciliated cells in affected areas
-Secretory cell hyperplasia may be present
-Chronic inflammatory cells including lymphocytes and plasma cells
-Stromal fibroblast proliferation and collagen deposition.
Architectural Patterns:
-Complete loss of normal mucosal folds (plicae)
-Smooth, flattened epithelial surface
-Pseudostratification of remaining epithelial cells
-Formation of epithelial polyps in some areas
-Muscular hyperplasia alternating with areas of atrophy
-Submucosal and subserosal fibrosis.
Grading Criteria:
-Mild: Partial preservation of tubal architecture
-Moderate: Significant architectural distortion with epithelial atrophy
-Severe: Complete loss of normal tubal structure with extensive fibrosis
-Grading based on degree of epithelial damage and muscular changes.

Immunohistochemistry

Positive Markers:
-Cytokeratin marks residual epithelial cells
-CD10 may be positive in stromal cells
-Smooth muscle actin highlights muscular wall (often disrupted)
-Vimentin positive in stromal and inflammatory cells
-PAX8 positive in tubal epithelium.
Negative Markers:
-Beta-catenin nuclear staining typically absent
-P53 usually negative (wild-type pattern)
-Ki-67 typically low proliferation index
-Calretinin negative (helps distinguish from mesothelial hyperplasia)
-Hormone receptors (ER, PR) may be reduced.
Diagnostic Utility:
-IHC mainly used to exclude malignancy in chronic cases
-PAX8 confirms tubal epithelial origin
-Helps distinguish from paratubal cysts or ovarian cysts
-Smooth muscle actin assesses muscular wall integrity
-CD10 helps identify endometriosis if present.
Molecular Subtypes:
-Not applicable for benign tubal dilatation
-Molecular studies may identify infectious agents in some cases
-Cytogenetic analysis typically normal
-May show inflammatory gene expression patterns
-Ciliary gene mutations rarely associated with congenital cases.

Molecular/Genetic

Genetic Mutations:
-No specific genetic mutations associated with acquired hydrosalpinx
-Ciliary dysfunction genes may be involved in rare congenital cases
-CFTR mutations associated with some cases of tubal obstruction
-Inflammatory pathway genes may influence susceptibility
-Most cases are acquired secondary to infection.
Molecular Markers:
-Inflammatory cytokines may be elevated in tubal fluid
-Prostaglandin levels often altered
-Matrix metalloproteinases involved in tissue remodeling
-Growth factors may be decreased
-Antimicrobial peptides production may be impaired.
Prognostic Significance:
-Significantly reduces fertility (pregnancy rates <10% per cycle)
-Bilateral disease has worse prognosis than unilateral
-Severity of dilatation correlates with pregnancy outcomes
-Presence of hydrosalpinx fluid toxic to embryos
-Surgical treatment may improve IVF outcomes.
Therapeutic Targets:
-Salpingectomy prior to IVF treatment
-Tubal ligation to prevent reflux of toxic fluid
-Laparoscopic fimbrioplasty in selected cases
-Proximal tubal occlusion (tubal coils)
-Anti-inflammatory therapy may have limited role.

Differential Diagnosis

Similar Entities:
-Paratubal cysts (separate from tube, lined by different epithelium)
-Ovarian cysts (arise from ovary, different location)
-Pyosalpinx (purulent rather than serous fluid)
-Hematosalpinx (contains blood)
-Tubal ectopic pregnancy (positive β-hCG, different history).
Distinguishing Features:
-Hydrosalpinx: Serous fluid content
-Hydrosalpinx: Arises from fallopian tube
-Hydrosalpinx: History of PID
-Paratubal cyst: Separate from tube
-Paratubal cyst: Different epithelial lining
-Pyosalpinx: Purulent fluid
-Pyosalpinx: Acute symptoms
-Ovarian cyst: Ovarian origin
-Ovarian cyst: Different imaging characteristics.
Diagnostic Challenges:
-Distinguishing from complex ovarian cysts on imaging
-Differentiating from paratubal cysts (anatomical relationship)
-Identifying bilateral vs unilateral disease
-Assessing degree of tubal damage for treatment planning
-Excluding associated malignancy in elderly patients.
Rare Variants:
-Hematosalpinx (blood-filled tube, often due to endometriosis)
-Pyohematosalpinx (mixed purulent and bloody fluid)
-Pseudosalpinx (congenital absence of tube with cystic remnant)
-Tuberculous hydrosalpinx (secondary to TB, may have calcifications)
-Intermittent hydrosalpinx (cyclical filling and emptying).

Sample Pathology Report

Template Format

Sample Pathology Report

Complete Report: This is an example of how the final pathology report should be structured for this condition.

Specimen Information

[fallopian tube specimen], measuring [length] cm in length and [diameter] cm in maximum diameter

Diagnosis

Hydrosalpinx, [unilateral/bilateral]

Dilatation Grade

Dilatation: [mild/moderate/severe] with [diameter] cm maximum diameter

Histological Features

Shows [epithelial changes] with [muscular wall changes] and [chronic inflammatory changes]

Epithelial Status

Epithelium: [atrophic/metaplastic/preserved] with [presence/absence] of ciliated cells

Associated Findings

Associated findings: [adhesions/endometriosis/chronic inflammation/none]

Fimbrial End

Fimbrial end: [completely obliterated/partially patent/not assessed]

Special Studies

Culture: [negative/not performed]

IHC: [performed/not performed], results: [results]

[other studies]: [results]

Fertility Implications

Fertility impact: [significant impairment/moderate impairment/minimal impact]

Final Diagnosis

Final diagnosis: [complete diagnosis with laterality and severity]