By SIDNEY RUBIN, M.D., RODGER W. LAMBIE, M.D., HENDRICK C. DAVIDSON, M.D., AND EDWIN M. HERMAN, M.D.
ARIUM VAGINOGRAPHY is a safe, simple, and reliable procedure capable of demonstrating pathology that may be elusive to other means, even direct visualization. If this procedure is utilized in certain conditions (as described in this Seminar) it will provide the referring physician and radiologist with detailed information essential to the proper care of the patient. HISTORY
The radiologic literature on use of a contrast substance for outlining the vagina is scanty. The earliest reference to the subject is credited to Calandra et al.,l who, in 1959, inserted a Foley catheter into the vagina in attempting hysterosalpingography and colpohysterosalpingography. However, in 1954, Xatzen and Trachtman’ had demonstrated an ectopic ureter draining into the vagina by distending the vaginal vault with 40 per cent Hippuran solution. In 1963, in back-to-back publications, Coe* and two of the present authors5 reported their technique and experience with the procedure, including its use for demonstrating enterovaginal fistulas. ROENTGEN ANATOMY
The vaginal vault is a cul-de-sac which, in spite of its varying size, has a relatively consistent appearance (Figs. 1 and 2). The barium-filled vagina is shaped like an inverted bottle, slightly wider at the waist than at the dome,
Fig. 1.-AP projection of normal barium-filled vagina.
tmt Professor in Radiology, University of Kansas Medical , Kansas City, Kans.; Associate Professor, Unit;ersity of Missouri, Columbia, MO. R W. LAMBIE, M.D.: Instructor in Radiology, University of Kansas Medical School, Kansas City, Kans. KENDRICK C. DAVXBON, M.D.: Assistant Professor in Radiology, University of Kansas Medical School, Kansas City, Kans. EDWIN M. HERMAN, M.D.: Resiaknt in Radiology, A4enorah Medical Center, Kansus City, MO.
Fig. 2.-Lateral projection of normal barium-filled vagina.
The smoothborders of the vaginal vault as well as the normal impression of the cervix at the dome of the vagina are emphasized.
and converging at the introitus as a cone or neck. A small indentation in the superior aspect of the cul-de-sac is caused by the cervix. Normally, the vaginal outline shows a smooth upper border with symmetrical lateral margins, and no barium enters the uterine cavity, The anterior surface of the vagina is in close proximity to the fundus of the urinary bladder above and the urethra below. Its posterior surface is separated from the rectum and anal canal by the recta-uterine escavation above, the rectovaginal fascia in the middle, and thr perineal body below. The terminal portions of the ureters passing forward and medially to reach the bladder, lie close to the lateral fornices of tht sngina and enter the bladder slightly in front of the anterior fornix. TECHSIQUE
We have modified our technique slightly so that the retention type of catheter is used only when the simple catheter fails to provide an adequate study. A standard rectal enema tip, thrust through the center of a sponge 6 X 4 X 1 inches, is inserted into the introitus with the patient supine ou the fluoroscopic table. The patient is instructed to keep her legs together. and the enema tip is advanced into the vagina while the sponge approximates the labia. Under television-monitored fluoroscopy, a thin solution of barium is instilIed into the vagina and photofluorograms are exposed in the Al?: lx>tlt obliques, and lateral projections. The patient is then permitted to “evacl~atr” the barium. A double contrast study can be carried out if desired. The patient is given a cleansing douche at the termination of the examination. Discussion
Vaginography is of value in a variety of conditions. Vaginal extension from cancer of the cervix can readily be demonstrated by vaginography (Fig. 3). Such information serves as a valuable adjunct to tumor staging and treatment planning. The same applies to vaginal extension from carcinoma or sarcoma of the bladder, rectum, and other tijacent organs (Figs. 5 and 6). Occasionally the extent of involvement by a primary or secondary cancer of the vagina can be determined better by vaginography than from the clinical examination. This is especially true when the tumor reduces the size of the
Fig. 3 .-Vaginogram in carcinoma of the cervix. Right lateral view. The
flattened anterior fornix defines the area of vaginal carcinomatous exten-
introitus or canal to such a degree that direct observation and palpation are prevented (Fig. 4). The demonstration of jistulas is another important indication for vaginography. The most common cause of colonic-vaginal fistulas, in our experience, is diverticulitis associated with pericolonic inflammation and abscess. Such was the case in Mrs. E.P., in whom abdominal pain was followed by a foul vaginal discharge. The colon examination revealed multiple large diverticula associated with localized tenderness (Fig. 7), but failed (as usual) to show a fistnla. A vaginogram demonstrated the fistula at the dome of the vagina, extending to the sigmoid. Enterovaginul fistzdas following irradiation are often multiple. Both large and small intestine may be involved but the barium studies often fail to demonstrate all of the existing communications. This information is not purely academic but is essential to the surgeon who contemplates a corrective operative procedure. For example, closing a vaginocolic fistula would fail to eliminate the vaginal discharge if there is also a small bowel communication.
with extensive infiltration along the POSterior wall into the dome of the vagina and invasion of the cervix.
Fig. S.-Lateral vaginogram in bladder carcinoma. The anterior wall of the vagina is fixed and flattened. The metal frame is a localization aid for irradiation.
Fig. 6.Lateral vaginogram in rectal carcinoma. The tumor extended into the vaginal fascia, blunting the superior posterior fornix of the vagina. A small amount of contrast medium is present in the r-ectum.
Fig. 7.-Diverticulitis with vaginal fistula. A. Lateral roentgenogrnm of rectum demonstrating several large diverticula. The fistula is not outlined. B. \‘oginogram reveals the fistula connecting the dome of the v-agina with the area of cliv-erticulitis.
RURIX ET AL.
Having experienced this regrettable situation on several occasions, we have learned to use vaginography to avoid this pitfall. A 59 year old woman was hospitalized with profuse vaginal fecal drainage of 3 weeks’ duration. Eighteen months before, she had undergone a total hysterectomy and bilateral salpingooophorectomy for papillary adenocarcinoma of the right ovary. This was followed by cobalt therapy, 4500 r over 5 weeks. A subsequent barium enema demonstrated an area of spasm and induration in the region of the sigmoid colon but did not reveal fistula formation (Fig. SA). Immediately following the colon examination, a vaginogram was performed (Fig. 8B). Fistulas to the sigmoid and terminal ileum were demonstrated. These were confirmed at operation and corrected surgically. In a patient with a surgically-induced vaginal fistula, an error in roentgen interpretation arose when two fistulas were noted. One of these, directed to the right lower quadrant, was mistakenly assumed to enter the small bowel. Actually this fistula communicated with a redundant sigmoid that curved toward the cecum (Fig. 9). Delayed films are helpful to observe the passage of the contrast medium along the intestinal tract and thereby verify the site of intestinal communication. For this reason, we recommend that the vaginogram be the initial study in order to avoid the difficulty incurred by the presence of residual barium. SUMMARY
Barium vaginography offers information not obtainable by clinical examination or other roentgen procedures. Primary and secondary invasive carcinoma involving the vagina are best outlined by vaginography. The knowledge derived from this procedure helps in tumor staging and treatment planning. Intestinovaginal fistulas can be clearly delineated by this method.
Fig. S.-Vaginal fistulas secondary to surgery and irradiation for ovarian carcinoma. A. Barium enema shows a long segment of spasm and induration in the sigmoid but fails to depict a fistula. B. Vaginogram reveals fistulous communication to the sigmoid and terminal ileum.
Fig. 9.--Surgically induced vaginal fistulas. A. Oblique vaginogram demonstrates two fistulas arising from the vagina, one extending anteriorly and one posteriorly. B. Later vaginogram shows filling of the sigmoid and rectum and confirms the double colon fistnlas. The vaginogram preceded the barium enema to avoid confusion introduced by retained colonic barium. REFERENCES of vaginal ectopic ureter by vaginogram. J. C., and Calan-
1. Calandra, D., Gluck, dra, N.: Hysterosalpingography hysterosalpingography: New modifications. Obstet. Gynec. 2. Coe, Roentgen.
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3. Goss, C.: Gray’s Anatomy. Philadelphia, Lea & Febiger, 1956, p. 1404. 4. Katzen,
Ural. 72:808, 1954. 5. Lambie, R. W., Rubin, S., and Darm, D. S.: Demonstration of fistulas by vaginography. Amer. J, Roentgen. 90:717, 196.3. 6. Lambie, R. W., Rubin, S., and Dann, D. S.: Vaginigraphy. In Merrill, V. (Ed.): Atlas of Roentgenographic Positions (ed. 3). St. Louis, C. V. Mosby Co., 1967, pp. X0751.