Herlyn-Werner-Wunderlich syndrome: merits of sonographic and magnetic resonance imaging for accurate diagnosis and patient management in 13 cases

Unusual clinical presentations, pathogenesis and radiological review of Herlin-Werner-Wunderlich syndrome: A case report and literature review

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare anomaly of the female urogenital tract characterized by the combination of uterine didelphys, obstructed hemivagina, and ipsilateral renal anomalies. The exact incidence of the syndrome remains unknown, but it has been reported to be 1 per 2000 to 1 per 28,000 women. It is believed that the triad is a mesonephric duct-induced paramesonephric duct anomaly. In majority of the cases with complete hemivaginal obstruction, the pathology is diagnosed after menarche due to retained menstrual flow. While the common clinical presentations are dysmenorrhea, pelvic pain, intermenstrual bleeding, and pelvic mass, it can also manifest itself with unusual gastrointestinal and urinary tract symptoms. We present a case of HWW syndrome with gastrointestinal symptoms like worsening constipation and abdominal fullness. The unusual clinical presentation of this syndrome makes diagnosis more challenging. To solve such medical puzzles and prevent complications, detailed history-taking and radiological guidance are critical.

Herlyn-Werner-Wunderlich syndrome also known as obstructed hemivagina and ipsilateral renal anomaly: A case report and a comprehensive review of literature

Herlyn-Werner-Wunderlich syndrome, also known as obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), is a Müllerian duct anomaly. It is a rare clinical condition consisting of a duplicated uterus with an oblique vaginal septum that causes partial genital tract outflow obstruction. A urinary tract anomaly, most commonly renal agenesis, is usually present on the obstructed side. The diagnosis of genital tract outflow obstruction is often delayed due to the normal functioning of the unaffected side. The most frequent complications are dysmenorrhea, chronic pelvic pain, infection, infertility and endometriosis. This report describes a 17-year-old G0P0 patient with a history of severe dysmenorrhea and left-sided renal agenesis, who was admitted for complaints of foul vaginal discharge over the past 3 months that was unsuccessfully treated with antibiotics. Transrectal ultrasound revealed the presence of 2 separate hemicavities on transverse and longitudinal views. A cystic lesion with ground-glass opacities was detected between the bladder and a normal-appearing cervix, which was determined to be hematocolpos. The diagnosis of OHVIRA was made. This case highlights the importance of excluding a Müllerian anomaly in the presence of renal system abnormalities. Being aware of the type of anomalies, combinations and variants is crucial to determine the diagnosis and the best surgical approach. Ultrasound was an invaluable imaging exam to determine the type of anomaly and its complexity. Awareness of this syndrome and its variants will prevent misdiagnosis and will help to define the appropriate treatment for these patients.

Síndrome de Herlyn-Werner-Wunderlich: reporte de caso y revisión de la literatura

Objetivo:

Presentar un reporte de caso de síndrome de Herlyn Werner Wunderlich (SHWW) y hacer una revisión de la literatura para determinar los hallazgos clínicos e imagenológicos en estas pacientes.

Materiales y métodos:

Se presenta el caso de una mujer de 16 años que consultó, en un hospital de las fuerzas militares en Bogotá, por dolor pélvico recurrente, su diagnostico final fue SHWW. Se realizó una búsqueda sistemática de la literatura en las diferentes bases de datos, revisiones sistemáticas, cohortes, series de casos y reportes de casos en pacientes con diagnóstico de SHWW en cualquier edad, se obtuvo información sobre las características de presentación clínica, y las tecnologías diagnósticas más frecuentemente utilizadas. Se hace resumen narrativo de los hallazgos.

Resultados:

Se incluyeron 77 publicaciones, un total de 676 pacientes. Los síntomas más frecuentes fueron dismenorrea (63,9 %), seguido de dolor pélvico (35,2%). Las tecnologías diagnósticas más utilizadas fueron el ultrasonido pélvico en un 92,1% y la resonancia magnética nuclear en un 74,6% de los casos. La histeroscopia y laparoscopia son poco utilizados en el diagnóstico.

Conclusión:

El SHWW es una entidad poco frecuente, debe hacer parte del estudio complementario de la agenesia renal del paciente pediátrico y del diagnóstico diferencial de la dismenorrea primaria en pacientes en la adolescencia. Se requiere evaluar con estudios de cohorte más grandes la utilidad de la histeroscopia en estas pacientes.

Multiple variants of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome - one clinical center case series and the systematic review of 734 cases

INTRODUCTION

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare female urogenital tract malformation.

STUDY OBJECTIVE

To present 10 patients with OHVIRA treated at the clinical center. To perform a systematic review of OHVIRA case series related to the prevalence of anatomical variants, surgical interventions and endometriosis, and to compare them with our case series.

MATERIALS AND METHODS

Medical records from 10 OHVIRA patients treated between 2016 and 2020 were retrospectively reviewed. For the systematic review, PubMed and Web of Science were used to search for relevant studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were strictly followed.

RESULTS

The most common anatomical variant includes left obstructed hemivagina (50.7%) with isolated hematocolpos or hydrocolpos (55.9%), uterus didelphys (82.9%), and ipsilateral renal agenesis (92.2%). Vaginal septectomy was the most common surgical approach (86.5%). Hemivaginectomy (2.2%), hemihysterectomy (4.2%), or total hysterectomy (0.7%) were also performed in several patients. Some subjects required salpingectomy (3.3%) or oophorectomy (1.8%). 7.5% of patients, mainly infants, did not require surgery due to the spontaneous resolution of hydrocolpos. Endometriosis was fortuitously found in 13.6% of the selected cases who underwent laparoscopy or laparotomy.

DISCUSSION

The most common variant of OHVIRA includes isolated hematocolpos and a thick vaginal septum between adjacent hemivaginas. Endometriosis was present in approximately 14% of OHVIRA patients, but this number is probably underestimated. Routine laparoscopy is not required. However, all patients need further monitoring due to a higher risk of endometriosis. Based on the analyzed studies and our case series, vaginal septectomy is a sufficient surgical technique to relieve symptoms and prevent possible complications in most OHVIRA patients.

Síndrome de Herlyn-Werner-Wunderlich. Reporte de caso

Introducción. El síndrome de Herlyn-Werner-Wunderlich (SHWW) es una malformación congénita rara del tracto urogenital que se caracteriza por la triada útero didelfo, hemivagina obstruida y anomalía renal ipsilateral, y que suele diagnosticarse después de la menarquia. Su tratamiento consiste en resección del tabique vaginal y drenaje de la hemivagina obstruida, con un buen pronóstico postquirúrgico. Presentación del caso. Mujer de 22 años con un cuadro clínico de 9 años de evolución que inició cuando tuvo su primera menstruación, consistente en dismenorrea, dolor pélvico y ciclos menstruales irregulares, quien asistió al servicio de ginecología de un hospital de segundo nivel en Sogamoso, Boyacá (Colombia). La paciente reportó haber visitado múltiples especialistas y recibido tratamiento con vitamina E, metformina y anticonceptivos, sin mejoría de los síntomas y signos. Luego de ser valorada, y teniendo en cuenta los hallazgos en ecografía y resonancia magnética, fue diagnosticada con SHWW, por lo que se le realizó colpotomía más resección de masa paracervical derecha de aproximadamente 60x60 mm y de tabique vaginal, lográndose la resolución completa de los síntomas. Finalmente, 10 meses después de la cirugía, la joven refirió encontrarse en estado de embarazo, sin presentar complicaciones. Conclusión. El SHWW es una malformación poco común que debe considerarse como diagnóstico diferencial en mujeres de cualquier edad con anomalías de los conductos paramesonéfricos, dolor pélvico, dismenorrea y masa en el tracto genital, pues su diagnóstico temprano y un tratamiento oportuno mejoran considerablemente la calidad de vida de estas pacientes al reducir la severidad de los síntomas, disminuir la incidencia de complicaciones y mejorar el pronóstico obstétrico.

Clinical characteristics and management of patients with complete septate uterus, double cervix, obstructed hemivagina, and ipsilateral renal agenesis

AIM

To analyze the clinical characteristics and management of patients with complete septate uterus, double cervix, obstructed hemivagina, and ipsilateral renal agenesis.

METHODS

This retrospective study reviewed the medical records of 17 patients with complete septate uterus, double cervix, obstructed hemivagina, and ipsilateral renal agenesis admitted to the Third Xiangya Hospital of Central South University between June 2007 and December 2019.

RESULTS

The median age at surgery was 23 years. The most common presenting complaint was infertility. Seven (41.2%) patients were misdiagnosed previously. The obstruction was complete in five patients. All 17 patients underwent vaginoplasty, in which seven adolescent girls underwent vaginoscopic vaginal septum resections. Eight patients underwent hysteroscopic resections of the uterine septum for infertility or spontaneous miscarriage. Laparoscopy was performed in seven patients for specific indications, and only one patient was found to have pelvic endometriosis during the laparoscopy. During the follow-up, seven patients wished to conceive, and there were five living infants (four cesarean deliveries at term and one preterm vaginal delivery).

CONCLUSION

Complete septate uterus with double cervix, obstructed hemivagina, and ipsilateral renal agenesis is an variant of obstructed hemivagina and ipsilateral renal agenesis syndrome. Consequently, healthcare providers should be aware of this potential variant.

In-office Hysteroscopic Treatment of Herlyn-Werner-Wunderlich Syndrome: A Case Series

Herlyn-Werner-Wunderlich syndrome (HWWs) is a rare congenital malformation of the female urogenital track characterized by a triad consisting of didelphys uterus, obstructed hemivagina, and ipsilateral renal agenesis. We report 5 consecutive cases of patients diagnosed with HWWs treated in our center. Imaging studies with 2-dimensional/3-dimensional ultrasound and abdominopelvic magnetic resonance imaging were obtained to confirm the diagnosis. The treatment consisted of a 1-step surgical in-office hysteroscopic incision of the vaginal septum using 5 Fr hysteroscopic bipolar electrodes. At the follow-up visit, between 1 and 2 months after the initial procedure, the patients underwent a diagnostic vaginoscopy with excision of exceeding vaginal tissue if needed, performed with a vaginal hysteroscopic approach. In-office hysteroscopic treatment of patients diagnosed with HWWs is a safe and effective, minimally invasive treatment modality that provides symptomatic relief and preserves fertility, avoiding the cost and risks of the use of general anesthesia in an operating room setting. We recommend shifting the management of this challenging condition to the office setting.

An unusual appearance of the post-pubertal Herlyn-Werner-Wunderlich syndrome with acute abdominal pain: A case report

Background

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital urogenital defect. It is detected by unilateral low vaginal obstruction, uterus didelphys, and ipsilateral kidney agenesis. It usually becomes apparent with pain, dysmenorrhea, and presence of a vaginal or pelvic mass. Purulent vaginal discharge may also happen rarely because of infective complications of the obstructed hemivagina. In this report, we describe a post-pubertal case with acute abdominal pain.

Case

The patient was a 13-yr-old girl who was referred to us with acute abdominal pain one year after the onset of her menarche. In the pelvic examination, we detected hematocolpos. Abdominopelvic-computed tomography scan confirmed the presence of mullerian duct anomalies with uterus didelphys. This case of HWW syndrome along with pyocolpus was managed by vaginal septum resection, drainage of pus, and salpingectomy.

Conclusion

The symptoms of HWW syndrome should be monitored in early puberty to prevent more complications.

Virginity-sparing management of hematocolpos with imperforate hymen: case report and literature review

Imperforate hymen results from failure of the endoderm of the urogenital sinus to completely canalize and has an incidence of 0.01% to 0.05%. This sometimes presents as a pelvic mass that compresses the bladder causing acute urinary retention. A 13-year-old girl was referred to our department with a history of primary amenorrhea, cyclic lower abdominal pain, abdominal–pelvic mass, constipation and acute urinary retention. She had an ultrasonography misdiagnosis of a huge ovarian mass before referral to our unit. On examination, the vagina was bulging and compressing the rectum. Repeat abdominal ultrasonography confirmed the diagnosis of hematometrocolpos. She underwent X-shaped hymenotomy with a favorable outcome. Diagnosis of imperforate hymen requires high suspicion index. Virginity-sparing surgery constitutes a good treatment option for cultural and religious reasons.

Successful preterm pregnancy in a rare variation of Herlyn-Werner-Wunderlich syndrome: a case report

Background

Herlyn–Werner-Wunderlich syndrome (HWWS) is an uncommon congenital anomaly of the female urogenital tract, characterised by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. We reported the difficult pregnancy course complicated by an extremely rare and unique case of this syndrome associated with ectrodactyly, a clinical combination never described in literature.

Case presentation

A 28- year-old nulliparous woman previously diagnosed for HWWS associated with ectrodactyly of the right foot and with a history of abdominal left hemi-hysterectomy, ipsilateral salpingectomy, vaginal reconstruction when she was an adolescent. She suffered from threats of abortion in the first trimester, recurrent urinary tract infections during all pregnancy. At 33 weeks + 5 days of gestational age, she was hospitalized for premature rupture of the membranes and uterine contractions and a caesarean section was performed because of breech presentation. Postpartum period was complicated by a pelvic abscess resolved with parental antibiotic therapies.

Conclusions

Our literature review shows an unusual aspect in our case: HWWS is not classically associated with skeletal anomalies. Moreover, the most frequent urogenital side affected is the right, not left side as in this woman. Preterm spontaneous rupture of membranes and fetal abnormal presentation represent frequent complications and probably post-caesarean infections are related to pregnancies in the context of this syndrome.

Ultrasonic evaluation of congenital vaginal oblique septum syndrome: A study of 21 cases

The aim of the present study was to investigate the ultrasound features and classify the lesion types of congenital vaginal oblique septum syndrome (CVOS) in 21 patients prior to surgery. Grey-scale pelvic ultrasound was performed to evaluate the uterus, vagina and kidneys in 21 patients with suspected CVOS. Ultrasound features, including the presence of a double uterus, hematocolpos masses and renal absence, in CVOS types I, II and III were studied and compared with intra-operative results and the results of surgery. Ultrasound identified the presence of double uteruses and cervices with ipsilateral renal agenesis on the oblique septum side in all 21 patients. There were 14 hematocolpos lesions on the right and 7 on the left of the vagina. Type I CVOS was diagnosed in 15 patients with a large hematocolpos mass (volume, 64-268 ml) and these diagnoses were confirmed by surgery. Furthermore, there were 4 patients with type II and 2 patients with type III CVOS exhibiting small hematocolpos lesions (volume, 5-36 ml) identified by ultrasound, which were all confirmed by surgery. Therefore, ultrasound imaging is useful tool to evaluate the abnormal features of CVOS and determine the type of CVOS in patients prior to surgical intervention.

A case report on Herlyn-Werner-Wunderlich syndrome with spontaneous abortion

INTRODUCTION

Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare congenital abnormality of the urogenital tract characterized by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. It is usually diagnosed after menarche, with a clinical presentation of dysmenorrhea, recurrent abdominal pain, and irregular menses. However, it is rare to diagnose it during pregnancy, subsequently resulting in spontaneous abortion.

CASE PRESENTATION

A 22-year-old Chinese woman with HWWS whose left uterine pregnancy underwent spontaneous abortion presented with a right perforated obstructed hemivagina and right renal agenesis. The right vaginal septum was resected and the hematocolpos was drained, thereby relieving lower abdominal pain and preserving future fertility.

CONCLUSION

Co-presentation of unilateral renal agenesis and uterus didelphys should encourage clinicians to rule out HWWS. Early diagnosis and subsequent treatment can avoid possible serious complications.

A rare case of pelvic pain caused by Herlyn-Werner-Wunderlich Syndrome in an adult: A case report

INTRODUCTION

Herlyn-Werner-Wunderlich Syndrome (HWWs) is a rare congenital anomaly. This abnormality has 5% percentage of the total Mullerian dysgenesis. The symptomatic patients come with varies condition, such as urinary incontinence, urinary retention endometriosis, pelvic infection and acute pelvic pain. Here we present investigation and management of HWWs with pelvic pain in adult woman.

PRESENTATION OF CASE

A 23 years old woman came with pelvic pain. We found abnormalities of HWW syndrome i.e. uterus didelphys with obstructed hemivagina and right renal agenesis through ultrasound imaging, CT scan and MRI. After concluding the diagnosis, the patient underwent vaginal septum excision and vaginoplasty procedures to relieve obstruction which was the cause of pelvic pain. The symptom was improved after surgery and she felt no more pain after a year of follow up.

DISCUSSION

The main symptom of HWWs is dysmenorrhea associated with obstruction mass or endometriosis. MRI with capability of tissue differentiation is the gold standard for diagnostic. The primary purpose of surgery is to release the obstruction and to prevent further complication.

CONCLUSION

Rarely, HWWs causes an acute pelvic pain with secondary cystic mass finding. Surgery aimed to release obstruction will improve this symptom.

Herlyn-Werner-Wunderlich syndrome: An "early" onset case report and review of Literature

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We describe a case of a 3 years old girl, with all features of Herlyn–Werner–Wunderlich syndrome (HWWS) who came to our attention for lower abdominal mass.

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Only six cases are reported in Literature with early onset of this syndrome under 5 years.

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The aim of this article is to share our experience and focus the attention on the importance of high level of suspicion of HWWS in neonatal period to early diagnosis and treatment.

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The possible early presentation of this syndrome should be suspected in all neonates (females) with renal agenesia confirmed postnatally or with prenatal diagnosis.

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An error of evaluation with planning of removal of mass, that can damage patients in term of chance for a successful reproductive outcome.

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Our team consider HWWS as differential diagnosis in newborn with prenatal ultrasonography of a cystic mass behind the urinary bladder in the absence of a kidney and plan a pelvic ultrasound (with aim to identify an uterus, normal or dydhelfus, and presence or absence of pelvic mass), an examination under anesthesia and cisto-vaginoscopy, if it is necessary. A high level of suspicion, indeed, is the key to early diagnosis.

Herlyn–Werner–Wunderlich syndrome (HWWS) is a rare congenital mullerian anomaly consisting of uterus didelphys, hemivaginal septum, and unilateral renal agenesis [1,2]. Most authors reported cases of Herlyn–Werner–Wunderlich syndrome with prepuberal or postpuberal onset with cyclical abdominal pain and a vaginal mass (3–8). Only six cases are reported in Literature with early onset of this syndrome under 5 years (9–14). Our case is about 3 years old girl, with all the features of this syndrome who came to our attention for lower abdominal mass. The aim of this article is to share our experience and focus the attention on the importance of high level of suspicion of HWWS in neonatal period to early diagnosis and treatment. The possible early presentation of this syndrome should be suspected in all neonates (females) with renal agenesia confirmed postnatally or with prenatal diagnosis. It is common, in fact, an error of evaluation with planning of removal of mass, that can damage patients in term of chance for a successful reproductive outcome. For all these reasons, our team consider HWWS as differential diagnosis in newborn with prenatal ultrasonography of a cystic mass behind the urinary bladder in the absence of a kidney and plan a pelvic ultrasound (with aim to identify an uterus, normal or dydhelfus, and presence or absence of pelvic mass), an examination under anesthesia and cystoscopy and vaginoscopy, if it is necessary. A high level of suspicion, indeed, is the key to early diagnosis.