Vaginal agenesis: classification by MR imaging

Imaging of the Vagina: Spectrum of Disease with Emphasis on MRI Appearance

The vagina is a median fibromuscular structure of the female reproductive system that extends from the vulva inferiorly to the uterine cervix superiorly. As most vaginal lesions are detected at gynecologic examination, imaging performed for nongynecologic indications can frequently cause concomitant vaginal pathologic conditions to be overlooked. The vagina is often underevaluated at routinely performed pelvic transvaginal US because of a narrow scan area and probe positioning. MRI has progressively become the imaging method of choice for vaginal pathologic conditions, as it provides excellent soft-tissue detail with unparalleled delineation of the complex pelvic floor anatomy and helps establish a diagnosis for most vaginal diseases. It is important that radiologists use a focused approach toward understanding and correctly recognizing different vaginal entities that may otherwise go unnoticed. In this case-based review, the authors discuss the key imaging features of wide-ranging vaginal pathologic conditions, with emphasis on appearance at MRI. Knowledge of vaginal anatomy and embryology is helpful in evaluating congenital anomalies at imaging. Often seen incidentally, vaginal inflammation can cause diagnostic confusion. Because of its central location in the pelvis, the vagina can form fistulas to the urinary bladder, colon, rectum, or anus. Vaginal masses can be neoplastic and nonneoplastic and include a myriad of benign and malignant conditions, some of which have characteristic imaging features. Therapeutic and nontherapeutic vaginal foreign bodies include pessaries, vaginal mesh, and packing that can be seen with or without associated complications. Online supplemental material is available for this article. ^©RSNA, 2021.

Spectrum of MRI Appearance of Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome in Primary Amenorrhea Patients

INTRODUCTION

Mayer-Rokitansky-Kuster-Hauser (MRKH) synd-rome is a malformation in female genital tract due to interrupted embryonic development of para-mesonephric ducts leading to uterine and proximal vagina aplasia or hypoplasia.

AIM

To analyse the MRI findings in females suspected of MRKH syndrome in a primary amenorrhea workup.

MATERIALS AND METHODS

A cross-sectional study comprising of 11 patients of MRKH syndrome presented in a tertiary care centre from March 2016 to February 2017 evaluated in 1.5 Tesla MRI scanner.

RESULTS

Normal positioned small vestigial uterus demonstrated in two patients (18.2%) and complete uterine and proximal vaginal agenesis were noted in nine patients (81.8%). The mean volume of rudimentary right uterine bud was 2.26 mL ±3.3 (SD) and left uterine bud was 1.27 mL±1.1 (SD). The mean volume of right ovary was 4.74 mL±2.58 (SD) and left ovary was 4.65 mL±2.2 (SD). The mean developed vaginal length was 26.2 mm±6.34 (SD).

CONCLUSION

The rudimentary uterine buds associated with MRKH syndrome always maintained caudal relationship with ovary. Ovaries or rudimentary uterine buds can be ectopic and should be recognized with MRI before undergoing fertility treatment. Following MRI diagnosis, surgery allows patients to have sexual function with possible attainment of reproduction after assisted reproduction technique or surrogacy.

Magnetic resonance imaging of benign uterine pathology

Magnetic resonance imaging is commonly used for the identification and characterization of many pelvic abnormalities. Magnetic resonance provides the most comprehensive and detailed view of the uterus of any imaging modality. This article focuses on the magnetic resonance imaging features used to recognize and describe congenital uterine anomalies and benign conditions of the uterus.

Müllerian Duct Anomalies: Imaging and Clinical Issues

While estimates of the frequency of müllerian duct anomalies vary widely owing to different patient populations, nonstandardized classification systems, and differences in diagnostic data acquisition, these anomalies are clinically important, particularly in women who present with infertility. An understanding of the differences between these uterovaginal anomalies, as outlined in the most widely accepted classification system-that published by the American Fertility Society (AFS) in 1988-is imperative given the respective clinical manifestations, different treatment regimens, and prognosis for fetal salvage. Although the AFS classification system serves as a framework for description of anomalies, communication among physicians, and comparison of therapeutic modalities, there often is confusion about appropriate reporting of certain anomalies, particularly those with features of more than one class. Many of the anomalies are initially diagnosed at hysterosalpingography and ultrasonography; however, further imaging is often required for definitive diagnosis and elaboration of secondary findings. At this time, magnetic resonance imaging is the study of choice because of its high accuracy and detailed elaboration of uterovaginal anatomy. Laparoscopy and hysteroscopy are reserved for women in whom interventional therapy is likely to be undertaken.

Magnetic resonance imaging of mullerian duct anomalies of the uterus

Congenital uterine anomalies (mullerian duct anomalies) comprise a spectrum of developmental malformations associated with varying degrees of adverse reproductive outcomes. Although traditionally diagnosed by hysterosalpingography or ultrasound, further elaboration of the findings frequently was performed with laparoscopy/laparotomy and hysteroscopy. The need for diagnostic surgical intervention has largely been eclipsed with the advent of magnetic resonance imaging, which has become the imaging modality of choice for characterization of congenital mullerian anomalies.

MRI Appearances of Müllerian Duct Abnormalities

Müllerian duct abnormalities are a well-documented cause of sub-fertility, and in some cases can be successfully treated in order to preserve fertility and prevent complications. In this paper we review the various types of anomaly and present their appearances as demonstrated by magnetic resonance imaging (MRI). MRI provides an excellent, non-invasive method of differentiating between the different types of anomaly and defining their suitability for surgical treatment.

A comparison of MRI and laparoscopy in detecting pelvic structures in cases of vaginal agenesis

OBJECTIVE

To determine whether laparoscopy improves detection of uterine structures over MRI in cases of vaginal agenesis.

DESIGN

Prospective case series.

SETTING

Ambulatory pediatric gynecology clinic in a tertiary care children's hospital.

PARTICIPANTS

Subjects with vaginal agenesis who had an MRI to detect uterine structures.

MAIN OUTCOME MEASURES

A chart review identified subjects with vaginal agenesis who had an MRI to assess müllerian structures. The MRI findings were correlated with physical exam, presenting symptoms, and operative findings. We assessed degree of agreement between laparoscopy and MRI in patients both with and without pelvic pain to determine sensitivity and specificity of MRI in predicting uterine structures confirmed on laparoscopy.

RESULTS

Twenty-two subjects with vaginal agenesis were identified and 14 had both an MRI and laparoscopic evaluation. MRI successfully predicted uterine anomalies in six cases (43%) and lack of uterine structures in one case (8%). MRI diagnosis did not correlate with laparoscopic findings in the remaining seven cases (50%). Among subjects presenting with no complaints of pelvic pain (n = 6), three had negative MR imaging but positive laparoscopy. Using laparoscopy as a gold standard, MRI had a sensitivity of 53% for accurately detecting uterine anomalies confirmed on laparoscopy.

CONCLUSION

Laparoscopy improves detection of uterine structures over MRI alone in women with vaginal agenesis.

Imaging techniques to assess the pelvis in young females

This article is designed to help the nonradiologist to form a logical imaging plan when presented with a diagnostic dilemma involving the pelvis of a young female. Common presenting problems are grouped under the categories of fetus, neonate and infant, child, and adolescent. Ultrasound is frequently the initial, and sometimes the only, examination indicated. The appropriateness of other modalities, such as plain radiography, genitography, computed tomography, and magnetic resonance imaging, is described. Details of examination performance and interpretation are beyond the scope of this discussion, but can be gleaned from the references cited.

Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging in a 15-year-old girl

STUDY OBJECTIVE

Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging (MRI) in a 15-year-old girl with primary amenorrhea is reported.

DESIGN

The presentation, MRI, and the subsequent evaluation and treatment of an adolescent female patient with Rokitansky syndrome are described. Correlation is made with previous clinical, pathologic, and imaging reports in the literature.

SETTING

An adolescent girl with primary amenorrhea was referred to our institution for completion of her diagnostic work-up. Previous limited evaluations suggested the presence of anomalies of the genitourinary tract. Further delineation of the suspected congenital defects was necessary.

PARTICIPANT

The 15-year-old female patient was evaluated by the gynecology service. Diagnostic radiology and pediatric urology were consulted.

INTERVENTIONS

MRI, physical examination under anesthesia, and cystoscopy were performed. After initial nonoperative treatment, the patient underwent hysterectomy and sigmoid vaginoplasty.

MAIN OUTCOME MEASURES

The patient's primary amenorrhea was explained. Mayer-Rokitansky-Kuster-Hauser syndrome was diagnosed. Vaginal agenesis and widely separated rudimentary uterine horns were well shown by the MRI. Associated skeletal anomalies were noted. A treatment plan was initiated based on a good understanding of the anatomic defects.

RESULTS

The MRI and physical examination firmly established the diagnosis. The patient was counseled and managed conservatively at first. Hysterectomy and vaginoplasty were subsequently performed.

CONCLUSIONS

Mayer-Rokitansky-Kuster-Hauser syndrome is an unusual müllerian-duct anomaly that is a cause of primary amenorrhea. It can be confidently and noninvasively diagnosed with MRI. The MRI demonstration of vaginal, cervical, and uterine morphology contributes significantly to treatment planning and patient management.

Imaging of uterovaginal anomalies in the pediatric patient

Uterovaginal anomalies are relatively common congenital disorders whose diagnosis at a young age is important but often difficult. The various modalities currently employed for this evaluation are discussed, including MRI, the most recent available tool. The embryology of female reproductive tract anomalies is included.

Gynecologic magnetic resonance imaging

Magnetic resonance imaging (MRI) is an excellent modality with which to delineate normal anatomic structures and a variety of pathologic conditions in the female pelvis. It excels at demonstrating the extent of local tumor involvement in cases of endometrial and cervical cancer. It can help to elucidate the origin and nature of a variety of benign pelvic masses in cases where ultrasound findings are equivocal, and it is an accurate tool in demonstrating congenital abnormalities of the female reproductive tract. As technology continues to evolve, MRI will likely assume an even greater role in evaluating the female pelvis.

MRI in distal vaginal atresia

Magnetric resonance imaging in two young females with abdominal pain revealed vaginal atresia with massive hematocolpos but a normal cervix and uterine body. Information obtained with MRI was superior to ultrasound and CT and is suggested as the examination of choice prior to surgical correction.

Utero vaginal malformations: a trap for the unsuspecting surgeon

Eighteen girls with major uterovaginal malformations were admitted to the Pediatric Surgical Service over a 17-year period. The diagnosis was not suspected or delayed in more than one half of the patients. The encountered anomalies were divided into four groups: I, isolated uterovaginal malformations (UVM) (4); II, UVM with anorectal anomalies (8); III, UVM with cloacal (urogenital sinus) abnormalities (5); and IV, caudal twinning (1). Imperforate hymen, vaginal web, low vaginal obstruction, or disorders of gonadal or chromosomal development were excluded. Patients presented with an abdominal mass or distension (5), abdominal pain (4), "sciatic"-like pain (1), purulent vaginal discharge with perineal pain (1), amenorrhea (2), and a pelvic and prerectal mass (1). The introitus was reported as normal in 11 patients with vaginal atresia or agenesis by the primary physician. Diagnostic studies, in addition to clinical and endoscopic examination, included routine radiological workup, genitourinary contrast studies, pelvic and perineal sonography, computerized tomography (CT) scanning, and more recently, magnetic resonance imaging. In complicated UVM, especially vaginal duplications with unilateral atresia, the CT scan was the most helpful diagnostic tool. Laparotomy was necessary, not only for therapeutic, but diagnostic reasons; even so, complex anomalies, such as vaginal duplication with unilateral atresia and a septate uterus, could not be suspected. Treatment was directed toward the restoration of a functional uterovaginal tract and the frequently associated anorectal anomalies. A review indicated that contrary to our expectations, the major UVM occurred in children with a low imperforate anus rather than the high variety.