Hysterosalpingography and Ultrasonography Features of Herlyn-Werner-Wunderlich Syndrome Detected during Infertility Workup

The Herlyn-Werner-Wunderlich syndrome (HWWS) is a very rare congenital anomaly of the urogenital tract. It is characterized by a combination of didelphys uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis. MRI imaging is usually used for diagnosis; however, the authors present a case of HWWS diagnosed by ultrasonography (HSG) and hysterosalpingography (HSG) in a 22-year-old lady who has undergone an imaging workup of infertility.

Prenatal Diagnosis of Fetal Obstructed Hemivagina and Ipsilateral Renal Agenesis (OHVIRA) Syndrome

Background: Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome, also known as Herlyn-Werner-Wunderlich syndrome, is a rare syndrome characterized by the triad of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. Most cases of OHVIRA have been reported in adolescents or adults. Gartner duct cysts, including those manifesting as vaginal wall cysts, are also rare. Fetal OHVIRA syndrome and Gartner duct cysts are difficult to diagnose. Case Presentation: Here, the authors report a case of combined OHVIRA and Gartner duct cyst diagnosed prenatally by ultrasonography, along with a brief review of the relevant published reports. A 30-year-old nulliparous female was referred to our institution at 32 weeks’ gestation for fetal right kidney agenesis. Detailed ultrasonographic examinations using 2D, 3D, and Doppler ultrasounds revealed hydrocolpometra, and uterus didelphys, with a normal anus and right kidney agenesis. Conclusions: When encountering female fetuses with ipsilateral renal agenesis or vaginal cysts, clinicians should be aware of OHVIRA syndrome and Gartner duct cysts and perform systematic ultrasonographic examinations for other genitourinary anomalies.

Acute abdomen: Unusual presentation of Herlyn-Werner Wunderlich syndrome

Introduction and importance

The presentation of an acute abdomen has a wide range of differentials. Developmental anomalies are rarely considered as part of the clinical reasoning process due to it being a mimicker of other commoner diseases. The importance of considering such anomalies and recognizing them early is essential in order to prevent complications, such as infertility.

Case presentation

Our case report presents an approach to a female of pediatric age complaining of right lower abdominal pain mimicking appendicitis. The physical examination and clinical findings were also in line with appendicitis. Thus, the initial work-up focused on that as the top differential. Due to the patient being female, other work-ups were conducted in order to rule out gynecological conditions such as a pelvic ultrasound. The ultrasound findings changed the approach, warranting a CT and MRI. The subsequent diagnosis was Herlyn-Werner-Wunderlich Syndrome. Intervention involved incision and dilation of the vaginal septum as it is the most effective and least traumatic method. On follow-up, the patient's symptoms resolved.

Clinical discussion

Rare diseases can mimic common diseases. Clinically, findings of other work-ups indicated a completely different diagnosis than originally suspected. Clinical reasoning thus shifted the focus to another approach and intervention.

Conclusion

Clinical features of appendicitis, a clinical diagnosis, were most evident. An inappropriate management may have ensued if investigations were not conducted. Ultimately, the case report illustrated the importance of radiological investigations in an acute abdomen.

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An unnecessary appendectomy was avoided by considering acute abdomen mimickers.

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The usual ‘acute abdomen’ should include unusual developmental anomalies.

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Early recognition of rare syndromes, such as HWW syndrome, prevents complications.

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Preserving fertility in HWW syndrome is key and is preventable if detected early.

Ultrasound Diagnosis of Abnormalities in the Development of the Uterus and Vagina with Impaired Menstrual Blood Flow in Girls

The objective: to study and analyze the indicators of the diagnostic informativeness of the echographic study of anomalies in the development of the uterus and vagina with impaired outflow of menstrual blood in girls. Materials and methods. For the study, a group of 37 patients (n=37), from 10 to 19 years old, was selected, who were divided into 2 subgroups: 1 subgroup – patients with doubling of the uterus and vagina without disturbing the outflow of menstrual blood (n=25), 2 subgroup – patients with doubling uterus and vagina with partial aplasia of one vagina (n=12). Most of the subjects – 26 girls (10,3 %) – applied for a referral to clarify the diagnosis, 11 (29,7 %) – without complaints from the genitals for differential diagnosis. Results. At vaginoscopy at all patients the mucous membrane of pink color with well expressed folding. According to ultrasound of the pelvic organs in 1 subgroup in 17 patients the vagina was divided into 2 parts full, and in 8 – incomplete septum, two uteruses were located, parallel to each other, the contours were smooth, clear, M-echo was determined in both uteruses, two cervix with cervical canals. In subgroup 2, 9 patients showed protrusion of different sizes of one of the walls of the vagina, 2 patients in the lateral, 1 – in the upper lateral zone of the vagina was determined by a punctate hole with an inflammatory roller – fistulous entrance to the second vagina. In all patients from the side of the aplasia of the vagina, the uterine cavity is expanded from 10 to 25 mm, filled with echonegative contents. The reliability of the results of ultrasound scanning of anomalies of genital development is equal: the sensitivity of the method – 84,0 %, specificity – 90,9 %, accuracy – 89,1 %. Conclusions. Manifestation of malformations of the genitals with impaired outflow of menstrual blood occurs at puberty, as after menarche above the aplastic segment of the genital tract accumulates menstrual blood and tumor formation, accompanied by characteristic clinical manifestations. Diagnosis of this pathology is quite complex, which can lead to errors in determining the nature of the pathological condition and, as a consequence, unwarranted surgery. Thus, the need to further improve the methods of diagnosis and management of patients with doubling of the uterus and vagina with impaired menstrual blood flow remains relevant, which will identify diseases at an earlier age or immediately after the appearance of complaints and symptoms.

Herlyn Werner Wunderlich Syndrome with Vagino-umbillical Fistula: A Most Unique Presentation

The Herlyn–Werner–Wunderlich (HWW) syndrome is an uncommon Mullerian duct anomaly composed of a triad of obstructed hemivagina, renal agenesis, uterine didelphys with a prevalence of <1/1,000,000 females. Aside from its usual presentation of cyclic hypogastric pain and abdominal mass, there has been no other reported case in literature of the syndrome presenting with a vagino-umbilical fistula. Presented here is a unique case of a 35-year-old woman presenting with purulent, foul-smelling discharge extruding from a fistula on her umbilicus and her vagina associated with a tender hypogastric mass. Three-dimensional transvaginal ultrasonography aided the diagnosis of HWW syndrome with a concomitant vagino-umbilical fistula. Excision of the vaginal septum together with antibiotic coverage resolved her symptoms. The syndrome’s embryopathogenesis, classification, diagnostics, definitive surgical management and other issues during follow up are discussed.