Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) Syndrome

Multimodality imaging of acute gynecological emergencies-a pictorial essay

Gynecological emergencies can often present with a myriad of non-specific signs and symptoms, posing a diagnostic challenge to the clinician. They can be grossly divided into uterine or adnexal pathologies. Uterine pathologies can be secondary to intracavitary accumulation of blood [like in patients with transverse vaginal septum, Robert's uterus, accessory and cavitated uterine mass, unicornuate uterus with contralateral non-communicating functional horn], bleeding per vaginum [like in patients with retained products of conception, enhanced myometrial vascularity], pyometra [secondary to pelvic inflammatory disease, cervical obstruction secondary to benign and malignant causes] or complications of fibroids [like red degeneration, torsion of subserosal fibroid]. The adnexal pathologies can range from ectopic pregnancy in a urine pregnancy test (UPT) positive patient to haemorrhagic ovarian cyst, ovarian torsion, ruptured dermoid cyst and tubo-ovarian abscess in a UPT negative patient. Multimodality imaging including ultrasound (USG), computed tomography (CT) scan and magnetic resonance imaging (MRI) can narrow down the differentials and help in formulating an accurate diagnosis. The objective of this article is to familiarize the readers with multimodality imaging findings in common as well as uncommon acute gynecological emergencies and provide an algorithmic imaging approach for acute gynecological emergencies. USG is typically used as the first line diagnostic modality in diagnosis of acute gynecological emergencies. CT scan & MRI are helpful as a problem-solving tool in acute gynecological emergencies when USG findings are indeterminate.

Diagnosis of congenital oblique vaginal septum syndrome: A case report and literature review

INTRODUCTION

This report details a case of Type I oblique vaginal septum syndrome (OVSS), highlighting its complexity as a congenital uterine malformation.

CASE PRESENTATION

A 12-year-old girl presented with severe lower abdominal pain coinciding with her first menstrual period. Ultrasound revealed a septate uterus and an oblique vaginal septum, prompting an emergency hysteroscopic procedure that confirmed the diagnosis of Type I OVSS.

DISCUSSION

OVSS is a rare urogenital anomaly often diagnosed during adolescence. Common symptoms include abdominal pain, abdominal masses, and irregular vaginal bleeding. Due to its atypical presentation, OVSS is frequently misdiagnosed. Early surgical intervention is crucial to relieve pain and restore normal uterine morphology.

CONCLUSION

Diagnosing OVSS can be challenging, but early detection is vital to prevent complications such as retrograde menstruation and long-term issues.

A rare case of obstructed hemivagina with uterus didelphys and ipsilateral renal anomaly syndrome

Obstructed hemivagina and ipsilateral renal anomaly syndrome, also known as Herlyn-Werner-Wunderlich syndrome, represents a rare congenital anomaly characterized by the presence of an obstructed hemivagina with uterus didelphys and concomitant ipsilateral renal abnormalities. Typically, the clinical presentation includes cyclical abdominal pain, vaginal discharge, and/or a vaginal mass occurring post-menarche. Accurate diagnosis requires a high index of suspicion among clinicians, coupled with a comprehensive understanding of the distinctive features associated with this anomaly. Herein, we present the case of a 13-year-old female patient who complained of persistent lower abdominal pain. Magnetic resonance imaging confirmed the diagnosis of obstructed hemivagina and ipsilateral renal anomaly syndrome, and the patient was successfully treated with a laparotomy involving blood aspiration and hysterectomy. This case report highlights the significance of clinical awareness, prompt diagnosis, and timely therapeutic interventions to mitigate the adverse effects and optimize outcomes in individuals affected by obstructed hemivagina and ipsilateral renal anomaly syndrome.

Herlyn-Werner-Wunderlich syndrome: Challenges in diagnosis and management

Herlyn-Werner-Wunderlich syndrome (HWWS), also known as OHVIRA syndrome (obstructed hemivagina and ipsilateral renal anomaly) is a complex congenital malformation characterized by a triad including uterine didelphys, hemivaginal obstruction, and ipsilateral renal agenesis. In this case report, we present a case of HWWS along with the challenges in diagnosis and multi-step treatment processes. A 25-year-old woman presented to Dr. Zainoel Abidin Hospital in Banda Aceh, Indonesia with a chief complaint of lower back pain for the past six months (two months after the marriage). The patient also complained of late menstruation, followed by thick yellow vaginal discharge resembling malodorous pus occurring after menstruation. Additionally, a history of fever and pain during intercourse was reported. Vaginal examination revealed purulent fluid emerging from a pinpoint hole on the right vaginal wall. Vaginal palpation revealed a two-branched uterus, along with a palpable cystic mass on the right vaginal wall. Ultrasound examination indicated the presence of the right and left hemi-uteri, measuring 4.7x1.35 cm and 5.7x1.26 cm in size, respectively with both ovaries appearing normal. Fluid accumulation was observed in the right hemivagina, while the left kidney exhibited normal features, and the right kidney showed signs of hypoplasia. The patient was diagnosed with uterus didelphys, fluid accumulation in the hemivagina, and right kidney hypoplasia. Magnetic resonance imaging (MRI) confirmed uterus didelphys and revealed narrowing of the right hemivagina, suggestive of HWWS. Hysteroscopy was performed to resect the vaginal septum with laparoscopic guidance, along with drainage of hematocolpos, pyocolpos and placement of an intracervical mold. Despite HWWs having conservative gradual management, it was opted to perform vaginal septum resection, hematocolpos and pyocolpos drainage and placement of an intracervical mould in this case, in order to relieve symptoms and restore the reproductive and sexual functions.

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.

Challenges in Diagnosing Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome: Case Report of a Rare Condition

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a very rare type of Müllerian duct anomaly. Cases of OHVIRA syndrome have varied clinical manifestations. We report the case of a 15-year-old virgin with endometrial cyst and OHVIRA syndrome. Magnetic resonance imaging confirmed the diagnosis of OHVIRA syndrome. A salpingo-oophorectomy laparotomy was performed, but the patient refused to perform a septotomy or vaginal septal resection. We compared the cases of OHVIRA syndrome that we found with several other reports. The complaints of patients with OHVIRA syndrome may vary from one another, with different histories. Imaging investigations can confirm the diagnosis. The main treatment in OHVIRA syndrome is intended to alleviate symptoms that appear.

Usefulness of Endoscopy for Female Genital Plastic Surgery: A Series of 4 Cases with Genital Malformations

BACKGROUND Female genital plastic surgery is rare and requires specific patient anatomical information to successfully carry out the appropriate procedure for each female genital malformation. Performing endoscopic surgery can increase the amount of information intraoperatively. We report on our experience of proactively using endoscopy to obtain additional intraoperative information to perform the appropriate surgical procedure suited to each female genital malformation, and evaluate the usefulness of concurrent endoscopy for improved surgical outcomes. CASE REPORT In Case 1, an 18-year-old woman underwent colpoplasty for Mayer-Rokitansky-Küster-Hauser syndrome using the laparoscopic Davydov procedure, wherein the pelvic peritoneum was precisely dissected using light from a laparoscope as a guide. In Case 2, a 25-year-old woman presented with suspected Wunderlich syndrome. Since the junction of the affected uterus with the normal uterus was unclear on preoperative imaging, we performed total hysterectomy of the affected uterus after identifying the anatomical structure by hysteroscopy. In Case 3, a 12-year-old girl with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome underwent transvaginal fenestration of the obstructed vaginal wall to prevent future menstrual molimen. Simultaneous hysteroscopy and laparoscopy allowed us to determine the location of a unilateral vaginal wall cyst and drain it safely. In Case 4, a 29-year-old woman had OHVIRA syndrome, and we conducted a laparoscope-based fenestration of the cervical canal safely and accurately. CONCLUSIONS Our series showed how, even for gynecological malformations without established standards for surgical procedure, a safe and minimally invasive surgery can be ensured if the amount of anatomical information is increased via endoscopy.

A Rare Case of Massive Hematometra with a Tubo-ovarian Abscess in a 16-year-old Female

Imperforate hymen is a congenital defect of the lower genital tract and specifically the vagina. The examination of a neonatal can be quite helpful to avoid a multitude of complications in puberty like hematocolpos and tubo-ovarian abscess.

We present the case of a 16-year-old who presented to the emergency department with fever (37.9° C), which was progressive the last two days, swollen abdomen, and pain in the lower abdomen. She also had a one-year history of cyclic abdominal pain. The patient had primary amenorrhea, the secondary sexual characteristics were normal for her age (Tanner III), and there was no family history of primary amenorrhea. The physical and ultrasound examination revealed an imperforate and bulging vaginal membrane and a multilocular adnexal mass, respectively.

Every doctor should suspect this medical condition when there is a triad of symptoms like cyclic lower abdominal pain, primary amenorrhea, and swollen abdomen. Early diagnosis of an imperforate hymen can prevent serious complications for young patients.

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.