Uterus didelphys with unilateral obstructed hemivagina and renal agenesis on the same side

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.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system

STUDY QUESTION

How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies?

SUMMARY ANSWER

The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system.

WHAT IS KNOWN ALREADY

Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment.

STUDY DESIGN, SIZE AND DURATION

The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies.

MAIN RESULTS AND THE ROLE OF CHANCE

The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system.

LIMITATIONS, REASONS FOR CAUTION

The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare.

WIDER IMPLICATIONS OF THE FINDINGS

The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research.

STUDY FUNDING/COMPETING INTERESTS

None.

Müllerian anomalies

The development of the Müllerian system and the female reproductive tract is a complex process involving an integrated series of events with significant potential for abnormal development and anomalies. Structural anomalies of the female reproductive tract may be isolated or occur in association with other congenital anomalies, including renal or bladder anomalies and anorectal malformations. Although rare in occurrence, it is important to be familiar with these conditions for appropriate diagnosis, management, and possible referral. The diagnosis, management, and surgical treatments of female reproductive tract anomalies in girls and young women have advanced with improvements in diagnostic imaging techniques, surgical and nonsurgical techniques and innovative instrumentation and developments.

Müllerian duct anomalies: comparison of MRI diagnosis and clinical diagnosis

OBJECTIVE

The objective of our study was to assess agreement between MRI and clinical diagnosis of müllerian duct anomalies and identify causes of discrepancy.

MATERIALS AND METHODS

Images of 103 patients who underwent MRI for suspected müllerian duct anomaly were reviewed. Imaging included axial T1-weighted spin-echo (SE) (TR/TE, 500/10) and sagittal, long-uterine-axis, and short-uterine-axis T2-weighted fast SE (5,000/80) sequences. Agreement between original MRI diagnosis and final clinical diagnosis was assessed using the kappa statistic. Two radiologists retrospectively reviewed all cases with inconsistent MRI and clinical diagnoses to identify causes of discrepancy.

RESULTS

There was excellent agreement (kappa = 0.8) between MRI and clinical diagnoses of müllerian duct anomalies. For evaluation of the uterus, there was agreement in 83 of 103 patients, disagreement in 15 of 103, and agreement could not be determined in five of 103 because of uncertain MRI diagnoses. The main causes of disagreement were MRI diagnosis of septate uteri with two cervices clinically diagnosed as didelphic, partial septate uteri clinically diagnosed as arcuate, and complex anomalies with features of more than one class. The main difficulties for MRI were the detection of small uteri or remnants, characterization of cervical dysgenesis and rare anomalies, overestimation of cervical mucosal folds, characterization of anomalies in the presence of fibroids, and delineation of vaginal abnormalities.

CONCLUSION

Despite excellent agreement between MRI and clinical diagnoses of müllerian duct anomalies, there are discrepancies and pitfalls resulting mostly from the absence of a precise and integrated classification scheme, unfamiliarity with rare and complex entities, and suboptimal depiction of some structures on MRI.

Asymmetric lateral distribution of obstructed hemivagina and renal agenesis in women with uterus didelphys: institutional case series and a systematic literature review

OBJECTIVE

To investigate if an asymmetry exists in the lateral distribution of obstructed hemivagina and renal agenesis in women with uterus didelphys.

DESIGN

All English-language medical papers on uterus didelphys, obstructed hemivagina, and associated renal agenesis published from 1980 to 2005 and identified by Embase, Medline, and Pubmed database searches were retrieved. In addition, 41 institutional cases are described. We considered articles in which the presence of a uterus didelphys, obstructed hemivagina, and renal agenesis was assessed as well as the affected side. Data were stratified based on surgical confirmation or imaging evidence of the specific müllerian anomaly. Two authors abstracted data independently on standardized forms, and the combined frequency of right- and left-side malformation subtype was computed.

RESULT(S)

Thirty-six reports including 138 subjects were selected. Unilateral hemato- or pyocolpos was on the right side in 91 patients (66%). Among the 125 cases with surgical demonstration of the müllerian malformation subtype, 81 (65%) had the anomaly on the right side. In the institutional series, lesions were on the right side in 25 cases (61%). Combining the above figures, the observed proportion of right-sided anomalies (116/179) was 65% (95% CI 57% to 72%).

CONCLUSION(S)

Left-right asymmetry may be induced before organogenesis, establishing differences in morphogenesis on the left and right sides of the embryo.

Uterus didelphys with unilateral imperforate hemivagina and ipsilateral renal agenesis

Eight patients with a double uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis are described. The most common clinical presentation was that of the onset of pelvic pain and dysmenorrhea, in association with the finding of a pelvic mass. In seven patients, a window was created between two vaginae by transvaginal route. In one patient, the blind vagina with hematocolpos and attending uterus were extirpated by an abdominal approach. The postoperative courses were uncomplicated in all patients. A greater awareness of this syndrome should lead to accurate diagnosis. Excision of the obstructing vaginal septum offers a complete relief of symptoms while preserving reproductive capacity.