Imaging Diagnosis of Herlyn-Werner-Wunderlich Syndrome- An Extremely Rare Urogenital Anomaly

[(Uro)genital developmental disorders]

CLINICAL ISSUE

Congenital anomalies of the urogenital tract are common, whereas isolated developmental disorders of the genital organs are rare and varied. The type and timing of imaging to characterize these developmental disorders and the planning of any treatment are the subject of discussion. The aim of this article is to provide a brief overview of embryology, diagnostic procedures, and examples of findings.

STANDARD RADIOLOGICAL METHODS

The primary procedure for imaging the genitals is sonography, which must be performed with appropriate empathy. In addition to the genitals, the general situation of the kidneys and urinary tract should be examined, as urogenital malformations are often combined. Dedicated magnetic resonance imaging (MRI) is indicated as advanced imaging in interdisciplinary consultations. Invasive procedures, such as genitography combined with micturition cystourethrography (MCU) using X‑rays or contrast-enhanced sonography, are rarely required. Computed tomography (CT) or excretory urography play no role.

CONCLUSION

Imaging plays an important role in the assessment of genital anomalies. Knowledge of embryology facilitates anatomical understanding and the assessment of pathologies.

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.

Uterine Didelphys with Transverse Vaginal Septum – A Complex rare Müllerian anomaly

During the development of the female genital tract, any insult to the normal development process results in a set of intriguing abnormalities known as Müllerian duct abnormalities. The uterine didelphys is the second least common type of anomaly among these, which may commonly be associated with a longitudinal vaginal septum (lateral fusion defect). However uterine didelphys along with a transverse vaginal septum (lateral fusion plus resorption defect) is a very rare finding and to the best of our knowledge, thecase that we hereby report is the second one in literature.A 16-year-old unmarried girl presented with primary amenorrhoea and cyclical pain for 18months.On clinical examination and imaging, a case of uterine didelphys and transverse vaginal septum was found. Her urinary tract was normalon USG and MRI evaluation. Excision of the septum was done by abdomino-vaginal approach. The patient was discharged well.We conclude that a patient presenting with primary amenorrhea especially with cyclical dysmenorrhea with a transverse vaginal septum on examination should be thoroughly investigated for associated upper genital tract abnormalities as the treatment strategy and prognosis is largely dependent on the correct classification of the anomaly.

Herlyn-Werner-Wunderlich syndrome with borderline serous cystadenoma of the ovary: case report and literature review

Herlyn-Werner-Wunderlich syndrome, is a rare urogenital congenital anomaly. Coexisting Mullerian ducts anomalies and ovarian neoplasms are rarely reported. We present the first case of Herlyn-Werner-Wunderlich syndrome with borderline serous neoplasm of the ovary. A 29-year-old married female with primary infertility and elevated level of cancer antigen 125 (CA-125), underwent pelvic magnetic resonance imaging for evaluation which revealed uterus didelphys, obstructed right hemivagina, right renal agenesis as well as right ovarian cystic lesion. Ovary preserving laparoscopic cystectomy was performed with a pathological diagnosis of a serous borderline tumor. Although rarely reported, Mullerian ducts anomalies and uterine or ovarian remnant neoplasms can occur. These few case reports may suggest an underlying, yet to be discovered, genetic association of Mullerian ducts anomalies and development of ovarian neoplasms of various pathological subtypes.

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.

True management of Obstructed Hemi-vagina and Ipsilateral Renal Anomaly syndrome

Herlyn-Werner-Wunderlich syndrome is an unusual congenital anomaly of the female genitourinary system, which is described as uterine didelphys with Obstructed Hemi-vagina and Ipsilateral Renal Anomaly (OHIRA), also known as OHVIRA syndrome. Typical symptoms are pelvic pain, tenderness, pelvic mass due to blood collection in the obstructed hemi-vagina and uterus, and dysmenorrhea that usually begins shortly after menarche. Clinical suspicion is very important for diagnosis and correct management avoids both short- and long-term complications. Surgical removal of the vaginal septum is the main treatment method. Herein, we describe the evaluation and surgical management of a patient with OHVIRA syndrome who was diagnosed using magnetic resonance imaging and pelvic ultrasound.

Locally advanced adenocarcinoma of the cervix on uterus didelphys: a case report

In November 2013, a woman with Herlyn-Werner-Wunderlich (HWW) syndrome was diagnosed with a locally advanced left cervical adenocarcinoma. The patient’s malformation consisted of two uteri with two cervixes, a obstructed vagina, and a left renal agenesis. Classification FIGO: stage IIIa because of infiltration of the inferior third of the vagina wall. Locoregional management comprised an infrarenal lateral aortic lymphadenectomy followed by concomitant radio-chemotherapy to the pelvic (inguinal, pelvic, and infrarenal para aortic nodes) volumes. A total of 50.4 Gy were delivered (1.8 Gy/fraction/day) to the node (inguinal, pelvic, and aortic infrarenal) and pelvic volume; a concomitant boost to the primary cervical tumor and macroscopic nodes to 59.92 Gy (2.14 Gy/fraction/day) was performed. 20 Gy were delivered with intracavitary brachytherapy boost with mold technique and a pulsed-dose-rate technique due to the rarity of this uterine malformation. After 30 months of follow-up, there was no evidence of locoregional or distant recurrence.

Treatment of Virgin OHVIRA Syndrome with Haematometrocolpos by Complete Incision of Vaginal Septum without Hymenotomy

Mullerian malformations result from defective fusion of the Mullerian ducts during development of the female reproductive system and have an incidence of 2-3%. The American Fertility Society classification of Mullerian anomalies is the most commonly utilized standardized classification. The least common form of these malformations is Herlyn-Werner-Wunderlich syndrome characterized by obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). This syndrome has been described with case reports since 1922. Early diagnosis and surgery that include drainage of fluid and resection of the vaginal septum is necessary for OHVIRA to prevent late complications (i.e. pyocolpos, chronic cryptomenorrhea). Here in we report a case of Herlyn-Werner-Wunderlich syndrome that hymen has been preserved during the operation of non-fenestrated transverse vaginal septum resection with hysteroscopy.