Teaching File

Institute of Radiology "P. Cignolini" - University of Palermo, Italy

Hematometrocolpos in uterus didelphys
associated with renal agenesis


April 5, 1996


Clinical History

Female, 12 year old.
She complained of an abdominal pain in concomitance with the menstrual cycle; the symptomatology remitted at the end of every cycle.
She occasionally had dysuria. A lower abdominal palpable and painful mass was found at physical examination.
A compression by an extrinsecal mass on the right wall of the upper vagina was observed at the vaginalscopy.
She underwent US examination which showed an oval, liquid mass, with low-level echoes in the pelvis and the emptiness of the right renal fossa.
MRI examination was then performed.

MR Findings

  • Coronal SE T1W image (TR= 480/600, TE=25, NEX=3 )
  • Axial FSE T2W image (TR= 2500, TE=110, NEX=3, ETL= 11 )
  • Sagittal FSE T2W image (TR= 2500, TE= 110, NEX=3, ETL= 11)

    Coronal T1W image shows the characteristically hyperintense hematometrocolpos (*), the agenesis of the right kidney and the vicar hypertrophy of the controlateral kidney (K).
    Axial FSE T2W image confirms the presence of a right hematometrocolpos (*) and shows a thin, linear, high signal structure on the left, which indicates the presence of another uterus with its endometrium (arrow). Two separate cervices, joining together at the level of the vagina, were found on the caudal scans.
    Sagittal T2W image shows a transverse vaginal septum (arrow), obstructing the right cervix and determining the hematometrocolpos (*).


    Diagnosis

    Uterus didelphys with right hematometrocolpos. The diagnosis was proven by the drainage of the hematometrocolpos.


    Discussion

    The association of genital and urinary malformation is well known, with a frequency of 50 - 80%. The embryological development of the urinary and genital tract is interdependent and the renal agenesis is always associated with the genital tract malformation.
    Uterus didelphys results from the nonfusion of the mŸllerian ducts and the persistence of the intervaginal septum.
    Vaginal obstruction is due to the partial reabsorption of the septum.
    The MRI appearance of the uterus didelphys consists of double, separate, uterus, cervix and upper vagina. A concomitant right hematometrocolpos, due to the obstruction of the vaginal septum, may be detected.
    The clue for the diagnosis is provided by the presence of a double endometrium, one of which usually appears very thickened because of the hematometra. On the other hand hematometra and hematocolpos are easily recognizable by the increased signal intensity on T1 e T2 weighted images.
    Either sagittal or coronal images may be very useful for the demonstration of the vaginal septum, obstructing the cervix.
    In our case both US and MRI detected the mass, but only MRI was able to demonstrate the malformation and the vaginal septum, which had determined the hematometrocolpos.


    REFERENCES

    1) Gilsanz V, Cleveland RH Reid BS. Duplication of the mŸllerian ducts and genitourinary malformations. Radiology 1982; 144: 791-801.

    2) Mintz MC, Thickman DI, Gussman D, Kressel HY: MR evaluation of uterine anomalies AJR 1987; 148:287-290.

    3) Reuter KL, Daly DC, Cohen SM: Septate versus bicornuate uteri: errors in imaging diagnosis. Radiology 1989; 172: 749-752.

    4) Carrington BM, Hricak H, Nuruddin RN, Secaf E, Laros Jr RK, Hill EC. MŸllerian duct anomalies: MR imaging evaluation. Radiology 1990; 176: 715-720.

    5) AciŽn P, Ruiz JA, Hernandez JF, Susarte F, Del Moral AM. Renal agenesis in association with malformation of the female genital tract. Am J Obstet Gynecol 1991; 165:1368-70.


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    University of Palermo, Institute of Radiology "P. Cignolini"

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