Clinical Case.11.12

8/6/2019 Clinical Case.11.12

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Clinical Case11.12.2008


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General

Girl 11 years old

Progressive lower abdominal pain since 3 days

No fever

Ultrasound: No right kidney at the right kidney fossa.

Big cyst mass in the pelvis may be ovarian cyst orright kidney ectopic


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Ultrasound


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Ultrasound


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Ultrasound


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Overview

The incidence of unilateral renal agenesis ascertained atautopsy averages between 1/600 1/1,200.Concomitant genital anomalies are very common.

In males, anomalies of the genital tract are less frequentand functionally less striking, the most common beingcryptorchidism .

In females, the incidence of associated genitalanomalies has been conservatively estimated as 50%. Inmost women, the genital anomaly consists of somedegree of duplication of the uterus, cervix, and/or vagina,and less commonly some form of partial


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Embryology

Duplication of the female reproductive

tract results from a lack of fusion of the

paired mullenian ducts which appear atthe sixth week of embryonic development.

The mullenian ducts develop just lateral to

the mesonephnic (urinary) ducts, which

have been postulated to act as a guide tothe growth of the mullenian ducts


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Hematocolpos


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Case 1

This young female patient presented with

primary amenorrhoea and abdominal mass.

Ultrasound images reveal hypoechoic contents

s/o fluid distending the uterus and vagina. Fineparticulate debris is seen within the fluid (blood).

These findings suggest vaginal outflow

obstruction due to imperforate hymen. Nearly

800 ml. of blood was drained during surgery onthis patient.

Images courtesy of Dr. Arun Mahajan,


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Case 2

14-year-old girl presented to hospital's

emergency department with a complaint of lower

abdominal pain.

Her history included an emergency departmentvisit 25 days earlier for a urinary tract infection

and an ongoing workup for a large right-sided

adnexal mass by a private practice gynecologist.

She described her pain as "on and off" for2

months and as increasing in severity


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Transabdominal sonogram (transverse view) shows large well-defined

mass, which was later identified as markedly distended uterus.


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Hematometrocolpos in 14-year-old girl who presented with lower

abdominal pain. Axial CT image through lower pelvis shows markedly

distended cervicovaginal canal.


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Axial CT image through uterine corpus shows incomplete longitudinal

septum of bicornuate uterus. Examination under anesthesia revealed

imperforate hymen. Hymenotomy was performed, yielding

approximately 500 mL of coagulated blood. Repeat pelvic sonography

on the first postoperative day revealed a bicornuate uterus


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Obstructed hymen. Sagittal T1-weighted spin-echo image (500/8)

shows a dilated hematometrocolpos. The obstruction is at the level of

perineum (arrow).


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DDx

The main differential diagnosis is that of aGartners cyst on mesonephnic duct remnant.Gartners cysts occur anywhere between thehymen and the ovary along the vagina and uterinewalls or the broad ligament. They represent anincomplete normal resorption of the mesonephnicduct in the female and may communicate with thevagina or uterus at any level.

Gartners cysts are lined with a single layer ofcuboidal epithelium, while vaginal duplicationshave a stratified squamous epithelial lining.Gartners cysts do not attain the size of a

hematocolpos and do not contain blood.Ipsilateral renal agenesis may also occur withGartners duct cysts


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Documents

Clinical Case.11.12