Urethro vaginal reflux – A case report

Urethro

o vaginal reflux - A

A case reeport

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Case Report

Urethro vaginal reflux e A case report*

Suryakant Choubey, Nagendra Tripathy*, Pavan K.V., A. Nagaraj Rao,A. Mohan

St.John's Medical College, Koramangala, Bangalore, Karnataka 560034, India

a r t i c l e i n f o

Article history:

Received 12 December 2013

Accepted 30 July 2014

Available online xxx

Keywords:

Day time incontinence

Paediatric incontinence

Urethro vaginal reflux

Post micturition dribbling

* Presented as a poster in SZ-Usicon 2013* Corresponding author. Office of Dept of U

560034, India.E-mail address: [email protected] (N

Please cite this article in press as: Choudx.doi.org/10.1016/j.apme.2014.07.016

http://dx.doi.org/10.1016/j.apme.2014.07.0160976-0016/Copyright © 2014, Indraprastha M

a b s t r a c t

Objective: The purpose of this study was to describe a case of day time incontinence due to

Urethro vaginal reflux.

Methods: This is a case report of a 18 yr old girl who had presented to the out patient

department with day time incontinence and post void dribbling. Ultrasound suggested an

urethral diverticulum but the actual diagnosis was arrived by performing a MCU which is

suggestive of a Urethro Vaginal reflux.

Results: She improved significantly by proper toilet training and is predominantly dry at 1 yr

follow-up.

Conclusions: Urethro vaginal reflux can produce vaginal distension that is sonographically

identical to obstructive hydrocolpos and may present with day time incontinence in young

girls. This may be due to dysfunctional voiding issues. Postvoid sonography allows proper

diagnosis and it can be treated by early clinical suspicion, proper diagnosis and advice.

Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Urethro Vaginal reflux is a condition where the voided urine

refluxes into the vagina due to anatomical or pathological

causes.1

It is known to be a cause of incontinence in the paediatric

age group.

Hydrocolpos is Commonly due to an anatomical obstruc-

tion like Imperforate hymen, Vaginal septum or Hypoplastic

vagina.

Gross distention of the vagina due to refluxed urine has

been rarely described.

We report one such rare case of adult urethro vaginal reflux

with classical manifestations.

held in Mysore.rology, In-patient Block

. Tripathy).

bey S, et al., Urethro va

edical Corporation Ltd. A

2. Case report

2.1. History

A 18 yr old young unmarried girl presented to the outpatient

department with complaints of day time incontinence of

urine. She is predominantly dry at night time.

She had no other urological complaints. Her

Menstrual cycles were regular and normal. There was no h/o

Neurological/Psychiatric illness. No h/o Trauma/

Instrumentation.

2.2. Examination

Abdominal, genital and rectal examination e Unremarkable.

, St.John's Medical College, Koramangala, Bangalore, Karnataka

ginal reflux e A case report, Apollo Medicine (2014), http://

ll rights reserved.

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http://dx.doi.org/10.1016/j.apme.2014.07.016



Fig. 1 e Contrast filled Urinary bladder just before the Micturating Cysto Urethrogram to rule out any fistula.


2.3. Investigations

Complete HaemogrameNormal, RBSe 111, S.Creatininee

0.8, Electrolytes e Normal, Urine routine e 8e10 WBC,

Urine C/s e No growth.

UFRe voided volumee 369ml, max flowe 26.8, Avg flowe

17.8, PVR e 16 ml.

Ultrasound abdomen e Normal Kidneys and Upper tracts,

Urinary bladder e Normal, Hydrocolpos þ

Voiding cystourethrography e

Filling phase e Normal, No extravasation (Fig. 1).

Fig. 2 e MCU film demonstrating F

Please cite this article in press as: Choubey S, et al., Urethro vadx.doi.org/10.1016/j.apme.2014.07.016

Early voiding phase e progressive gross distention of the

vagina due to retrograde filling as the bladder emptied

(Fig. 2).

Late voiding phase e progressive complete evacuation of

the vagina. No vesicoureteral reflux (VUR) was seen

bilaterally.

2.4. Management

Instructions on proper voiding form a key element in the

management of UVR.

Toilet training:

, Sit steadily on the toilet brim, legs fully supported.

illing of vagina with contrast.




Fig. 3 e CT KUB showing distension of vagina with contrast.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e4 3

, Keep the legs well apart.

, Lean the trunk forward (as much as you can) making

the pelvis tilt forward and the urinary stream more

vertical.

, Separate the labia before voiding.1

Fig. 4 e CT reconstruction showing contrast in b


, At the end of voiding, use the toilet paper to press and

lift the perineum forward/upward (from the base of the

vagina and away from the rectum) to empty urine from

the vagina.

The patient got completely cured with this simple

advice.

oth bladder and vagina without any fistula.





3. Discussion

Urethro Vaginal Reflux Causes retrograde filling of the vagina

during micturition causing Hydrocolpos2 and post void in-

continence of urine. It can occur in both supine and the up-

right positions.

It is Common in pre pubertal girls; But may also be seen in

post pubertal girls and women.

Hydrocolpos can be complete, partial or minimal. Gross

distension is relatively uncommon.

3.1. Aetiology

, A relatively horizontal vagina in the prepubertal age,

, Tightly apposed labia in obese subjects,3

, Labia minora adhesions,3,4

, Hypospadias and

, Spastic pelvic floor muscles5 (as in cerebral palsy)

3.2. Presentation

, Urinary incontinence3

, Recurrent UTI1

, Bed wetting3

, Vulvo-vaginitis1

, Irritation of the genitalia

, Foul smell and

, Vaginal discharge

The UTI may be real or due to contamination of urine by

the vaginal flora.1,6,7 The urogenital tract anatomy is usually

normal for age.

3.3. Management

Instructions on proper voiding form a key element in the

management of UVR.3 With proper assistance, the condition


can be entirely cured by non pharmacological and non surgi-

cal methods.3

4. Conclusion

Vesicovaginal reflux can produce vaginal distension that is

sonographically identical to obstructive hydrocolpos and may

present with day time incontinence in young girls. Postvoid

sonography allows proper diagnosis and it can be treated by

early clinical suspicion, proper diagnosis and advice. Even

though it most commonly occurs in young girls, the urologist

should consider it as a differential diagnosis in older girls and

women with incontinence as it may present late in the adult

hood (Figs. 1e4).

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Linshaw M. Controversies in childhood urinary tractinfections. World J Urol. 1999;17:383e395.

2. Schaffer RM, Taylor C, Haller JO, Friedman AP, Shih YH.Nonobstructive hydrocolpos: sonographic appearance anddifferential diagnosis. Radiology. 1983;149:273e278.

3. Stannard MW, Lebowitz RL. Urography in the child who wets.AJR Am J Roentgenol. 1978;130:959e962.

4. Capraro V, Greenberg H. Adhesions of the labia minora: a studyof 50 patients. Obstet Gynecol. 1972;39:65e69.

5. Saxton H, Borzyskowski M, Mundy A, Vivian G. Spinning topurethra: not a normal variant. Radiology. 1988;168:147e150.

6. Kelalis P, Burke E, Stickler G, Hartman G. Urinary vaginal refluxin children. Pediatrics. 1973;51:941e943.

7. Butcher C, Donnai D. Vaginal reflux and enuresis. Br J Urol.1972;45:501e502.


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Health & Medicine

Urethro vaginal reflux – A case report