1. Case Presentation
NEW ENGLAND SOCIETY OF INTERVENTIONAL RADIOLOGY (NESIR) Sept 12th, 2016
Department of Interventional Radiology
Harshna Vadvala, MD
Steven Dawson, MD
Peter Mueller, MD

2. Case
38 y.o. female presented to MGH ED with 10/10 right sided abdominal pain since 3 AM that morning. Complaint of increased non-foul- smelling vaginal discharge.
PMH – GYN: amenorrhea to oligomenorrhea. No h/o STI or PID. Sexually inactive for 1 year.
Vitals: BP 105/66 mm Hg, HR 88 bpm, T 98.3 F.
Physical exam:
Abdomen- RLQ palpable mass, + tender and + guarding. No rebound.
Labs: WBC 14.

3. Question: 1
38 yo F, G0, presents to the ED with RLQ pain. Per abdomen exam revealed palpable mass with tenderness and guarding. WBC 14. BP 105/66 mm Hg. T-98.3 F. What is the next step ? US
CT abdomen-pelvis with contrast
MRI
Surgical exploration

4. Answer: 1
38 yo F, G0, presents to the ED with RLQ pain. Per abdomen exam revealed palpable mass with tenderness and guarding. WBC 14. BP 105/66 mm Hg. T-98.3 F. What is the next step ? US
CT abdomen-pelvis with contrast
MRI
Surgical exploration

5. CT scan with contrast

6. CT scan with contrast

7. Question: 2
CT scan showed 8 cm right tubo-ovarian abscess (TOA) and a mullerian duct anomaly (MDA). Which type of MDA was detected ?
Type II B- Unicornuate non communicating
Type IV- Bicornuate
Type V A- Septate complete
Type III- Didelphus

8. Answer: 2
CT scan showed 8 cm right tubo-ovarian abscess (TOA) and a mullerian duct anomaly (MDA). Which type of MDA was detected ?
Type II B- unicornuate non communicating
Type IV- Bicornuate
Type V A- Septate complete
Type III- Didelphus

9. The American Fertility Society Classification of Mullerian Anomalies

10. Question: 3
Which of the following is not associated with Mullerian duct anomalies ?
Renal agenesis
Duplex kidney
Congenital megaureter
Crossed fuse renal ectopia

11. Answer: 3
Which of the following is not associated with Mullerian duct anomalies ?
Renal agenesis
Duplex kidney
Congenital megaureter
Crossed fuse renal ectopia

12. Question: 4 How will you manage the right TOA ? US guided aspiration
US guided drain placement
CT guided aspiration
CT guided drain placement

13. Question: 4 How will you manage the right TOA ? US guided aspiration
US guided drain placement
CT guided aspiration
CT guided drain placement

14. CT guided Right TOA drain placement
8 Fr Dawson-Mueller in right TOA using tandem trocar technique.
Drained 20 cc greenish pus.

15. Management and Follow-up
Interim management
Cefoxitin, Doxycycline and Flagyl IV
Follow up
WBC downtrending: 10 (12)(15)(18)
Micro: negative for aerobic, anerobic, fungal and mycobacterial organism
Bloor culture: negative over 5 days

16. Question: 5
S/p IR drain in right TOA with reduced RLQ pain. Persistent endocervical abscess. WBC 15(14). BP 105/66 mm Hg. T- 101 (98.3) F. What is the next best step ?
MRI
Laproscopy
Exam under anesthesia (EUA) & Per vaginal drainage
Dilatation & curettage (D & C)

17. Answer: 5
S/p IR drain in right TOA with reduced RLQ pain. Persistent endocervical abscess. WBC 15(14). BP 105/66 mm Hg. T- 101 (98.3) F. What is the next best step ?
MRI
Laproscopy
Exam under anesthesia (EUA) & Per vaginal drainage
Dilatation & curettage (D & C)

18. Post contrast
T2 sag
Post contrast
Post contrast

19. Restricted on DWI - abscesses
ADC
Right tubo-ovarian absces
Endocervical abscess

20. Endometriosis
T1 axial
T2 axial: Shading sign

21. Herlyn-Werner-Wunderlich (HWW) syndrome
Introduction:
Mullerian duct anomalies (MDA) - prevalence of 2% to 3%, incidence of 1/ among fertile women.
Herlyn-Werner-Wunderlich (HWW) syndrome, is a rare anomaly characterized by a triad - didelphys uterus (Type III MDA) , obstructed hemivagina and ipsilateral renal agenesis
AKA- Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA)
Clinical presentation:
Usually after menarche with pelvic pain due to the obstructed hemivagina.
There may be a palpable pelvic mass.

22. Illustration
Herlyn-Werner-Wunderlich syndrome (C) Drawing illustrates the triad. A 15-years-old girl presenting the triad of didelphys uterus (class III MDA), an obstructed right hemivagina (class I MDA), and ipsilateral renal agenesis. (A) Axial turbo spin-echo T2 weighted MR image (B) Axial turbo spin-echo T1 fat-saturated weighted MR image showing centrally a wide hematocolpos (asterisk), corresponding to the obstructed right hemivagina. On the left side the uterus normally communicating with non-obstructed hemivagina.
Herlyn-werner-wunderlich syndrome: MRI findings, radiological guide (two cases and literature review), and differential diagnosis. Del Vescovo R et al. BMC 2012.

23. EUA and per vaginal drainage
Only 1 cervix was visualized along with a right side bulge
US guided needle drainage - 22 gauge spinal aspiration through the vaginal epithelium at 7 o'clock from the visualized cervix toward the visualized pelvic collection. Total 8cc of purulent fluid drained.

24. Question: 6
Which of the following is not usually a laproscopic treatment for Herlyn-Werner-Wunderlich (HWW) syndrome ?
Drainage of hematocolpos/hematometrocolpos
Hemihysterectomy
Septectomy
Marsupialization of the blind hemivagina

25. Question: 6
Which of the following is not usually a laproscopic treatment for Herlyn-Werner-Wunderlich (HWW) syndrome ?
Drainage of hematocolpos/hematometrocolpos
Hemihysterectomy - preserve the obstructed uterus as there is equal chances of pregnancy
Septectomy
Marsupialization of the blind hemivagina

26. Role of IR in Mullerian duct anomalies
In adjunct to hysteroscopy: otherwise limited role.
In the case of a failed laparoscopic-assisted resection of a unicornuate non-communicating horn- US-guided tract dilatation.
Asherman syndrome - where dense synechiae obstruct access to the tubal ostium, a wire can be inserted transvaginally into the fallopian tube to safely direct the hysteroscopic dissection.
Cervical stenosis- an ultrasound-guided puncture into an occluded endocervical canal followed by balloon catheter angioplasty where standard attempts at cervical dilatation are unsuccessful.
Müllerian duct anomalies: from diagnosis to intervention. Chandler TM et al.
Br J Radiology Dec.

27. Type II B Bicornuate non communicating horn
A 22-year-old with intense menstrual pain.
(a) Hysterosalpingogram reveals filling of the left horn (arrow) but not the obstructed right horn of unicornuate uterus.
(b & c) Intraoperative ultrasound-guided needle is advanced into the cavity and dilatation of the tract is performed. a. b. c.
Müllerian duct anomalies: from diagnosis to intervention.
Chandler TM et al. Br J Radiology Dec.

28. References
Mullerian duct anomalies: imaging and clinical issues. Troiano RN et al. Radiology Oct;233(1): Epub 2004 Aug 18.
Herlyn-werner-wunderlich syndrome: MRI findings, radiological guide (two cases and literature review), and differential diagnosis. Riccardo Del Vescovo,1 et al. BMC Med Imaging. 2012; 12: Mar 9. doi: /
Herlyn-Werner-Wunderlich syndrome: uterus didelphys, blind hemivagina and ipsilateral renal agenesis. Sonographic and MR findings in 11 cases. Orazi C1, et al. Pediatr Radiol Jul;37(7): Epub 2007 May 15.
Case 94: Uterus didelphys with obstructing hemivaginal septum and ipsilateral renal agenesis. Madureira AJ et al. Pediatr Radiol Jul;37(7): Epub 2007 May 15.
Uterus didelphys associated with obstructed hemivagina and ipsilateral renal agenesis: MR findings in seven cases. Tanaka YO et al. Abdom Imaging Jul-Aug;23(4):
Successful pregnancy following surgery in the obstructed uterus in a uterus didelphys with unilateral distal vaginal agenesis and ipsilateral renal agenesis: case report and literature review. Altchek A et al. J Pediatr Adolesc Gynecol Oct
Herlyn–Werner–Wunderlich syndrome presenting with infertility: Role of MRI in diagnosis. Zohra Ahmad et al. Indian J Radiol Imaging Jul-Sep; 23(3): 243–246.

29. THANK YOU