45. Undiagnosed OHVIRA Presenting as Tubo-ovarian Abscess Managed With Interval Vaginal and Abdominal Drainage

Abstract

<h3>Background</h3> Obstructed hemi-vagina and ipsilateral renal anomaly (OHVIRA) typically presents with pelvic pain after menarche due to outflow obstruction. We present a case of a 17-year-old girl with history of renal anomaly who developed fever and pain and was found to have a tubo-ovarian abscess (TOA) and OHVIRA, treated with antibiotics and vaginal and intra-abdominal drainage. <h3>Case</h3> A 17-year-old female presented with fevers, abdominal pain, vomiting and diarrhea. She had menarche at age 11, and history of obesity, hearing loss, and right nephrectomy for unilateral congenital kidney disease. She denied prior sexual activity. At an outside hospital, she was diagnosed with rhinovirus and had a white blood cell count (WBC) of 27 × 10(3)/mcL. On exam, she had abdominal tenderness and a suspected oblique vaginal septum. MRI imaging confirmed the diagnosis of OHVIRA with 12 × 7 × 5 cm tubo-ovarian abscess and she was transferred to our tertiary care pediatric hospital. She was started on doxycycline, metronidazole, and piperacillin-tazobactam, but had persistent pain and was taken to the operating room for exam under anesthesia and drainage. We noted purulent vaginal discharge and a palpable right vaginal wall bulge which was incised, revealing purulent fluid. A 24 French Malecot drain was placed through the vaginal septum incision. She continued to have pain and WBC of 20 × 10(3)/mcL. Interventional radiology performed ultrasound-guided drainage and placed two transabdominal pigtail catheters into the TOA. Both vaginal and abdominal catheters drained purulent fluid, with gram negative and positive rods on gram stain, no growth on culture. Due to persistent pain and high WBC, she then underwent diagnostic laparoscopy/washout which showed uterine didelphys, normal left fallopian tube and ovary, and persistent right tubo-ovarian abscess, which was copiously irrigated and suctioned. Postoperatively, pain resolved and WBC normalized. Abdominal drains were removed and she was discharged home with norethindrone for menstrual suppression and oral doxycycline and metronidazole, followed by prophylactic doxycycline until definitive vaginal septum resection. <h3>Comments</h3> Obstructed hemi-vagina and ipsilateral renal anomaly (OHVIRA) is a Mullerian anomaly typically presenting with worsening dysmenorrhea +/- a pelvic mass. This patient had never been sexually active, had negative STI testing, and had menstruated for six years. We suspect she may have had microperforation in her septum allowing for both a path for ascending infection and delayed presentation of OHVIRA due to menstrual outflow. While patients with OHIVRA often undergo vaginoplasty at time of diagnosis, she required staged intervention due to elevated risk of infectious complications.