AQUEOUS VAGINAL CONTRAST AND SCHEDULED HEMATOCOLPOS WITH MAGNETIC RESONANCE IMAGING TO DELINEATE COMPLEX MÜLLERIAN ANOMALIES

Abstract

To demonstrate the advantage of using aqueous vaginal contrast and scheduled hematocolpos with MRI to improve the delineation of gynecologic anatomy, and to recommend that this modality be considered in patients with complex müllerian anomalies. OHVIRA is a unilateral obstructed müllerian anomaly that can be definitively treated with resection of the obstruction. When the obstructed hemivagina is within close proximity to the patent hemivagina, vaginal septum resection should be performed. However, when the obstructed hemivagina and uterus are not adjacent to the patent hemivagina, the risk of post-resection stenosis is increased due to the thickness of the obstructing tissue. Laparoscopic removal of the obstructed side should be considered as an alternative approach. In the presented case, a 17-year-old patient with OHVIRA presented for definitive surgical management. A pelvic MRI was performed, but due to hormonal suppression the vaginal cavity was decompressed, making it very difficult to discern the relationship between the two uteri and vaginas. To better determine whether vaginal septum resection was feasible, norethindrone was discontinued to allow menstrual blood to fill the obstructed hemivagina, followed by a subsequent pelvic MRI with aqueous vaginal contrast gel to improve the visualization of the decompressed vaginal cavities. The addition of vaginal aqueous contrast clearly delineated the course and caliber of the patent vagina and its relationship to the obstructed hemivagina, now filled with blood. The inferior margin had a <1 cm narrow segment adjacent to the patent vagina, and the obstructed cervix was superiorly displaced 3.5 cm above the patent vagina. Given these findings, the risk of post-operative stenosis following a vaginal septum resection was determined to be too high. The decision was made to proceed with a laparoscopic resection of the obstruction, and a laparoscopic resection of the right hemiuterus, fallopian tube, cervix, and vagina was performed. The patient recovered without complication post-operatively, and her menses resumed without any pain. We highlight the use of two techniques to optimize MRI imaging of pelvic anatomy in a patient with a complex müllerian anomaly. First, the use of aqueous vaginal contrast is advantageous to clearly delineate the course and caliber of the patent vagina. Second, the cessation of hormonal suppression to allow menstruation to develop hematocolpos helped delineate the relationship between the obstructed vagina and the patent vagina. These MRI adjuncts provided necessary detail that could not be appreciated with standard MRI to confirm that vaginal septum resection to preserve the right uterus would be too high risk for post-operative stenosis in this patient.