Interactive Transcript
0:01
Moving on to our next case, this is a 12-year-old
0:03
who came into the ED with acute pelvic pain.
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Generally, you don't start with a CT scan, but
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in this particular case, this is what we have.
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So starting from the bottom up, we can
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already see this IV contrast-enhanced CT
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that something is going on in the pelvis.
0:19
We have this large fluid collection
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surrounded by different structures right here.
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It's certainly quite a bit lower than you'd
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expect to see an ovarian cyst, for example.
0:28
We do have a little bit of free fluid
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back here as well, anterior to the rectum.
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And then it's hard to figure out
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exactly what's going on right here.
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We have this structure leading out to the right
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adnexa, the structure leading to the left adnexa.
0:40
So again, whenever you're looking at
0:42
female pelvic imaging on a CT, CT is not
0:44
the best modality to show you everything
0:46
going on with the female pelvis.
0:48
However, it's worthwhile trying to figure out
0:50
what you're seeing because you can, a lot of
0:51
times, at least lead to what should happen next.
0:54
I would argue this is probably the ovary
0:56
right here is a little follicle right there.
0:58
You can follow it all the
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way up if you're not sure.
1:01
All the way up.
1:02
And you can follow it all the way
1:03
up to the ovarian vein as it dumps
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into the left renal vein there.
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But going back to what's going on down deeper
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in the pelvis, let's move to our coronal.
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In this case, starting anteriorly with the
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bladder right here and moving posteriorly,
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we have this big fluid-filled, slightly
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heterogeneous structure right here.
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And if you stop right here, we can see those
1:23
two structures that were sort of heading
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out towards the adnexa bilaterally.
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They sort of meet right here.
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So these are not fallopian tubes.
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These are way too thick to be fallopian tubes.
1:34
To have this amount of fluid in them
1:35
and then have this degree of thickness
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symmetrically, that would just be unusual.
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So what this is, are these are
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two divergent uterine horns.
1:44
And then you have this
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process going on down here.
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So what this is, is a didelphys
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uterus with hematocolpos, most
1:52
likely due to a vaginal septum.
1:55
Here's our transverse uterus picture from her.
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So we have our bladder right here.
1:59
This is transabdominal.
2:00
She's 12 years old.
2:00
So we were not going to do
2:01
transvaginal in this particular case.
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As we scroll through.
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And the uterus cervix is going to be
2:07
down here in this particular area.
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This is post-operative, I should let you know.
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There's no specific structure
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that you're going to see.
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And you can nicely see here the two horns,
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and they're very, very widely divergent
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as we head out into the adnexa there.
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Very widely divergent.
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So let's go back here again, you can see as
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we're coming from the fundus down, down here.
2:29
You never actually see them meet if there's
2:31
two separate cavities this entire time
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until we get down to the vaginal area.
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So in this particular case, she was
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diagnosed with Herlyn-Werner-Wunderlich syndrome, which is
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obstructed hemivagina with renal agenesis.
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And if we go back to the CT scan now, you can
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see there's one large hypertrophied kidney.
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And there is no right-sided kidney.
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Another way you can tell if there was ever a
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right kidney is to try and look at the adrenal
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gland, which she's so skinny, it's hard to see.
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But a normal adrenal gland
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will form a V or a Y shape.
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And if there is never a kidney in this
3:01
position, you'll have a pancake or a
3:03
flat adrenal gland, which is right here.
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There was never a normal kidney
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in that right renal bed.
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Instead, you have a single left kidney,
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which has compensatory hypertrophy,
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which is why it's so large right there.
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So didelphys, that is a failure of Mullerian
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duct fusion, so both of them form, but
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they don't fuse together, and they don't
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fuse at all in any particular area.
3:26
So you will have two horns that are widely
3:28
divergent, and you'll have two cervices.
3:31
About 75% of the time, these are
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associated with a proximal vaginal septum.
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And that may be how these
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patients end up coming in.
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They don't necessarily get a period or
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they start their periods, but part of
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it's going to be obstructed right here.
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And they come in with these
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heterogeneous fluid collections.
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So if you have an MRI on a patient,
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you should always look for that vaginal
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septum because that changes management.
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It's again, other things you're looking
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for besides that deep fundal cleft.
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You can see how widely spaced these
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two horns are very widely spaced.
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And if you have a transvaginal ultrasound,
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you're going to look for two cervixes.
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And again, MRI always looks for a hemivagina.
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If you think you have a didelphys uterus.
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