Diagnosis of malformations of the vagina and uterus

Gradual diagnosis of vaginal and uterine malformations includes a careful study of the anamnesis, gynecological examination (vaginoscopy and recto-abdominal examination). Ultrasound and MRI of the pelvic organs and kidneys, endoscopic methods.

Anamnesis

Diagnosis of malformations of the uterus and vagina presents significant difficulties. According to the research, inadequate surgical treatment before admission to a specialized hospital is performed in 37% of girls with malformations of the genitals with a violation of outflow of menstrual blood, and unreasonable operations or conservative treatment - for every fourth patient with aplasia of the vagina and uterus. Insufficient knowledge of the doctors of this pathology leads to the fact that on the basis of the clinical picture and gynecological examination, when doubling the uterus and vagina with partial aplasia of one of them, mistakes are often made: the cyst of the Gardner's passage, the paraurethral cyst, the paravaginal cyst. Retroperitoneal formation, vaginal tumor, cervical tumor, ovarian cystoma, recurrent nonspecific vulvovaginitis, ovarian dysfunction, acute appendicitis, "acute abdomen", etc. Among the unreasonable surgical interventions, the most frequent are the dissection of the "atrezirovannoy" hymen, the puncture and drainage of the hematocolpos, the bougie of the "stricture" of the vagina, the diagnostic laparotomy. At best, laparoscopy, puncture, hematometry, attempted metroplasty, removal of the appendages of the uterus or tubectomy, appendectomy, an attempt to remove the "non-functioning" kidney, resection of the ovaries.

Physical examination

With aplasia of the vagina and uterus, the structure of the external genitalia in patients has its own characteristics. The external aperture of the urethra is often widened and displaced downwards (can be taken as a hole in the hymen).

The vestibule vestibule can be represented by several variants of the structure and look like:

• smoothed surface from the urethra to the rectum;
• hymen without a recess in the perineum;
• hymen with an opening through which the blindly terminating vagina is 1-3 cm long;
• a capacious, blindly terminating canal in patients who live sexually (as a result of natural colposcopy).

Rectoabdominal examination indicates the absence of the uterus in the cavity of the small pelvis. Patients of the asthenic physique manage to palpate one or two muscle cushions.

Hymenal atresia in a number of cases is diagnosed in infants by crotch swelling in the area of the hymen as a result of mucopolis formation. However, mostly clinical symptoms appear at pubertal age. When gynecological examination visualize the swelling of unperforated hymen, the transmission of dark contents. When recto-abdominal examination in the cavity of the small pelvis, the formation of a tight (or soft) elastic consistency is determined, at the apex of which a more dense formation, the uterus, is palpated.

In patients with complete or incomplete aplasia of the vagina with a functioning rudimentary uterus during gynecological examination, note the absence of the vagina or the presence of its only lower part on a small extent. With recto-abdominal examination, a small pelvis is found in the small pelvis, which is sensitive to palpation and attempted displacement (uterus). The cervix is not determined. In the appendages, palpation of the retort form (hematosalpinx) is often observed.

In girls with aplasia of the vagina with a full functioning uterus during recto-abdominal examination at a distance of 2-8 cm from the anus (depending on the level of vaginal aplasia), a tautoelastic consistency (hematocolposus) is found that can extend beyond the small pelvis and be determined by palpation of the abdomen. And the lower the level of the aplastic part of the vagina is, the larger the size can reach the hematocolpos, but at the same time, as noted above, the hematometer arises later, and therefore the pain syndrome is less pronounced. At its apex palpate a more dense formation (uterus), which can be increased in size (hematometer). In the field of appendages, sometimes formations of retort form (hematosalpinks) are determined.

With a rudimentary closed horn of the uterus, one vagina and one cervix of the uterus are visually determined, however, with a recto-abdominal examination, a small painful formation increases during the menstruation next to the uterus, and hematosalpinx is on its side. A distinctive feature of this defect is aplasia of the kidney on the side of the closed vagina in all patients.

When vaginoscopy in patients with uterus doubling and aplasia of one of the vaginas, one vagina, one cervix of the uterus, a protrusion of the lateral or upper-lateral wall of the vagina is visualized. With a significant amount of protrusion, the cervix can be inaccessible for inspection. During recto-abdominal examination, a tumor-like formation of a tightly-elastic consistence is detected in the small pelvis, fixed, painless, the lower pole of which is 2-6 cm above the anus (depending on the level of the vaginal aplasia), the upper sometimes reaches the umbilical region. It is noted that the lower the level of aplasia of one of the vaginas (determined by the lower pole of the hematocolpos), the less pronounced is the pain syndrome. This is due to the greater capacity of the vagina in the aplasia of its lower third, its later overgrowth and the formation of hematomas and hematosalpinx.

Laboratory research

Laboratory studies are not very informative for detecting the developmental defects of the uterus and vagina, but are necessary for clarifying background conditions and diseases, in particular, the state of the urinary system.

Instrumental Research Methods

When ultrasound in patients with complete aplasia of the vagina and uterus in the small pelvis, the uterus is not detected or seen by one or two muscle rolls (2.5x1.5x2.5 cm), the ovaries are more likely to correspond to the age norm and are located high at the pelvic wall.

With aplasia of the vagina and rudimentary functioning uterus on the echogram there is no cervix and vagina, they determine hematosalpinxes, and in patients with full-fledged uterus - an echographic picture of the hematocolpos and, quite often, hematomas. Having the form of echo-negative formations filling the cavity of the small pelvis.

The rudimentary horn on the echogram is visualized as a rounded shape adjacent to the uterus with a heterogeneous internal structure. However, with this defect, ultrasound does not always allow us to correctly interpret the echographic picture, treating it as an intrauterine device, a bicornic uterus, a torsion of the ovarian cyst, a nodal form of adenomyosis, and so on. High diagnostic value in this situation are MRI and hysteroscopy, in which only one mouth of the uterine tube is visualized in the uterine cavity.

MRI is a modern safe highly informative, non-invasive and non-radiological method for diagnosing vaginal and uterine malformations. It allows you to determine the type of defect with an accuracy approaching 100%.

Despite the high diagnostic value, CT is accompanied by radiation on the body, which is extremely undesirable at pubertal age.

The last stage of diagnosis - laparoscopy, which performs not only a diagnostic, but also a therapeutic role.

Differential diagnosis of vaginal and uterine malformations

Differentiated diagnosis of complete vaginal and uterine aplasia should be carried out with various options for delaying sexual development, especially ovarian genesis (gonadal dysgenesis, testicular feminization syndrome). It should be remembered that for women with aplasia of the vagina and uterus, the presence of a normal female karyotype (46.XX) and the level of sexual chromatin, female phenotype (normal development of the mammary glands, hair and development of the external genital organs by female type) is characteristic.

Differentiated diagnosis of defects associated with the violation of outflow of menstrual blood should be carried out with adenomyosis (endometriosis of the uterus), functional dysmenorrhea and acute inflammatory process of the pelvic organs.

The pathology of the kidneys and the urinary system requires consultation of a urologist or nephrologist.

[1], [2], [3], [4], [5], [6], [7], [8]