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.

0:07

Generally, you don't start with a CT scan, but

0:09

in this particular case, this is what we have.

0:11

So starting from the bottom up, we can

0:14

already see this IV contrast-enhanced CT

0:17

that something is going on in the pelvis.

0:19

We have this large fluid collection

0:21

surrounded by different structures right here.

0:24

It's certainly quite a bit lower than you'd

0:25

expect to see an ovarian cyst, for example.

0:28

We do have a little bit of free fluid

0:30

back here as well, anterior to the rectum.

0:33

And then it's hard to figure out

0:34

exactly what's going on right here.

0:35

We have this structure leading out to the right

0:37

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

0:59

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

1:05

into the left renal vein there.

1:07

But going back to what's going on down deeper

1:10

in the pelvis, let's move to our coronal.

1:13

In this case, starting anteriorly with the

1:14

bladder right here and moving posteriorly,

1:17

we have this big fluid-filled, slightly

1:19

heterogeneous structure right here.

1:22

And if you stop right here, we can see those

1:23

two structures that were sort of heading

1:25

out towards the adnexa bilaterally.

1:27

They sort of meet right here.

1:30

So these are not fallopian tubes.

1:32

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

1:37

symmetrically, that would just be unusual.

1:40

So what this is, are these are

1:41

two divergent uterine horns.

1:44

And then you have this

1:45

process going on down here.

1:47

So what this is, is a didelphys

1:49

uterus with hematocolpos, most

1:52

likely due to a vaginal septum.

1:55

Here's our transverse uterus picture from her.

1:57

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.

2:03

As we scroll through.

2:06

And the uterus cervix is going to be

2:07

down here in this particular area.

2:09

This is post-operative, I should let you know.

2:11

There's no specific structure

2:12

that you're going to see.

2:13

And you can nicely see here the two horns,

2:15

and they're very, very widely divergent

2:17

as we head out into the adnexa there.

2:19

Very widely divergent.

2:23

So let's go back here again, you can see as

2:24

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

2:33

until we get down to the vaginal area.

2:35

So in this particular case, she was

2:37

diagnosed with Herlyn-Werner-Wunderlich syndrome, which is

2:40

obstructed hemivagina with renal agenesis.

2:43

And if we go back to the CT scan now, you can

2:46

see there's one large hypertrophied kidney.

2:49

And there is no right-sided kidney.

2:51

Another way you can tell if there was ever a

2:53

right kidney is to try and look at the adrenal

2:54

gland, which she's so skinny, it's hard to see.

2:57

But a normal adrenal gland

2:58

will form a V or a Y shape.

3:00

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.

3:05

There was never a normal kidney

3:07

in that right renal bed.

3:08

Instead, you have a single left kidney,

3:12

which has compensatory hypertrophy,

3:13

which is why it's so large right there.

3:16

So didelphys, that is a failure of Mullerian

3:19

duct fusion, so both of them form, but

3:21

they don't fuse together, and they don't

3:24

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

3:34

associated with a proximal vaginal septum.

3:36

And that may be how these

3:37

patients end up coming in.

3:39

They don't necessarily get a period or

3:40

they start their periods, but part of

3:42

it's going to be obstructed right here.

3:44

And they come in with these

3:45

heterogeneous fluid collections.

3:48

So if you have an MRI on a patient,

3:49

you should always look for that vaginal

3:51

septum because that changes management.

3:54

It's again, other things you're looking

3:55

for besides that deep fundal cleft.

3:57

You can see how widely spaced these

3:59

two horns are very widely spaced.

4:02

And if you have a transvaginal ultrasound,

4:04

you're going to look for two cervixes.

4:06

And again, MRI always looks for a hemivagina.

4:08

If you think you have a didelphys uterus.