Pelvic Diagnostic Challenges of Appendiceal Neoplasm Mimicking a Hematosalpinx: A Case Report.

Appendiceal mucinous neoplasms are rare and can be easily misdiagnosed as adnexal masses. Fertility is a concern in cases requiring cytoreductive surgery involving the ovaries and if hyperthermic intraperitoneal chemotherapy is considered. We present the case of a 35-year-old patient with primary infertility who was suspected to have a hematosalpinx on ultrasonography and magnetic resonance imaging (MRI) but was found to have an appendiceal mucinous neoplasm on laparoscopy. Fertility preservation was offered to this patient. Appendiceal mucinous neoplasms should be considered in the differential diagnosis of patients in their reproductive years presenting with adnexal masses. Fertility preservation should be discussed with these patients, especially when gonadotoxic treatments are planned.

A Case Report on a Left Unicornuate Uterus With Communicating Right Rudimentary Horn Associated With Hematometra and Hematosalpinx.

Congenital uterine anomalies (CUAs) or Müllerian duct anomalies are rare and can be either complete failure or partial failure in the development of the Mullerian duct, and they have a probability to result in a condition known as the unicornuate uterus. Partial development of one of the horns results in a rudimentary horn, which may be communicating consisting of category II A or noncommunicating consisting of category II B. This report illustrates a rare case of a 23-year-old female, unmarried, nulligravida, who presented to the outpatient department with chief complaints of acute abdominal pain and dysmenorrhea associated with an average menstrual flow. Pelvic ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of a left unicornuate uterus with communicating right rudimentary horn associated with hematometra and hematosalpinx. As a treatment option, the surgical intervention mainly involved laparoscopic excision of the rudimentary horn and right salpingectomy that was performed by aspiration of blood from the rudimentary horn of around 25cc. Then, the right hydrosalpinx was removed, followed by right salpingectomy and excision of the rudimentary horn to reduce the risk of ectopic pregnancy having an incidence of 10% for which laparoscopic or robotic-assisted removal is preferable and practicable for young girls, compared with the open procedure. The patient adhered well to the surgical intervention.

Surgical disorders in pediatric and adolescent gynecology: Adnexal abnormalities.

Surgical abnormalities of the adnexa in children and adolescents include a variety of ovarian and paraovarian lesions ranging from benign functional cysts to malignant tumors, torsion of the ovary and/or the fallopian tube, and adnexal infectious lesions ranging from salpingitis to tubo-ovarian abscesses. Presentations vary from asymptomatic pelvic masses to acute abdomen, and some ovarian tumors might present with precocious puberty or virilization. Acute pain might be caused by hemorrhage or rupture of ovarian or paraovarian cysts, adnexal torsion or adnexal infection. Differential diagnosis of adnexal masses should include peri-appendiceal abscess in all age groups, and endometriomas and ectopic pregnancy in adolescents. This review provides guidance on the differentiation between adnexal abnormalities, based on important clues from clinical assessment and diagnostic workup, and ultimately on the decision making about the need for surgery, its level of urgency, and the type of surgery to clinicians of all specialties involved in the care of young females.

MR Imaging of Endometriosis of the Adnexa.

Endometriosis is the presence of ectopic endometrial glands outside of the uterus. MR imaging is particularly useful for characterizing deep infiltrating endometriosis but can also be useful in characterizing endometriomas and hematosalpinges, characterizing broad ligament deposits, assessing for endometriosis-associated malignancy, and differentiating malignancy from decidualized endometriomas. Masses and cysts with hemorrhagic or proteinaceous contents can sometimes be difficult to distinguish from endometriomas. Imaging protocols should include pre-contrast T1-weighted imaging with fat saturation, T2-weighted imaging without fat saturation, opposed- and in-phase or Dixon imaging, administration of contrast media, and subtraction imaging.

Role of Laparoscopic Transillumination Guidance During Hysteroscopic Metroplasty in Simplifying Surgical Management of Type II Robert's Uterus.

Robert's uterus is a rare variant of septate uterus with an asymmetrical septum which divides the uterine cavity into a noncommunicating hemiuterus causing hematometra and other communicating hemiuterus with a single cervix and a normal fundal contour (U2bC3V4 ESHRE classification). It is a cause of severe dysmenorrhea in young girls. However, there is a type of Robert uterus (Type II) which does not have collection in the blind cavity and causes symptoms later, similar to our case. We describe a case of hysteroscopic septum resection (metroplasty) with laparoscopic guidance by transillumination in a case of Type II Robert's uterus in a 25-year-old nulliparous woman. Thick muscular septum posed a surgical challenge which was supplemented by astutely utilizing laparoscopic transillumination.

Secondary pyosalpinx after reconstructive surgery of vaginal agenesis patient with bilateral hematosalpinx: A case report.

INTRODUCTION AND IMPORTANCE: Congenital or hypoplasia vaginal agenesis is a very rare condition caused by the failure of developmental Mullerian ducts. The prevalence is 0.001%-0.025% populations. This condition often misdiagnosed because the symptom does not appear. Acute symptoms such as abdominal pain may occur due to the obstruction of retrograde menstrual flow. In this case, we presented a case complex management of vaginal atresia with pyosalpinx, hematometra and bilateral hematosalpinx. PRESENTATION OF CASE: A 12 years old teenager, non-sexually active, complained cyclic abdominal pain that worsening in seven months before admission. Patient never had menstrual blood flow during her life. Patient was diagnosed with hematometra, hematocolpos, bilateral hematosalpinx and distal vaginal agenesis. Amnion graft neovagina was performed. Five days after surgery, patient started to have fever. On the seventh days after surgery, amnion graft was removed. The next two days patient still had fever. Because of continuous fever, patient was test of COVID 19. The result was positive. On the eleventh days after the first surgery, patient complained abdominal pain VAS 3-4. Patient was diagnosed with pyosalpinx by ultrasound examination. Laparotomy was done performing adhesiolysis, bilateral salpingectomy, and omentectomy. DISCUSSION: In our case vaginal reconstruction surgery from vaginal approach has been done without management of the bilateral hematosalpinx because the consideration of small caliber of bilateral hematosalpinx. But then complications were developed when vaginal canal was opened, bilateral hematosalpinx were transformed into bilateral pyosalpinx and continue to developed into bilateral tubal abscess. We assume during this process, the bacteria from vagina could fastly infecting the blood and transformed it into pus and grew until tubal abscess. CONCLUSION: The surgical intervention in vaginal agenesis must be considered as a treatment and not only focus on the reconstruction. Laparoscopy or laparotomy may offered as options for combination treatment with vaginal approach reconstructive surgery for vaginal agenesis with obstruction complications such as hematometra and hematosalpinx to prevent the worst condition like ascending infection or misdiagnosed other severe conditions.

Robert's uterus with delayed diagnosis and potential consequences: a case report.

A 24-year-old woman who wished to become pregnant presented to our hospital with an enlarged ovarian endometrioma and developmental abnormality of the uterus. Robert's uterus complicated by hematosalpinx, ovarian endometrioma, and endometriosis were finally identified 1 year after previously being diagnosed with a cyst and uterine abnormality at a local hospital. The function of the salpinx and the pelvic environment were damaged because of the delayed diagnosis and operation. Gynecologists and sonologists should be aware of and alert to this rare entity while evaluating and managing cases of uterine abnormalities and endometriosis. Prompt early diagnosis and proper management of Robert's uterus are important for avoiding future morbidity because these are major factors in protecting fertility.

Case report of an un-usually large hematosalpinx.

Hematosalpinx is the accumulation of blood in fallopian tubes. Its most common cause is ectopic pregnancy, but the other causes include pelvic inflammatory disease (PID), endometriosis and pelvic trauma. We report a rare case of hematosalpinx in a 45-year-old female with no obvious cause. She presented with acute sharp right iliac fossa pain not relieving with analgesics. She did not have a history of fever, PID, endometriosis, or trauma. Her menstrual cycle was also normal and ß-hcG was negative. Ultrasound showed the right ovarian cyst and was suggesting of hemorrhagic. She was operated and a large hematosalpinx was observed. This rare case suggests the possibility of Hematosalpinx in the mid-40s besides ruling out the possibility of some of the causes hypothesized in the relevant literature. The case highlights the need to better understand the pathophysiology of hematosalpinx.

Posterior Sagittal Approach for Uterovaginal Anastomosis in a Case of Congenital Cervical Atresia with Anorectal Malformation.

Cervical atresia is a rare association with anorectal malformation (ARM) which can be missed till puberty in the presence of normal vaginal orifice. A 12-year-old girl operated for ARM in neonatal age presented with primary amenorrhea. She had a normal vaginal opening, short perineal body, and prolapsed anteposed anus and was diagnosed with cervical agenesis. As the posterior sagittal approach is standard to place the rectum in correct anatomical position, reconstruction of the anus along with adequate perineal body and uterovaginal anastomosis was performed through this approach. This report highlights the utility and versatility of this approach for the management of such complex cases.

Chronic tubal pregnancy manifesting as a heterogeneous adnexal mass with prominent neovascularization in a woman with a negative serum ß-human chorionic gonadotropin level.

A 41-year-old woman (gravida 2, para 1) underwent elective termination of pregnancy at approximately 7 weeks of gestation. At 1 month after the elective abortion, she was referred due to abnormal results in a cervical cytological examination. Transvaginal ultrasonography showed a heterogeneous mass of 16 mm in diameter in the left adnexal region. At 3 months after her referral, the asymptomatic left adnexal mass had increased to 55 mm in diameter. Prominent vascular flow was detected in the solid portion by color Doppler ultrasonography. Magnetic resonance imaging showed suspected hemorrhage in the left adnexal cystic mass. Three-dimensional computerized tomographic angiography showed the prominent development of tortuous blood vessels in the left adnexal region, which originated from the left ovarian artery. The patient had a negative ß-human chorionic gonadotropin (hCG) level. Left salpingectomy was performed by a single-port laparoscopic approach. A pathological examination revealed degenerated villous tissue with ß-hCG-positive syncytiotrophoblasts.

A second glance on Cervicovaginal Agenesis

@#Mullerian anomalies arise from the failure in the development of Mullerian ducts and their associated structures during organogenesis which confers adverse impact in fertility and reproductive health. Presented is a rare case of a 15 year old nulligravid, who presented with a chief complaint of severe cyclic hypogastric pain associated with primary amenorrhea. Complete clinical history, physical examination and sonographic findings pointed to a diagnosis of cervical hypoplasia associated with functioning uterine corpus and an absent vagina. Patient underwent total abdominal hysterectomy with left salpingectomy and bilateral oophorocystectomy, for hematometra, bilateral endometriotic cysts, and hematosalpinx. This case report discusses the management of cervicovaginal agenesis through a multidisciplinary approach by a team composed of an obstetrician-gynecologist, reproductive endocrinologist, pediatrician, and pediatric surgeon for proper evaluation, diagnosis, and management of this case.

Uncommon presentations of an uncommon entity: OHVIRA syndrome with hematosalpinx and pyocolpos.

Müllerian malformations result from defective fusion of the Müllerian ducts during development of the female reproductive system. The least common form of these malformations is Herlyn-Werner-Wunderlich syndrome characterized by obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). The most common presentation of this syndrome is a mass secondary to hematocolpos, pain, and dysmenorrhea. Clinical diagnosis is very challenging and requires imaging studies in which ultrasound and MRI play an essential role in the diagnosis, classification and treatment plan. We report two cases of this syndrome, featuring two very rare clinical presentations: hematosalpinx and pyocolpos. The clinical course of the pathology is not standard and each patient is treated accordingly.

Uterine conserving surgery in a case of cervicovaginal agenesis with unicornuate uterus.

The presence of cervicovaginal agenesis with unicornuate uterus is a very rare mullerian anomaly. Its true incidence is still unknown. The presence of functioning unicornuate uterus poses a great challenge for a gynecologist because a successful repair could restore normal menses and may preserve a patient's fertility. Hence, we report a case of 16-year-old unmarried female who presented with chief complaints of primary amenorrhea with cyclical lower abdominal pain. On clinical and radiological evaluation, she was diagnosed with complete cervicovaginal agenesis with right unicornuate uterus (hematometra and hematosalpinx). She underwent vaginoplasty (McIndoes method) along with uterovaginal anastomosis by neocervix formation, in order to preserve her uterus. On follow-up, her vagina was completely healed, and she was menstruating normally.

A rare case of chronic ectopic pregnancy presenting as large hematosalpinx.

Ectopic pregnancy is defined as implantation and subsequent development of an embryo outside the uterine lining. It has wide range of presentation from acute hemoperitoneum to chronic ectopic pregnancy. This is an unusual case of chronic ectopic pregnancy with large hematosalpinx without classical symptoms. A 22-year-old South Indian woman reported to the outpatient clinic with irregular spotting for a duration of 2 months which was not associated with pain. There was no preceding amenorrhea and previous menstrual cycles were regular. Clinically, the patient was hemodynamically stable but severely anemic. The abdomen was soft on palpation, cervical movements were not tender, and human chorionic gonadotropin was absent in the urine. Ultrasound revealed a complex adnexal mass. Magnetic resonance imaging (MRI) revealed a large hematosalpinx. Laparoscopic left salpingectomy was conducted and histopathology confirmed ectopic pregnancy. Ectopic pregnancy presents diagnostic dilemmas in the absence of classical symptoms. MRI and laparoscopy are important tools in such a diagnostic dilemma.

Himen imperforado como causa de dolor abdominal en la adolescencia: A propósito de un caso / Imperforate hymen as a cause of abdominal pain in adolescents: a case report

El himen imperforado es una anomalía congénita del desarrollo genital femenino. Es una patología poco frecuente, con una incidencia estimada del 0,1% de los recién nacidos del sexo femenino. En muchas ocasiones, el diagnóstico pasa inadvertido hasta la pubertad y debuta con dolor abdominal cíclico en adolescentes que no han presentado la menarquia. El diagnóstico se basa en la anamnesis y la exploración física, aunque las pruebas complementarias, en especial la ecografía, permiten la comprobación del diagnóstico clínico y la exclusión de otras malformaciones genitales. Se presenta el caso clínico de una paciente de 13 años que fue diagnosticada tras consultar en varias ocasiones por dolor abdominal recurrente.

The imperforate hymen is a congenital anomaly of the female genital development. This is a rare pathology with an estimated incidence of 0.1% in female newborns. In many cases, the diagnosis goes unnoticed until puberty, debuting with cyclical abdominal pain in adolescents who have not submitted menarche. Diagnosis is based on history and physical examination, although additional tests, especially the ultrasound that allows to confrm clinical diagnosis and to exclude other genital malformations. We report a case of a 13-year-old that was diagnosed after consulting several times for recurrent abdominal pain.

Himen imperforado como causa de dolor abdominal en la adolescencia: A propósito de un caso / Imperforate hymen as a cause of abdominal pain in adolescents: a case report

El himen imperforado es una anomalía congénita del desarrollo genital femenino. Es una patología poco frecuente, con una incidencia estimada del 0,1% de los recién nacidos del sexo femenino. En muchas ocasiones, el diagnóstico pasa inadvertido hasta la pubertad y debuta con dolor abdominal cíclico en adolescentes que no han presentado la menarquia. El diagnóstico se basa en la anamnesis y la exploración física, aunque las pruebas complementarias, en especial la ecografía, permiten la comprobación del diagnóstico clínico y la exclusión de otras malformaciones genitales. Se presenta el caso clínico de una paciente de 13 años que fue diagnosticada tras consultar en varias ocasiones por dolor abdominal recurrente.(AU)

The imperforate hymen is a congenital anomaly of the female genital development. This is a rare pathology with an estimated incidence of 0.1% in female newborns. In many cases, the diagnosis goes unnoticed until puberty, debuting with cyclical abdominal pain in adolescents who have not submitted menarche. Diagnosis is based on history and physical examination, although additional tests, especially the ultrasound that allows to confrm clinical diagnosis and to exclude other genital malformations. We report a case of a 13-year-old that was diagnosed after consulting several times for recurrent abdominal pain.(AU)