IS case 525: Uterine didelphys
Imaging Sciences URMC 2010
Publication Date: 2010-09-10
A 41-year old G0P0 female presented for a hysterosalpingogram as part of the planning process for in vitro fertilization (IVF). She was diagnosed with a mullerian duct anomaly several years prior, shortly after undergoing a left salpingoopherectomy for complications related to retained menses.
Two AP fluoroscopic spot images of the pelvis demonstrate two hysterosalpingogram catheters inserted within separate uterine cavities via distinct cervices. The left uterine cavity (Fig. 1) is tortuous, and comprises of two smaller compartments connected by a narrow channel. Tubal patency on the left ends abruptly, consistent with the patient's surgical history. The uterine cavity on the right (Fig. 2) exhibits fusiform morphology. Tubal patency with free intraperitoneal spill is observed on the right.
Uterine didelphys (a.k.a. double uterus) exists on a spectrum of mullerian duct anomalies (MDA), and consists of two noncommunicating uterine cavities that possess their own single fallopian tube and cervix. This anomaly arises from near-complete failure of fusion by the mullerian ducts during the 12th-16th week of embryologic development.
Uterine didelphys (UD) represents about 5% of all mullerian duct anomalies. The reported prevalence of MDA is variable, but appears to be roughly equivalent in fertile and infertile patients (0.16-10%, mean 1-3%). There is, however, an increased mean prevalence in patients with history of recurrent pregnancy loss (3-12.6%).
Reproductive implications of uterine didelphys include intrauterine growth restriction, spontaneous pregnancy loss (45%), and preterm birth (38%). 55% of pooled UD pregnancies result in live birth. In a broad sense, decreased uterine cavity size and compliance, as well as impaired vascularity, may contribute to the problems encountered with MDA.
In non-pregnant women, UD is often asymptomatic and therefore, remains undiagnosed. However, cyclic menstrual pain, endometriosis, and retrograde menstruation can be presenting symptoms of UD. Additionally, 75% of patients will also present with a longitudinal vaginal septum, which can cause dyspareunia and unilateral uterine/hemivaginal obstruction resulting in hematocolpos. The latter is commonly associated with ipsilateral renal agenesis, although this was not the case in our patient. A variety of upper urinary tract and renal anomalies are associated with UD, including horseshoe kidney and ectopic/duplicated collecting systems.
Hysterosalpingogram allows for visualization of the uterine cavity and assessment of tubal patency, which can be useful in diagnosis, classification, and planning management of MDA. More accurate identification of the MDA can be achieved with cross-sectional imaging such as ultrasound (90% accurate) and MRI (the gold standard).
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