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GENITO-URINARY IMAGING Table of Contents   
Year : 2009  |  Volume : 19  |  Issue : 3  |  Page : 235-237
Vesicovaginal reflux: A case report


Department of Radiodiagnosis, Narayana Hrudayalaya Institute of Medical Sciences, 258/A, Bommasandra Industrial Area, Bangalore-560 099, India

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Date of Web Publication4-Aug-2009
 

   Abstract 

Vesicovaginal reflux is a common cause of urinary incontinence in girls. A micturating cystourethrogram, which is the diagnostic investigation of choice, can demonstrate retrograde filling of the vagina during micturition and the complete emptying of the vagina at the end of micturition. Vesicovaginal reflux is a rare cause of gross hydrocolpos occurring without any anatomical obstruction. The condition may be associated with functional voiding disturbances.

Keywords: Hydrocolpos; incontinence; micturating cystourethrogram; vesicovaginal reflux; wide bladder neck

How to cite this article:
Warade M, Majid Y, Dayananda L, Gupta K. Vesicovaginal reflux: A case report. Indian J Radiol Imaging 2009;19:235-7

How to cite this URL:
Warade M, Majid Y, Dayananda L, Gupta K. Vesicovaginal reflux: A case report. Indian J Radiol Imaging [serial online] 2009 [cited 2020 Jun 6];19:235-7. Available from: http://www.ijri.org/text.asp?2009/19/3/235/54882

   Introduction Top


Hydrocolpos is commonly due to an anatomical obstruction such as imperforate hymen, vaginal septum or hypoplastic vagina. Gross distention of the vagina due to refluxed urine has been rarely described. Vesicovaginal reflux (VVR) is a common entity known to be associated with physiologic and pathologic incontinence in the pediatric age group. We report one such case of VVR with classical manifestations.


   Case Report Top


A 14-year-old adolescent, weighing 45 kg, with a normal menstrual history presented with urinary incontinence since childhood. Clinical examination revealed normal external genitalia. There was continuous dribbling of urine from the vagina. On limited per vaginal examination, the introitus admitted one finger and revealed a ballooned-out vagina. Renal function tests and blood counts were within normal limits. Urine examination revealed numerous pus cells, red blood cells and epithelial cells. There was significant bacteriuria (> 1 00 000 colony-forming units/ml);  Escherichia More Details coli was the organism isolated. Urodynamic study demonstrated interrupted voiding flow curves. Ultrasonography of the abdomen and pelvis revealed a grossly distended fluid-filled vagina that was suggestive of hydrocolpos [Figure 1]A, B. The uterus, both ovaries and the urinary bladder were normal [Figure 1]C. Postmicturition study showed complete evacuation of the vaginal fluid and postvoid residual urine of 50 ml in the urinary bladder [Figure 1]D. The ureteric jets on both sides were normally seen within the bladder. No obvious reproductive tract abnormalities were seen. An intravenous pyelogram (IVP) did not reveal any ureteral ectopia [Figure 2]A. A separate contrast-filled sac was seen posterior to the urinary bladder in the lateral projection of the pelvis, consistent with a distended vagina [Figure 2]B. Limited CT sections of the pelvis [Figure 3] were obtained in the same sitting as the IVP so as to rule out a vesicovaginal fistula and confirm the absence of ureteral ectopia. Voiding cystourethrography revealed a normal filling phase, without any extravasation. A widened urinary bladder neck was noted [Figure 4]A. The early voiding phase demonstrated progressive gross distention of the vagina due to retrograde filling as the bladder emptied [Figure 4]B and C. The late voiding phase demonstrated progressive complete evacuation of the vagina [Figure 4]D. No vesicoureteral reflux (VUR) was seen bilaterally.


   Discussion Top


Even though VVR is commonly encountered, it is an uncommon cause of hydrocolpos. Vesicovaginal reflux causes retrograde filling of the vagina during micturition. It can occur in both, the supine and the upright positions. [1] Urinary incontinence, recurrent urinary tract infection (UTI), wetting, vulvovaginitis, irritation of the genitalia, bad smell and vaginal discharge may be the various presentations. [1],[3],[5] The UTI may be real or due to contamination of urine by the vaginal flora. The condition is common in prepubertal children; however, it may also be seen in postpubertal girls and women. [3] The vaginal distention may be complete, partial or minimal; gross distention is relatively uncommon. [4] The urogenital tract anatomy is usually normal for age . [3],[4] A relatively horizontal vagina in the prepubertal age, tightly apposed labia in obese subjects, labia minora adhesions, hypospadiasis and spastic pelvic floor muscles (as seen in patients with cerebral palsy) are the various etiologies proposed for the occurrence of

VVR. [1],[3],[5],[6],[7] The diagnosis of VVR is indicated by resolution of the hydrocolpos on a postvoid USG and can be confirmed with a voiding cystourethrogram, which shows gradual distension of the vagina during micturition due to its retrograde filling as the bladder empties. A wide bladder neck, as seen in our patient, a spinning top urethra or low-bladder volumes may be the associated functional voiding disturbances. [1],[8],[9]

Gross hydrocolpos makes the present case unusual. Absence of hydrometra and a normal menstrual history ruled out an imperforate hymen. The fluid-filled vagina seen posterior to the distended urinary bladder could have been confused with a distended rectum on USG; however, this was ruled out on seeing the cervix suspended at its upper end. Instructions on proper voiding form a key element in the management of VVR. [3]

 
   References Top

1.Snyder EM, Nguyen RA, Young KJ, Coley BD. Vesicovaginal reflux mimicking obstructive hydrocolpos. J Ultrasound Med 2007;26:1781-4.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Schaffer RM, Taylor C, Haller JO, Friedman AP, Shih YH Nonobstructive Hydrocolpos: Sonographic appearance and differential diagnosis. Radiology 1983;149:273-8  Back to cited text no. 2    
3.Mattsson S, Gladh G. Urethrovaginal reflux-a common cause of daytime incontinence in girls. Pediatrics 2003;111:136-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Kelalis PP, Burke EC, Stickler GB, Hartman GW. Urinary vaginal reflux in children. Pediatrics 1973;51:941-2   Back to cited text no. 4  [PUBMED]  
5.Capraro VJ, Greenberg H. Adhesions of the labia minora: A study of 50 patients. Obstet Gynecol 1972;39:65-9.  Back to cited text no. 5  [PUBMED]  
6.Stannard MW, Lebowitz RL. Urography in the child who wets. AJR Am J Roentgenol 1978;130:959-62  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Szabó L, Lombay B, Borbαs E, Bajusz. Videourodynamics in the diagnosis of urinary tract abnormalities in a single center. Pediatr Nephrol 2004;19:326-31.  Back to cited text no. 7    
8.Hausegger KA, Fotter R, Sorantin E, Schmidt P. Urethral morphology and bladder instability. Pediatr Radiol 1991;21:278-80.  Back to cited text no. 8  [PUBMED]  
9.Saxton HM, Borzyskowski M, Mundy AR, Vivian GC. Spinning top urethra: not a normal variant. Radiology 1988;168:147-50.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Monali Warade
Department of Radiodiagnosis, Narayana Hrudayalaya Institute of Medical Sciences, #258/A, Bommasandra Industrial Area, Bangalore - 560099, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.54882

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

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