Vesicovaginal reflux presenting as transient urocolpos—A diagnostic dilemma

Abstract

Urocolpos refers to urinary distension of the vagina; it commonly results from vesicovaginal fistula or reflux. In this case report, we present the clinical and radiological aspects of an 18-year-old female presenting with no significant urinary complaints, but with imaging findings of hydrocolpos. This would disappear after voiding. Vesicovaginal reflux resulting in urocolpos is a rarely diagnosed condition, and the radiologist may be mystified by the intermittent nature of the findings. We emphasize the importance of recognizing the entity before proposing surgical treatment.

Introduction

Cystic distension of the vagina by the accumulation of urine is urocolpos. Vesicovaginal reflux (VVR) is defined as the retrograde reflux of urine into the vaginal vault during voiding. It is usually seen in adolescent girls with urinary incontinence [1]; however, middle-aged women are also affected [2]. The etiology is unclear, postulations are close apposition of labia, relatively horizontal orientation of the vagina or closing the legs when voiding [4]. In the absence of anatomic abnormalities such as ectopic ureteral insertion into the vagina, labial adhesions or vesicovaginal fistula (as in an older woman with surgical/radiation history), this may be considered functional and treated with behavioral modification, education and hygiene training.

Case presentation and investigations

The patient, an 18-year-old female presented to the gynecology department with complaints of frequent and excessive menstruation. On examination, she was overweight, weighing 106 kg with a BMI of 37. General examination was unremarkable. A blood workup showed anemia (Hemoglobin of 11.9 g) and blood glucose in the prediabetic range (5.82 mmol/L). Thyroid function tests, serum prolactin, follicular stimulating hormones, and luteinizing hormones were within normal limits. She denied any urinary incontinence or nocturnal bed wetting. Urine examination was unimpressive for infection. She was referred to radiology for a pelvic ultrasound.

Ultrasound revealed a large fluid-filled cystic lesion in the midline of the pelvis, distending the vagina. The uterine corpus and endometrial cavity appeared normal (Fig. 1a and b). The postvoid study showed complete disappearance of the cystic lesion with partial and complete emptying of the Urinary bladder (Fig. 2). Ovaries showed a polycystic appearance. At this point, differential diagnoses of hydrocolpos, bladder diverticulum, fluid in the rectum and even mirror-image artifact from the bladder were considered.

Fig. 1.

(A, B) Sagittal and transverse ultrasound sections of the pelvis. A fluid-filled cystic lesion in the midline of the pelvis (arrow) in continuity with the cervix.

Fig. 2.

Postvoid sagittal image of the pelvis showed the disappearance of the cystic lesion.

Thirteen days later, the patient underwent an MRI of the pelvis which revealed a normal appearance of the pelvic structures in both empty and filled bladder sequences (Fig. 3a and b). No evidence for vaginal septum/ stenosis, uterus didelphys or other uterine abnormalities were identified (Fig. 4).

Fig. 3.

(A, B) Sagittal T2 WI MRI in full and empty bladder phases. Normal appearance of the bladder, uterus and other pelvic structures.

Fig. 4.

Axial T2 MRI. No evidence for vaginal septum, atresia or uterus didelphys.

A week after the MRI, the patient was recalled for a re-look ultrasound. The large cystic lesion posterior to the bladder was observed again, the continuity of this cystic lesion with the cervix superiorly confirmed hydrocolpos and the previously listed differential diagnosis were eliminated. The diagnostic dilemma was resolved by establishing that this was urocolpos due to intermittent VVR. The medical team did not urge her to undergo voiding cystourethrogram, as we felt it would not contribute further to diagnosis and management, and the prospect of radiation involved.

Discussion

Hydrocolpos refers to a fluid-filled and distended vaginal cavity. When involving the uterine cavity, it is described as hydrometrocolpos. The most common causes are imperforate hymen [3], transverse septum or vaginal atresia; such obstructive lesions present earlier in life. Urocolpos due to VVR is a nonobstructive under-recognized condition in pubertal and adolescent girls presenting with urogynecological symptoms. The condition resolves as the patient grows into adulthood, explained by bladder descent and anatomic correction of the vesicourethral angle [4].

Various etiologies have been postulated, labia minora adhesions, ureteral duplication or ectopic ureter with insertion into the vagina, and female hypospadias (abnormal position of the urethral meatus in relation to the vaginal orifice and labia) [5]. Other causes may be improper toilet training resulting in the child attempting to pass urine with tightly crossed legs and pelvic floor dysfunction [4,5].

Vaginal reflux is a functional voiding disorder seen in prepubertal girls without anatomic or neurologic abnormality. When not associated with urinary tract infections, asymptomatic bacteriuria, postvoid dribbling or daytime enuresis it may be considered a normal finding [6]. Between 12% and 15% of girls are referred to Urological clinics because of urine incontinence present with VVR [7]. The most likely cause in our patient is tightly opposed labia, preventing the passage of urine and reflux from the meatus into the vagina through the introitus.

It must be distinguished from Vesicovaginal fistula and abnormalities of ureteric insertion. Normal pelvic anatomy as defined radiologically and prevoid vaginal distension that resolves after complete voiding will differentiate the two conditions [6].

Clinical presentation may be varied – ranging from urinary infections, abdominal pain, postvoid dribbling, bed wetting and passing urine from the vagina after voiding. Careful elicitation of history and encouraging the patient to maintain a bladder diary are important.

The first line imaging modality in radiology is the pelvic ultrasound which reveals vaginal distension by fluid in the full bladder phase. This finding is transient and disappears after voiding. MRI is the logical next step, to exclude uterine anomalies, septa, didelphys, and related Mullerian abnormalities. It also offers the advantage of excluding ionizing radiation. CT scan findings include opacification of the vaginal canal from the bladder in delayed phase scans, with the conspicuous absence of any communication between the two viscera [8]. Voiding cystourethrogram defines the retrograde filling of the vaginal canal during the early voiding phase to empty completely or sub-totally in the late voiding phase [8].

The condition is not exclusive to, albeit commoner in, adolescents. It is also an underestimated cause of urinary incontinence in adult women [4]. The occurrence of urocolpos due to VVR after a Caesarean section in adult females is a rare phenomenon; failure to recognize it may lead to misdiagnosis as vesicovaginal fistula and often leads to unnecessary medical interventions [2].

Treatment of VVR largely revolves around behavioral therapy and toilet training. The peripubertal adolescent is educated to keep her legs well apart while voiding and to devote adequate time to bladder emptying [1,7]. Postvoiding vaginal emptying by finger introduction/tampon in a cross-legged position and strengthening the pelvic floor by exercises are taught to the older patient [2].

Conclusion

From the above discussion, it is concluded that the VVR is a functional rather than anatomic cause for transient urocolpos. The treatment is accordingly focused on behavioral therapy, attention to local hygiene and reassurance from the medical team. Management of urinary infection symptomatically also forms part of the regimen.

Radiological diagnosis plays an important role in management. The intermittent nature of the findings may confound the unwary physician, and knowledge of this entity guides clinical management [9].

A comprehensive history and a high index of suspicion lead to the diagnosis. Micturating cystourethrogram may not be mandatory if the diagnosis is arrived at by less invasive modalities without the use of ionizing radiation. Imaging will also exclude anatomic abnormalities leading to hydrocolpos.

Patient consent

Informed written consent was obtained from the patient, and she affirmed that she accepted that the medical records, including radiology images, were to be utilized for research and publication in medical journal.