Vous êtes sur la page 1sur 3

Uterine Anomalies Associated with Renal Agenesis:

Role of Gray Scale Ultrasonography

ANDREW M. FRIED,1 MICHAEL OLIFF,1’2 EMERY A. WILSON,3 AND JOSEPH WHISNANT4

Anomalies of the female genital tract were successfully anteroposterior diameter by 2.5 cm wide), coupled with its
characterized by gray scale ultrasonography in three cases; displacement, led to the suspicion of a unicornuate uterus [2].
all three were found In association with unilateral renal Hysterosalpingography confirmed the presence of a solitary left
agenesls. Findings at Intravenous urography prompted ultra- cornu with a normal fallopian tube (fig. 2C).
sound studies. The high Incidence of genital tract anomalies Comment. This case illustrates the usual situation in which
associated with unilateral renal agenesis, particularly In fe- most of the genital anomalies have been found on the same side
males, indicates ultrasonography be used to examine the as the agenetic kidney [1].
pelvis (as well as the renal bed). Further diagnostic proce-
dures can then be assessed on a more Informed basis.
Case 3

Pathologic descriptions of unilateral renal agenesis date B. S. , a 42-year-old mentally retarded white female had a
at least to 1609 (Consiliorum) and possibly to Aristotle. A history of recurrent urinary tract infections. At excretory urog-
variety of associated anomalies of the genital tract are raphy she had a solitary left kidney; at cystoscopy, no right
ureteral orifice or hemitrigone could be identified. Gray scale
well documented in modern literature. Since the inci-
ultrasound demonstrated a symmetrically bibbed uterus with a
American Journal of Roentgenology 1978.131:973-975.

dence of such anomalies in females has been reported


clearly defined midline septum; the configuration was felt to
as high as 69.9% [1], discovery of a congenital solitary represent a bicornuate uterus (fig. 3). Because of the patient’s
kidney by intravenous urography should prompt evalua- age, mental status, and the extreme unlikelihood of fertility
tion of the female genital tract. We recently encountered being significant, no further workup of her genital tract was
three such cases. To our knowledge, gray scale ultra- considered warranted.
sound studies of this situation have not previously been
reported. Discussion

Previous reports have focused on varying aspects of


Case Reports
unilateral renal agenesis and associated genital anoma-
Case 1
lies; the reported incidence of this association varies [3-
D. K., a 15-year-old white female gravida 0 para 0. had 8]. In a comprehensive review study Collins [9] found 367
abnormal uterine bleeding and a pelvic mass. Physical findings cases of unilateral renal agenesis in 337,488 autopsies,
on admission included a soft anterior adenexal mass on the an incidence of 0.1%. The overall incidence of associ-
right about 8 cm in diameter, normal external genitalia, and a ated anomalies was 58%, with 48% having specific
foul vaginal discharge that subsequently grew E. co/i on culture.
genital anomalies. Fortune [10] found genital anomalies
Excretory urography revealed absence of the right kidney with
in 69.9% of females with congenital solitary kidneys and
compensatory hypertrophy of the left; cystoscopy confirmed a
left hemitrigone. Ultrasonography demonstrated a complex in 21 .2% of males; Longo [1] found a 54.1 % incidence in
right 6 cm adenexal mass in close contiguity with the uterus females and 45.9% in males. The M#{252}llerian duct system
(fig. 1). Oblique scans suggested a septum, and the preopera- develops at a later stage in embryogenesis than the
tive diagnosis of bicornuate uterus with occlusion of the right Wolffian duct and is therefore more likely to undergo
horn was made. After 5 days of parenteral antibiotic therapy, malformation, which has been postulated to account for
the right adenexal mass was smaller by clinical examination. At the higher incidence of associated genital anomalies in
laparoscopy, a bicornuate uterus was observed, united at the females than males. It is accepted that anomalies of the
upper part of the cervix; the right horn was still some 2 cm genital tract occur in a significant percentage of patients
larger than the left. The tubes and ovaries were normal.
with unilateral renal agenesis, and at least a modest
female predominance is generally held.
Case 2 The most common malformations of the female genital
tract associated with an absent kidney are bicornuate
S. S., a 21-year-old white
female, was found to have a solitary
hypertrophied leftkidney at excretory urography performed for
and unicornuate uterus; a complete spectrum of septa-
recurrent urinary tract infections. Cystoscopy demonstrated a tion anomalies involving both uterus and vagina are also
left hemitrigone with no identifiable right ureteral orifice. Ultra- described [9, 11, 12]. Anomalies of the fallopian tubes
sonography imaged a small slender uterus canted to the left and ovaries are reported with considerably less fre-
(figs. 24 and 2B).The small dimensions of the uterus (1 .5 cm quency.

Received June 13, 1978; accepted August 10, 1978.


Department of Diagnostic Radiology, University of Kentucky Medical Center, Lexington, Kentucky 40506. Address reprint requests to A. M. Fried.
2 Present address: Hardin Memorial Hospital, Elizabethtown, Kentucky 42701.
Department of Obstetrics and Gynecology, University of Kentucky Medical Center, Lexington, Kentucky 40506.
Department of Surgery/Urology, University of Kentucky Medical Center, Lexington, Kentucky 40506.

Am J Roentgenol 131:973-975, December 1978 973 0361 -803X/78/1 200-0973 $00.00


© 1978 American Roentgen Ray Society
974 FRIED ET AL.

/N
LJ
LO
*
a

B C
Fig. 1.-Case 1. A, Transverse scan about 6 cm above symphysis. Note rounded complex mass (arrowheads) representing right cornu of uterus and
notch between cornua (N). (LC = left uterine cornu, B = bladder.) B, Lower oblique scan better demonstrating division between cornua of uterus
(arrowhead). (LO = left ovary.) C, Longitudinal scan 3 cm right of midline demonstrating enlarged right cornu; echogenicity in region of endocervical
canal felt to represent purulent material (arrow).
American Journal of Roentgenology 1978.131:973-975.

a
*

a a
a
a
a
a
*
C
B S

A B
Fig. 2.-Case 2. A, Longitudinal scan 4 cm left of midline; left cornu of the uterus is 1.5 cm in anteroposterior diameter. B, Transverse scan 4 cm
above symphysis. Note only 2.5 cm wide left cornu visible (arrow) (B = bladder.) C, Hysterosalpingogram confirming solitary left cornu and tube.

Reports of ultrasonographic studies of uterine anom- screening method. It can be difficult, if not impossible,
alies have been scant and largely confined to the preg- in the pediatric and adolescent female and is at least
nant and puerperal uterus using bistable equipment [13- moderately invasive in any age group. Nonetheless, the
19]. With bistable equipment, HaIler et al. [20] concluded frequency with which genital anomalies are found in
that “abnormalities of septation of the immature uterus association with unilateral renal agenesis dictates further
cannot be identified” although Bennett [21] successfully evaluation of the female genital tract.
demonstrated one case of uterus bicornis unicollis in the The role of ultrasonography in evaluating the unilateral
nonpregnant state. Our experience with gray scale ultra- nonvisualized kidney is well established [22-27]. Suc-
sonography in delineating such abnormalities in three cessful delineation of uterine anomalies by gray scale
nulliparous women suggests that currently available ultrasonography suggests an extension of the logical
units can provide significant diagnostic information in sequence of diagnostic procedures. We propose that the
such cases. kidney not visualized at intravenous urography first be
Several considerations make this application of gray examined ultrasonograph ically. Failure to delineate a
scale ultrasonography significant. Hysterosalpingogra- kidney on ultrasound should suggest possible unilateral
phy, the only other currently available imaging technique renal agenesis, and the female pelvis should then be
for identifying uterine anomalies, is not a satisfactory examined to evaluate the uterus and adenexal structures
ULTRASONOGRAPHY OF UTERINE ANOMALIES 975

$ 5

Fig. 3.-Case 3. A, Transverse P


B C
B
scan 4 cm above symphysis. Note sep-
* C
tum (arrowheads) dividing two uterine
cornua. (B = bladder.) B, Slightly
oblique transverse scan at same level
more clearly demonstrating notch be-
tween cornua (arrowhead).

B
American Journal of Roentgenology 1978.131:973-975.

for congenital malformations. On the basis of ultrasono- 12. Radasch HE: Congenital unilateral absence of the urogeni-
graphic findings, the patient’s age, symptomatology, tal system and its relation to the development of the Wolf-
and clinical setting, a more informed decision can then fian and Muellerian ducts.AmJMedSci 136:111-118, 1908
13. Kobayashi M, Heilman LM, Cromb E: At/as of U/trasonog-
be reached concerning further diagnostic procedures
raphy in Obstetrics and Gyneco/ogy, 7th ed. New York,
(e.g., hysterosalpingography and laparoscopy).
Appleton-Century-Crofts, 1972
14. Arger PH, Zarembok I: Ultrasound efficacy in evaluation of
ACKNOWLEDGMENT lower genitourinary tract anomalies. JCU 3 :61-63, 1975
We thank Nancy Lail for preparing the manuscript. 15. Szoke B, Kiss D: The use of ultrasonic echo technique in
the diagnosis of developmental anomalies of the uterus.
REFERENCES Ann Chir Gynaeco/ 66 : 59-61 , 1977
16. Shkolnik A: B-mode ultrasound and the non-visualizing
1 . Longo VJ, Thompson GJ: Congenital solitary kidney. J Uro/ kidney in pediatrics. Am J Roentgeno/ 128 : 121 -1 25,1977
68:63-68, 1952 17. Von Miscky LI: Gynecologic ultrasonography, in Diagnostic
2. Miller El, Thomas RH, Lines P: The atrophic postmenopau- U/trasound, edited by King DL, St. Louis, Mosby, 1974, pp
sal uterus.JCU 5:261-263, 1977 207-241
3. Ashley DJB, Mostofi FK: Renal agenesis and dysgenesis. J 18. Fisch AE, Jacobson JB: Ultrasound findings in segmental
Uro/ 83:211-230, 1960 uterine distension. JCU 4 : 209-21 2, 1976
4. Meiraz D, Fischelovitch J, Lazebnik J: Agenesis of the 19. Bennett MJ: Puerperal ultrasonic hysterography in the di-
kidney associated with congenital malformation of the sem- agnosis of congenital uterine malformations. Br J Obstet
inalvesicle. BrJ Uro! 45:541-544, 1973 Gyneco/ 83:389-392, 1976
5. Furtado AJL: Three cases of cystic seminal vesicle associ- 20. HaIler JO, Schneider M, Kassner EG: Ultrasonography in
ated with unilateral renal agenesis. Br J Uro/ 45 : 536-540, pediatric gynecology and obstetrics. Am J Roentgeno/
1973 128:423-429, 1977
6. Friedrich M: Eine utero-vaginale Doppelmissbildung mit 21. Bennett MJ II: The ultrasonic diagnosis of uterine fundal
anschliessender Schwangerschaft. Geburtshi/fe Frauen- abnormalities. Excerpts Medica/ /nternationa/ Congress
hei/kd 32:602,1972 363:262-268, 1975
7. Braasch WF, Merricks JW: Clinical and radiological data 22. Sanders RC: The place of diagnostic ultrasound in the
associated with congenital and acquired single kidney. examination of kidneys not seen in excretory urography. J
Surg Gyneco/ Obstet 67: 281-286, 1938 Uro! 114:813-821,1975
8. Schumacker HB: Congenital anomalies of the genitalia 23. Goldberg BB, ed: Abdomina/ Gray Sca/e Ultrasonography.
associated with unilateral renal agenesis. Arch Surg New York, Wiley, 1977
37:586-602, 1938 24. Marangola JF, Bryan PJ, Azimi F: Ultrasonic evaluation of
9. Collins DC: Congenital unilateral renal agenesia. Ann Surg the unilateral nonvisualized kidney. Am J Roentgenol
95:715-726, 1932 126:853-862,1976
10. Fortune CH: The pathological and clinical significance of 25. Hasch E: Ultrasound in the investigation of the kidney and
congenital one-sided kidney defect, with the presentation urinary tract in children. Acta Paediatr Scand 63:42-48,
of three new cases of agenesia and one of aplasia. Ann 1974
/ntern Med 1:377-399, 1927 26. Sweet EM: The place of nephrosonography in renal investi-
11. Vinstein AL, Franken EA: Unilateral hematocoipos associ- gation in childhood.Ann Radio! 20:25, 1977
ated with agenesis of the kidney. Radiology 102:625- 27. Teele RL: Ultrasonography of the genitourinary tract in
627,1972 children. Radio! C/in North Am 15:109-128, 1977