Journal of Indian Association of Pediatric Surgeons Medknow Publications on behalf of the Indian Association of Pediatric Surgeons ISSN: 0971-9261 EISSN: 1998-3891 Vol. 12, Num. 4, 2007, pp. 235-237

Journal of Indian Association of Pediatric Surgeons, Vol. 12, No. 4, October-December, 2007, pp. 235-237

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Ultrasound diagnosis of pyocolpos

Gandage SG, Aironi VyankateshD, Agarwal Saurabh, Singh Jitendra

Department of Radiodiagnosis, Rural Medical College, Loni, Tal-Rahata, Ahmednagar, Maharashtra - 413 736
Correspondence Address:Department of Radiodiagnosis, Rural Medical College, Loni, Tal-Rahata, Ahmednagar, Maharashtra - 413 736, v_aironi@yahoo.com

Code Number: ip07077

Abstract

Introduction

Case History

A 45-day-old infant presented with the history of intermittent distension of abdomen since birth with cystic feel of abdomen on clinical examination.

Antero-posterior and lateral radiographs of abdomino-reveal a large soft tissue mass opacity in the abdomen-pelvis region displacing bowel loops superiorly and presenting with the distension of the abdomen and bulging of flank stripes [Figure - 1]A. On ultrasound of the abdomen and pelvis, a large conical structure with a size of 9 x 6 x 4 cm (volume: 90-100 cc) and cystic nature was found to be lying deep in pelvis, extending upto the epigastrium. It was found to be posterior to the urinary bladder and causing the anterior compression and displacement of urinary bladder [Figure - 1]B. The uterus was nondistended (measuring approximately 3 x 2 x 1.5 cm) and identified cranially in continuity with the cephalad aspect of the cystic mass in the epigastrium [Figure - 2]. The cystic lesion shows low-level internal echoes with fluid debris level in the dependent portion [Figure - 3]. On transperineal sonography, 1 cm in the distal portion of normal vaginal cavity was not observed, indicating vaginal atresia in the distal portion [Figure - 4]. There was bilateral mild to moderate hydronephrosis due to compression over the ureters by the cystic lesion [Figure - 5],[Figure - 6]. The patient underwent exploratory laparotomy, which revealed pyocolpos. Hugely dilated vagina extending from the pelvis to epigastrium was observed with the uterus positioned on the top of dilated vagina [Figure - 7],[Figure - 8]. The vaginal contents were drained from the vaginal aspect by a small incision, which revealed pus (approximately 100 ml) draining under pressure from the dilated vagina. The postoperative diagnosis was Pyocolpos.

The drained fluid was sent for culture and sensitivity and microscopy, which confirmed the diagnosis. Postoperative follow-up sonogram revealed normal vaginal echo and normally positioned uterus with normal endometrial echoes [Figure - 9].

Discussion

Hydrocolpos or pyocolpos is a rare congenital disorder with prevalence of 1 in 30000 births; it involves the cystic dilatation of vagina due to the accumulation of mucus/pus secretions resulting from genital tract obstruction. The produced cystic mass arises from the pelvis behind the urinary bladder and extends into abdomen. ^[1],[2] Urinary tract obstruction is due to compression over the ureters, leading to bilateral hydronephrosis. ^[1] Urinoma may develop due to the obstruction of the ureters.

In a neonate or infant, a large tubular cystic fluid-filled structure is observed on ultrasound, which is found low in the pelvis, extending into the abdomen. ^[1] A normal vagina cannot be separately identified. The uterus, whether distended or not, can be identified in continuity with the cephalad aspect of the mass. ^[1] There may be associated distension of uterus and fallopian tubes. The cervix is identified as an hourglass constriction between the dilated and the distensible uterus above and the vagina below. This helps to differentiate hydrocolpos from hydrometrocolpos. ^[1] Sonographically, it is difficult to differentiate hydrocolpos from pyocolpos because of similar appearance of pus and mucus secretions.

The differential diagnosis of hydrocolpos on ultrasound shows ovarian cyst, meconium cyst, duplication cyst, bladder or ureteral abnormality or rectovaginal fistula. ^[3] In order to plan a reconstructive surgery, it is essential to know not only the level of obstruction but also its cause. ^[1] Transperineal ultrasound can be used to evaluate the length of stenotic segment (usually 1-4 cm) ^[1] and to find any solid tissue septum extending from the caudal aspect of the distended vagina to the perineum. ^[1],[3]

The recognition of ultrasound features of pyocolpos is critical as the findings at clinical examination are often vague. In particular, if the case presents as a large lump in the abdomen in a neonate, many possibilities, including neoplasm, renal masses, duplication cysts, etc, are considered. Sonography helps to differentiate all these conditions and helps us in reaching a specific diagnosis.^[5]

References

Copyright 2007 - Journal of Indian Association of Pediatric Surgeons

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