(54) A case of obstructed hemivagina and ipsilateral renal anomaly complicated by pelvic abscess in an adolescent patient with history of cloacal anomaly

Background: An association between anorectal malformations and mullerian anomalies has been established in the literature. We present a unique case of a patient with cloacal anomaly and obstructed hemivagina and ipsilateral renal anomaly (OHIVRA) complicated by a pelvic abscess.

Case: An 18-year-old female with cloacal anomaly and history of genitourinary reconstruction at 3 months old and solitary right kidney presented to the emergency room with left lower quadrant pain and constipation. Ultrasound showed a mass on her left ovary, and she was referred to gynecology. In her workup, MRI found didelphys uterus and left hematocolpos. The patient had no prior knowledge of this anatomy and operative reports from her genitourinary surgeries in Italy reported a normal uterus and vagina. The patient was scheduled for excision of vaginal septum and drainage of hematocolpos. The patient returned to the emergency room 1 week before surgery with worsening pelvic pain. Mild leukocytosis was present, but there was low suspicion for infection due to negative urine cultures and her prophylactic antibiotic regimen. She was discharged in a day. During scheduled surgery, a rectovaginal exam revealed a 2-3 cm palpable fluid collection between the right hemivagina and rectum. Exploration of the right hemivagina revealed purulent fluid. The abscess was drained, intraoperative antibiotics were given, and augmentin was prescribed at discharge. One month later, the patient returned to the emergency room due to septic shock secondary to right-sided pyosalpinx. Infectious disease was involved early in care due to complexity of pelvic anatomy and renal history. An abscess drainage tube was placed by interventional radiology. The patient was given intravenous meropenem and doxycycline which was narrowed to oral amoxicillin and flagyl. MRI 3 months later showed a decrease in the size of the abscess. In follow up visits the patient denied fever or pelvic pain that was present before drainage of abscess.

Comments: Coexisting cloacal and renal anomalies should prompt consideration for OHIVRA early on. Normal uterine anatomy should not be assumed based on pre-pubertal records in patients with other anomalies. Re-evaluation at a later age may be necessary if the patient is presenting with menstrual irregularities and pelvic pain. Additionally, surgeons should consider pelvic abscess as a possible intraoperative complication in OHIVRA. The complex anatomy may lend to microperforations that allow a path for bacterial migration from the external environment to the obstructed vagina, as well as between the two vaginas.