Double uterus is a congenital anomaly of the structure of the genitals, characterized by the presence of two separate uterus and two forked vaginas. The clinic of double and vagina depends on the anatomical form of the defect; it may be accompanied by algodismenorrhea, hematocolpos formation, hematometers, infertility, miscarriage or be asymptomatic. Double uterus is diagnosed by gynecological examination, ultrasound, MRI, hysteroscopy, laparoscopy. The method of surgical treatment of uterine doubling depends on the nature of anatomical and functional disorders.
Double uterus and vagina is a dysembriogenetic disorder that develops due to incomplete fusion of paired Muller channels during intrauterine development. The effect of teratogenic factors during pregnancy can prevent the resorption of the walls of the Muller ducts and lead to the formation of various anatomical variants of doublie uterus and vagina. Risk factors for the development of the defect include the effect on the fetus of occupational hazards or harmful habits of a pregnant woman, viral infections (influenza, rubella, toxoplasmosis), toxic drugs, especially in the period from 8 to 16 weeks of gestation.
Classification of forms
The most pronounced form of the defect in gynecology is considered to be a variant of complete doublie uterus and vagina. At the same time, two isolated uterus are determined in the patient, from each of which one fallopian tube with an ovary, two separate cervixes and two vaginas depart. Both uterus and vagina can be separated from each other by the bladder and rectum, or closely touch the walls. In some cases, both halves are anatomically and functionally complete, in others – one of the halves is less developed.
A form of defect is possible in which there is a double uterus (body and cervix) with one vagina. When doubling only the body of the uterus and the presence of a common cervix and vagina, there are variants of a bicornuate uterus, a saddle uterus, an intrauterine septum, a uterus with a functioning rudimentary closed horn. Defects in which non-effusion and aplasia of the embryonic ducts occur simultaneously include variants of double uterus and vagina in combination with:
- partial (incomplete) aplasia of one vagina
- partial (incomplete) aplasia of two vaginas
- complete aplasia of two vaginas
- total unilateral aplasia of the entire duct (one-horned uterus).
Double uterus and vagina in most cases is combined with other defects of the genitourinary system. In particular, double uterus with partial aplasia of one of the vaginas is always accompanied by aplasia of the kidney on the side of the genital defect. Often, patients with double uterus have atresia of the hymen.
Symptoms of double uterus
The presence of two separate uteruses and vaginas may not cause clinical manifestations and be diagnosed during routine gynecological examination, ultrasound or surgical intervention. In the case of complete double uterus and vagina in combination with aplasia or atresia of one vaginal cavity, 3-6 months after the first menstruation, a picture of hematocolpos, hematometers, hematosalpinx develops on the side of the isolated cavity. In this case, the symptoms are characterized by severe bursting pains in the lower abdomen, not stopped by antispasmodics and painkillers. With a saddle uterus and an intrauterine septum, clinical manifestations in adolescence are usually absent.
In the presence of a fistula in the intervaginal septum, menstrual blood may partially flow through a full-fledged vagina. When a secondary infection is attached, piokolpos, pyometra, and piosalpinx are often formed. In patients with a fistula opening in the intervaginal septum, permanent bloody discharge or purulent whiteness from the genital tract are noted.
The combination of double uterus with hypofunction of the ovaries can be accompanied by algodismenorrhea, amenorrhea, infertility. With a full-fledged one or two uterine cavities, pregnancy is possible, but usually occurs with the threat of spontaneous termination and premature birth. Childbirth with double uterus is often complicated by discoordination or weakness of labor activity, copious postpartum bleeding, lochiometry.
With the development of the fetus in one uterine cavity, a decidual membrane is also formed in the other, which is rejected in the postpartum period. If for some reason an artificial termination of pregnancy is performed, then both uterine cavities are scraped. When pregnancy occurs in a rudimentary horn, it proceeds according to the type of ectopic, which is fraught with rupture of the horn and abundant, dangerously dangerous bleeding into the abdominal cavity.
In the complex of step-by-step diagnostics of double uterus and vagina, anamnesis, gynecological (including rectoabdominal) examination, vaginoscopy (colposcopy), hysteroscopy, ultrasound or MRI of the pelvis, ultrasound and CT of the kidneys, laparoscopy are carried out.
Complete doubling of the vagina and cervix can be visually determined already during gynecological examination and vaginoscopy. With aplasia of one vagina, only a full-fledged vagina is available for examination, in the dome of which one cervix is determined. Vaginoscopy with double uterus and aplasia of the accessory vagina reveals protrusion in the area of the lateral vaginal wall; rectoabdominal examination determines hematocolpos and hematometer in the form of a tumor-like motionless formation of a tugoelastic consistency.
In the presence of a fistula during the rectoabdominal examination, an increase in purulent discharge is noted. With a rudimentary closed horn, one vagina and one cervix are detected, but rectoabdominal examination allows you to palpate a painful formation next to the uterus, which tends to increase during menstruation; hematosalpinx is also determined on its side.
Ultrasound of the pelvis with typical forms of double uterus allows you to determine the size of both cavities, the size of the hematocolpos and hematometers. An obligatory stage of diagnosis is ultrasound of the kidneys to assess their condition. With atypical forms of uterine doubling, it is advisable to perform pelvic MRI, hysteroscopy and laparoscopy.
Double uterus and vagina often leads to diagnostic errors and, as a result, unjustified interventions – appendectomy, tubectomy or removal of appendages, augmentation of the cervical canal and vagina. If a pathology of the urinary system and kidneys is detected, a consultation with a urologist or a nephrologist is necessary.
Treatment of double uterus
Surgical tactics in the case of complete double uterus and partial aplasia of one vagina are indicated in cases of violation of the outflow of menstrual blood. At the same time, during the vaginal stage, dissection of the vaginal walls is performed with the formation of a message between the functioning and closed cavities, opening and drainage of the hematocolpos, sanitation of the vagina. At the laparoscopic stage, the relative position of the uterus is clarified, the hematometer and hematosalpinx are emptied, and the abdominal cavity is sanitized.
In case of hymen atresia, an X-shaped dissection of the hymen is performed under local anesthesia and the hematocolpos is eliminated. Surgical gynecology considers the identification of an additional closed horn as an indication for hysterectomy – extirpation of the rudimentary uterus with preservation of the ovary and fallopian tube. The presence of an intrauterine septum is an indication for metoroplasty only in violation of reproductive function. When doubling the uterus with complete or partial aplasia of both vaginas, various methods of colpoelogation and peritoneal colpopoiesis are used.