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MR Imaging Diagnosis of Uterovaginal Anomalies: Current State of the Art¹

¹ From the Radio-diagnosis Department, Cairo University Faculty of Medicine, Kasr Al-Ainy Hospital, 4 St 49 Mokattam, Cairo 11451, Egypt. Presented as an educational exhibit at the 2002 RSNA scientific assembly. Received March 21, 2003, revision requested May 15, revision received and accepted June 2. Address correspondence to the author (e-mail: saharsaleem@yahoo.com).

View larger version (44K): [in a new window]   Figure 2.  Diagram of a unicornuate uterus.

View larger version (52K): [in a new window]   Figure 3.  Diagram of a didelphic uterus.

View larger version (44K): [in a new window]   Figure 4.  Diagram of a bicornuate uterus.

View larger version (48K): [in a new window]   Figure 5.  Diagram of a septate uterus.

View larger version (141K): [in a new window]   Figure 6.  Normal uterine zonal anatomy in a woman of reproductive age. Sagittal T2-weighted FSE image (repetition time [msec]/echo time [msec]: 4,000/96) obtained with a pelvic phase-array coil shows a normal-size uterus and body-to-cervix ratio. The zonal anatomy, with differentiation between the high-intensity endometrium (E), low-intensity junctional zone (arrow), and intermediate-intensity outer myometrium, is well seen.

View larger version (148K): [in a new window]   Figure 7.  Normal vagina seen in the axial plane. T2-weighted FSE (4,000/96) image obtained with a pelvic phase-array coil shows the vagina as an intermediate-intensity tube (arrow) between the bladder base (B) anteriorly and the rectum (R) posteriorly.

View larger version (163K): [in a new window]   Figure 8.  Uterine hypoplasia (class 1). Sagittal T2-weighted spin-echo image (4,000/98) shows a small uterus with poorly developed zonal anatomy (arrow) in an 18-year-old woman with primary amenorrhea.

View larger version (158K): [in a new window]   Figure 9a.  Mayer-Rokitansky-Kuster-Hauser syndrome (class 1). (a) Sagittal T2-weighted FSE image (4,000/104) documents the absence of uterine tissues. A concurrent mature pelvic cystic teratoma (MCT) is noted. (b) Axial T2-weighted FSE image (4,000/104) shows absence of vaginal tissue between the bladder (B) and the rectum (R).

View larger version (135K): [in a new window]   Figure 9b.  Mayer-Rokitansky-Kuster-Hauser syndrome (class 1). (a) Sagittal T2-weighted FSE image (4,000/104) documents the absence of uterine tissues. A concurrent mature pelvic cystic teratoma (MCT) is noted. (b) Axial T2-weighted FSE image (4,000/104) shows absence of vaginal tissue between the bladder (B) and the rectum (R).

View larger version (136K): [in a new window]   Figure 10.  Transverse vaginal septum (class 2). Sagittal T2-weighted spin-echo image (4,000/98) shows a transverse septum in the middle of the vagina (arrow), causing dilatation of the proximal vagina (V) and uterus (U) (hematocolpos and hetmatometria).

View larger version (139K): [in a new window]   Figure 11.  Obstructed hymen (class 2). Sagittal T1-weighted spin-echo image (500/8) shows a dilated hematometrocolpos. The obstruction is at the level of perineum (arrow).

View larger version (167K): [in a new window]   Figure 12a.  Simple left unicornuate uterus associated with right renal agenesis (class 3). (a) Axial T2-weighted FSE image (2,000/120) shows a laterally deviated banana-shaped uterus (arrow). No rudimentary horn could be detected. (b) Coronal T1-weighed spin-echo image (500/8) with large FOV (45cm) shows right renal agenesis.

View larger version (144K): [in a new window]   Figure 12b.  Simple left unicornuate uterus associated with right renal agenesis (class 3). (a) Axial T2-weighted FSE image (2,000/120) shows a laterally deviated banana-shaped uterus (arrow). No rudimentary horn could be detected. (b) Coronal T1-weighed spin-echo image (500/8) with large FOV (45cm) shows right renal agenesis.

View larger version (173K): [in a new window]   Figure 13a.  Septate uterus: incomplete septum (class 3). Multiple images in different planes were obtained in the same patient. The solid red line in the right-lower-corner inset indicates the plane of section. (a) Direct coronal T2-weighted FSE image (5,000/96) shows double uteri but has limited value in evaluation of the fundus. (b, c) Oblique long-axis T2-weighted FSE images (4,000/96) obtained parallel to the long axis of the uterus show the convex external contour of the fundus (arrow in b). The intercornual distance (dotted line) is 3.5 cm. The intercornual angle between the distal ends of the horns is less than 60° (intersecting lines). The uterine septum is thick and isointense to myometrium, which indicates it is muscular. The lower extent of the uterine septum in the cervical canal is unclear (? arrow). (d) Oblique short-axis T2-weighted FSE image (4,000/96) of the cervix obtained perpendicular to the long axis of the uterus (dotted line in inset) shows a single cervical canal. The arrowhead points to normal infolding of the cervix seen in many cases without associated anomalies.

View larger version (169K): [in a new window]   Figure 13b.  Septate uterus: incomplete septum (class 3). Multiple images in different planes were obtained in the same patient. The solid red line in the right-lower-corner inset indicates the plane of section. (a) Direct coronal T2-weighted FSE image (5,000/96) shows double uteri but has limited value in evaluation of the fundus. (b, c) Oblique long-axis T2-weighted FSE images (4,000/96) obtained parallel to the long axis of the uterus show the convex external contour of the fundus (arrow in b). The intercornual distance (dotted line) is 3.5 cm. The intercornual angle between the distal ends of the horns is less than 60° (intersecting lines). The uterine septum is thick and isointense to myometrium, which indicates it is muscular. The lower extent of the uterine septum in the cervical canal is unclear (? arrow). (d) Oblique short-axis T2-weighted FSE image (4,000/96) of the cervix obtained perpendicular to the long axis of the uterus (dotted line in inset) shows a single cervical canal. The arrowhead points to normal infolding of the cervix seen in many cases without associated anomalies.

View larger version (161K): [in a new window]   Figure 13c.  Septate uterus: incomplete septum (class 3). Multiple images in different planes were obtained in the same patient. The solid red line in the right-lower-corner inset indicates the plane of section. (a) Direct coronal T2-weighted FSE image (5,000/96) shows double uteri but has limited value in evaluation of the fundus. (b, c) Oblique long-axis T2-weighted FSE images (4,000/96) obtained parallel to the long axis of the uterus show the convex external contour of the fundus (arrow in b). The intercornual distance (dotted line) is 3.5 cm. The intercornual angle between the distal ends of the horns is less than 60° (intersecting lines). The uterine septum is thick and isointense to myometrium, which indicates it is muscular. The lower extent of the uterine septum in the cervical canal is unclear (? arrow). (d) Oblique short-axis T2-weighted FSE image (4,000/96) of the cervix obtained perpendicular to the long axis of the uterus (dotted line in inset) shows a single cervical canal. The arrowhead points to normal infolding of the cervix seen in many cases without associated anomalies.

View larger version (162K): [in a new window]   Figure 13d.  Septate uterus: incomplete septum (class 3). Multiple images in different planes were obtained in the same patient. The solid red line in the right-lower-corner inset indicates the plane of section. (a) Direct coronal T2-weighted FSE image (5,000/96) shows double uteri but has limited value in evaluation of the fundus. (b, c) Oblique long-axis T2-weighted FSE images (4,000/96) obtained parallel to the long axis of the uterus show the convex external contour of the fundus (arrow in b). The intercornual distance (dotted line) is 3.5 cm. The intercornual angle between the distal ends of the horns is less than 60° (intersecting lines). The uterine septum is thick and isointense to myometrium, which indicates it is muscular. The lower extent of the uterine septum in the cervical canal is unclear (? arrow). (d) Oblique short-axis T2-weighted FSE image (4,000/96) of the cervix obtained perpendicular to the long axis of the uterus (dotted line in inset) shows a single cervical canal. The arrowhead points to normal infolding of the cervix seen in many cases without associated anomalies.

View larger version (140K): [in a new window]   Figure 14.  Complete septate uterus (class 3). Oblique long-axis T2-weighted FSE image (4,000/96) shows a septate uterus with a complete septum extending to the external os. The septum is thin and has low signal intensity, which indicates it is fibrous.

View larger version (129K): [in a new window]   Figure 15.  Bicornuate uterus (class 3). Oblique long-axis T2-weighted spin-echo image (4,000/12) shows double uterine bodies and a single cervix. The fundus is deeply notched (arrow) with a large intercornual distance (5.5 cm). The intercornual angle is also large. The ovaries are well displayed bilaterally.

View larger version (189K): [in a new window]   Figure 16.  Didelphic uterus (class 3). Axial T2-weighted spin-echo image (5,000/98) shows fully developed, widely splayed double uteri with two cervices.

View larger version (174K): [in a new window]   Figure 17.  Unicornuate uterus with an obstructed functioning rudimentary horn (class 3). Coronal T2-weighted spin-echo image (4,000/120) shows a right unicornuate uterus (arrow). The obstructed functioning rudimentary horn appears as a blood-filled dumbbell-shaped mass. Its shape corresponds to the obstructed uterine horn (H) and its fallopian tube (T), a hematometrosalpinx. Both ovaries (Ov) are identified; each is related to its ipsilateral uterine horn.

View larger version (180K): [in a new window]   Figure 18a.  Double uterus with complete obstructed hemivagina and ipsilateral renal agenesis (class 3). T2-weighted FSE image (3,500/120) were obtained in multiple planes. (a) Coronal view shows right unilateral distention (arrow) of a duplicated uterus with ipsilateral renal agenesis. (b) Axial view documents the asymmetric right uterine cavity. (c) Parasagittal T2-weighted FSE image (3,500/120) obtained in the right uterine cavity shows the obstruction at the level of the proximal vagina.

View larger version (154K): [in a new window]   Figure 18b.  Double uterus with complete obstructed hemivagina and ipsilateral renal agenesis (class 3). T2-weighted FSE image (3,500/120) were obtained in multiple planes. (a) Coronal view shows right unilateral distention (arrow) of a duplicated uterus with ipsilateral renal agenesis. (b) Axial view documents the asymmetric right uterine cavity. (c) Parasagittal T2-weighted FSE image (3,500/120) obtained in the right uterine cavity shows the obstruction at the level of the proximal vagina.

View larger version (169K): [in a new window]   Figure 18c.  Double uterus with complete obstructed hemivagina and ipsilateral renal agenesis (class 3). T2-weighted FSE image (3,500/120) were obtained in multiple planes. (a) Coronal view shows right unilateral distention (arrow) of a duplicated uterus with ipsilateral renal agenesis. (b) Axial view documents the asymmetric right uterine cavity. (c) Parasagittal T2-weighted FSE image (3,500/120) obtained in the right uterine cavity shows the obstruction at the level of the proximal vagina.

View larger version (124K): [in a new window]   Figure 19a.  Didelphic uterus and longitudinal vaginal septum combined with obstructed hymen (class 4). (a) Direct coronal T1-weighted spin-echo image (420/6) shows a markedly distended vagina with altered blood products (hematocolpos); obstruction is at the level of the hymen (arrow). A longitudinal septum (arrowhead) splits the vagina into two compartments, sparing its lowest part, which has a different embryologic origin. (b) Sagittal T2-weighted FSE image (4,000/98) shows that the uterus is connected to each vaginal compartment (only one side is shown).

View larger version (148K): [in a new window]   Figure 19b.  Didelphic uterus and longitudinal vaginal septum combined with obstructed hymen (class 4). (a) Direct coronal T1-weighted spin-echo image (420/6) shows a markedly distended vagina with altered blood products (hematocolpos); obstruction is at the level of the hymen (arrow). A longitudinal septum (arrowhead) splits the vagina into two compartments, sparing its lowest part, which has a different embryologic origin. (b) Sagittal T2-weighted FSE image (4,000/98) shows that the uterus is connected to each vaginal compartment (only one side is shown).

View larger version (98K): [in a new window]   Figure 20.  Pelvic phase-array coil. The anterior (A) and posterior (P) coils are held in opposition by straps around a sponge model.

View larger version (149K): [in a new window]   Figure 21a.  An ectopic anal opening in the vaginal fornix of a septate uterus (same patient in Fig 12). The clinical examination showed absent anus in the perineum, with fecal matter coming from the vaginal opening. (a) Sagittal T2-weighted FSE image (4,000/98) obtained with the body coil shows poor detail in the uterine hemicavity and surrounding tissues. (b) An identical sequence used with the pelvic coil shows more detail at the suggested site of the ectopic anal opening (arrow) in the posterior vaginal fornix. Note the markedly distended colon (C).

View larger version (142K): [in a new window]   Figure 21b.  An ectopic anal opening in the vaginal fornix of a septate uterus (same patient in Fig 12). The clinical examination showed absent anus in the perineum, with fecal matter coming from the vaginal opening. (a) Sagittal T2-weighted FSE image (4,000/98) obtained with the body coil shows poor detail in the uterine hemicavity and surrounding tissues. (b) An identical sequence used with the pelvic coil shows more detail at the suggested site of the ectopic anal opening (arrow) in the posterior vaginal fornix. Note the markedly distended colon (C).

View larger version (116K): [in a new window]   Figure 22.  Endovaginal MR coil. The RF coil loop is fixed inside an inflatable balloon mounted on a plastic rod. Fifty milliliters of air are usually sufficient to inflate the balloon inside the vagina.

View larger version (165K): [in a new window]   Figure 23a.  Cervical agenesis diagnosed with an endovaginal MR coil. (a) Coronal T1-weighted image (420/6) obtained with the body coil shows double uteri (R and L) ; the left one is functioning and blood-filled. The cervix could not clearly identified (?). (b) Coronal T1 weighted image after insertion of endovaginal MR coil (C) documents cervical agenesis. The cervix is replaced by a transverse band of low signal intensity (fibrous) connecting the double uteri (arrow) (class 4).

View larger version (148K): [in a new window]   Figure 23b.  Cervical agenesis diagnosed with an endovaginal MR coil. (a) Coronal T1-weighted image (420/6) obtained with the body coil shows double uteri (R and L) ; the left one is functioning and blood-filled. The cervix could not clearly identified (?). (b) Coronal T1 weighted image after insertion of endovaginal MR coil (C) documents cervical agenesis. The cervix is replaced by a transverse band of low signal intensity (fibrous) connecting the double uteri (arrow) (class 4).

View larger version (162K): [in a new window]   Figure 24a.  Incomplete septate uterus diagnosed with endovaginal MR coil. (a) Oblique long-axis T2-weighted FSE image (4,000/96) obtained with a pelvic phase-array coil shows a septate uterus. The lower extent of the uterine septum in the cervical canal is not clear. (b) Oblique long-axis T2-weighted FSE image image (3,600/98) obtained after insertion of endovaginal MR coil documents a single cervical canal (arrow), thus demonstrating an incomplete septate uterus.

View larger version (148K): [in a new window]   Figure 24b.  Incomplete septate uterus diagnosed with endovaginal MR coil. (a) Oblique long-axis T2-weighted FSE image (4,000/96) obtained with a pelvic phase-array coil shows a septate uterus. The lower extent of the uterine septum in the cervical canal is not clear. (b) Oblique long-axis T2-weighted FSE image image (3,600/98) obtained after insertion of endovaginal MR coil documents a single cervical canal (arrow), thus demonstrating an incomplete septate uterus.

View larger version (52K): [in a new window]   Figure 25.  Flowchart of a suggested five-step approach for disgnosing uterovaginal anomalies with MR imaging.