MRI STATION

30 September 2021| dr.Din, dr.Nan, dr.Wan, dr.Gun

Patient Identity
Woman Clinical Dx
18 Years Total posterior urethra
Old stenosis

ID number
MRI Pelvis
11511688
 Chief
• Chief Complaint:
Complaint: Unable
Unable to Urinate
to Urinate
Timeline of Case
One day after the accident: Reffered to Performed STSG of the bilateral
Undata General Hospital Palu, femoral region d.t Chronic wound of
performed percutaneous cystostomy the bilateral femoral region in Undata
d.t Urinary retention + PFUI by dr. General Hospital Palu, patient forgot
Aristo, SpU. who was the operator.
March 2018 March 2018 March 2019

March 2018 March 2019

• Had a sudden urinary retention
after being crushed by a truck in the
pelvic region, accompanied by
active bleeding from the genital.
• Delivered to the ER of Samaritan
Hospital Palu, then underwent
situational suture on the patient's
genital by the nurse in charge, and
no catheter insertion was done.
• Four days later: Referred to Urologist at
Wahidin Sudirohusodo Hospital Makassar for Patient has been waiting for the
reconstruction of the thigh and genitalia.
operation until May 2021,
• Queued up for surgery, but was advised to
wait until the wound become dry before
routinely control and underwent
undergo the next surgery. reinsertion of cystostomy
The patient was discharged. catheter in Undata General
• March 2018 until March 2019 the patient Hospital Palu.
come to the polyclinic in Wahidin
Sudirohusodo Hospital several times but still
advised to wait for the operation.
 Arrived at the Saiful Anwar General Hospital Urology
Polyclinic for the first time, then was done:
- Laboratory: CBC, Urinalysis, Ureum, Creatinin, Urine
Culture
- Consult to Orthopaedi Dept dt Bilateral inferior
rami pubic fracture + immobilization  was done
Pelvic Xray AP + Inlet Outlet
- Consult to Obsgyn Dept dt Vaginal Synechia +
Amenorhea)
June 2021 June 24th 2021

June 21st 2021

Referred to Saiful Anwar

General Hospital Malang by
dr. Aristo, SpU for urethral
and genitalia reconstruction
- Orthopaedic Dept (dr. Krisna, SpOT(K))  Planning Tx:
Conservative, ROM exercise
- Obsgyn Dept (dr. Rahajeng, SpOG (K))  Planning Tx:
Release vaginal synechia + neo vagina
 Anamnesis

• Before the accident, the patient had a normal menstruation cycle,

after the accident she did not have any menstruation cycle.
• History of menarche at 12 yo, with duration of 3-5 days, regular cycle
28 days, change pads 3-4 times/day.
• Could barely walk only 50-100 metres because the right hip has
limited movement and feel uncomfortable.
• Wound on the lower abdomen with the size of 3 cm, easy to bleed
and suppurate since the last 6 months.
Physical Examination
• General condition: CM, GCS 456
• BP: 120/80 mmHg, HR: 82x/m, RR: 18x/m, Tax: 36.5’c,
SpO2: 98% room air; Karnofsky Score: 70
• Weight: 48kg, Height: 150cm, BMI: 21.3
• General state:
• Tho: Pulmo/ Rh -/-, Wh -/-, Cor: S1S2 single,
murmur (-), gallop (-).
• Abd: BU + normal, soefl, pain (-)
• Extr: Hyperpigmented scar post skin graft on Right
and Left Femur
• ROM: Right HIP Flexion Limited (+)
• Gait: Limping
Urological state:
R/Flank: mass -/- , CVA Pain -/-
R/ Suprapubic: Unpalpable VU, 18 fr
Cystostomy (+), urine production
1200cc/24hours yellow clear, wound in
suprapubic region with 3x2cm in size, with
muscle base, easy to bleed, pus (+).
R/Ext. Genital: Female, synechia vagina,
MUE couldn’t be evaluated.
DRE: TSA normal, mass (-), BCR (+) N
Laboratory Result
22/06/2021 Value 19/07/2021 Value 19/07/2021 Value
Color Yellow Hb 11,0 FSH 6,23
Urine pH 8,5 Leucocyte 7.970 Estradiol 59,86
Urine Mol 1,010 Trombocyte 392.000
Urine Eritrocyte 3,0 Albumin 4,08
Urine Leucocyte 29,0 Ureum 21,3
Nitrite Positive Creatinine 0,6
Bacteria 4150,3 PPT 10,7 (11,4)
aPTT 31,1 (25,9)
 Abdominal NCCT + CT
Cystography AT RSSA (08/07/2021)

Conclusion
• Right kidney: Multiple Middle-lower pole stones and pyelum
stone, with largest size 14x8,3x3,2mm, density 640-720 HU.
No PCS widening.
• Left kidney: Multiple upper-middle-lower pole stones, with
largest size 4.9x11,2x7.5mm, density 720-1080 HU.
No PCS widening.
 Abdominal NCCT + CT
Cystography AT RSSA (08/07/2021)

Conclusion
• Right kidney: Multiple Middle-lower pole stones and pyelum
stone, with largest size 14x8,3x3,2mm, density 640-720 HU. No
PCS widening.
• Left kidney: Multiple upper-middle-lower pole stones, with
largest size 4.9x11,2x7.5mm, density 720-1080 HU. No PCS
widening.
 Abdominal NCCT + CT
Cystography AT RSSA (08/07/2021)

Conclusion
• Bladder: Stone with size of 15.2x7.98x15.5mm, density 770 HU.
 Abdominal NCCT + CT
Cystography AT RSSA (08/07/2021)

Conclusion
• The vagina appears to be filled with a fluid with lesion of 22 HU
density with a lesion inside with 620 HU density suggesting a
vesico-vaginal fistula, with hydrocolpos.
 Abdominal NCCT + CT
Cystography AT RSSA (08/07/2021)

Conclusion
• Isodense lesion with air density lesion (26-32 HU) associated
with the subcutaneous region of the suprasymphysis suspected
abscess.
MRI 28 September 2021
Tampak panjang urethra (dari bladder neck hingga pertengahan
urethra yang tervisualiasi) sepanjang ±1.9 cm, distal urethra
tidak berada pada pelvic floor ec disrupsi diafragma urogenital
dan injury urethra. Jarak urethra dengan pelvic floor ±3.5 cm.
Distal urethra bermuara pada vagina yang terisi cairan. Orificum
urethra externa sulit diidentifikasi
Tampak struktur tubuler yang menyerupai tract pada sisi anterior vesica urinaria yang fistulasi pada kutan
hemiabdomen kiri bawah dengan defek selebar ±2 cm sepanjang ±7.4 cm
Tampak distal vagina fistulasi ke anterior dan berhubungan dengan struktur tubuler tersebut
(anterior vesica urinaria), menuju kutan
Tampak distensi vagina dengan intensitas Tampak lesi hipointens pada pelvic
cairan iso-hipointens T1WI isohiperintens floor yang mengesankan jaringan
T2WI didalamnya ukuran ± 9.8x2.9x14 cm fibrotik
Uterus : Ukuran ±1.6x7.1 mm dengan endometrial Ovarium D: Ukuran ±1.9 x1.9x2.1 cm, tidak tampak lesi patologis. tampak folikel
line dan junctional zone baik. cavum uteri tidak multipel dengan ukuran terbesar ±1.1x0.7cm
terbuka. tidak tampak lesi patologis Ovarium S: Ukuran ±2x1.5x3 cm, tidak tampak lesi patologis. tampak folikel
multipel dengan ukuran terbesar ±0.8x0.6 cm
Vesica urinaria : terisi urin, dinding regular, tampak batu multipel ukuran terbesar ±1.7x0.7 cm. tampak terpasang
balon kateter.
Tampak disrupsi dengan intensitas hiperintens pada m. obturator externus-internus Ketebalan m. Gluteus maximus. Dextra: 1.1 cm. Sinistra: 2.3 cm
kanan, m. pectineus kanan
Kesimpulan
• Hydrocolpos disertai synechiae
vagina dengan fistel tract
vaginokutan hemiabdomen kiri
bawah
• Injury distal urethra dengan floating
bladder, urethra berhubungan
dengan vagina
• Atrophy musculus hemipelvis kanan
• Chronic injury pelvic floor
• Vesicolithiasis multipel
UNDERLYNG THEORY
 Hematocolpos

A term given to a blood-filled dilated vagina due to menstrual blood in the setting of

an anatomical obstruction, usually an imperforate hymen.
Patients may present with amenorrhea or vague abdominal pain.
 Hydrocolpos
• Characterized by an expanded fluid filled vaginal cavity
• When it is associated with distention of the uterine cavity,
the term hydrometrocolpos should then be used.
• It may present in infancy with a lower abdominal mass, or be
delayed till menarche.
Schematic illustrations show coronal views of congenital
urogenital anomalies causing hematocolpos. The accumulated
blood in the vagina is colored in red.
a Imperforate hymen.
b Distal vaginal agenesis.
c Complete transverse vaginal septum.
d Obstructed hemivagina and ipsilateral renal anomaly
(OHVIRA)
 Differential diagnosis

• Hematometrocolpos
• Hematocolpos
• Pelvic abscess
• Rhabdomyosarcoma
• Ovarian tumor
Development of the vagina. a After the caudal tip of the
fused Müllerian ducts reaches the urogenital sinus, a
sinovaginal bulb grows out of the sinus. b The
sinovaginal bulb proliferates and forms a solid vaginal
plate. Proliferation continues at the cranial end of the
plate. c By the 5th month, the vaginal plate is entirely
canalized and forms the vagina
Instilling of jelly through the vaginal introitus for
evaluating transverse vaginal septum. a Schematic
illustration shows a sagittal view of
hematometrocolpos due to transverse vaginal
septum. There is a difficulty to distinguish the vaginal
septum from the collapsed lower vagina. b After
instilling of jelly through the vaginal introitus,
hematometrocolpos (colored in red), the vaginal
septum (arrow), and the lower vaginal segment
containing jelly (colored in blue) are clearly shown.
Intravaginal infusion of jelly has been reported to
provide information on the level and thickness of the
vaginal septum
 Labial Synechiae
 Labial synechiae, also referred to as labial adhesion or labial agglutination, is a disorder of the female
genitalia characterized by thin, membranous adherence of the labia minora.

 Typically, the fusion originates from the posterior fourchette and advances toward the clitoris. Complete
labial fusion may conceal the vaginal introitus completely. Partial labial fusion is also possible and may
occur near the posterior fourchette.
 Labial Synechiae
 Labial synechiae is not a congenital disorder.
 Synechiae is probably the result of chronic inflammation as a result of vulvovaginitis or chronic dampness resulting
from urinary incontinence.
 Few layers of epithelial cells may denudate from the labia minora and apposition of the eroded areas can result in
labial synechiae formation.
 The relative hypoestrogenic state has been postulated to be the cause behind its prevalence in childhood and in elderly
women.
 Labial synechiae has also been reported secondary to childhood sexual abuse and may be related to consequential
lacerations or hematoma formation.
 The use of nappies has also been incriminated as a cause.
 Labial Synechiae
Synechia vulvae (adhesions of the labia minora) are characterized by a complete or partial fusion of the
labia minora in the midline.

In the majority of cases, vulvae adhesion causes no symptoms but occasionally it can cause urinary
infections and difficulties in micturition. It is usually observed within the first 2 years of life