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DOI:10.2214/AJR.07.3679
AJR 2008; 191:W71
© American Roentgen Ray Society

Uterine Diverticula and Accessory Ducts

Peter Evan and Beverley Kramer

Netcare Park Lane Clinic Johannesburg, Republic of South Africa
University of Witwatersrand Johannesburg, Republic of South Africa



 
WEB—This is a Web exclusive article.

Our patient is a 34-year-old woman investigated for secondary infertility. She has two children born by uncomplicated vaginal delivery. The patient has no history of surgery, trauma, or pelvic infection. Hysterosalpingography revealed an anteflexed uterus. Both fallopian tubes were normal. An additional tubular structure arising from the left side of the uterus at the junction of the body and cervix was noted (Figs. 1A and 1B). Two small diverticula were seen on the right.


Figure 1
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  		Fig. 1A —34-year-old woman examined for secondary infertility. Hysterosalpingogram shows extra tube on left (white arrow). Two uterine diverticula are seen on right (black arrows).

 

Figure 2
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  		Fig. 1B —34-year-old woman examined for secondary infertility. Hysterosalpingogram shows extra tube on left (white arrow). Two uterine diverticula are seen on right (black arrows).

 
In our opinion, these findings are a developmental anomaly, not an acquired condition. We consider this to be a true duplication (splitting) of either mesonephric or paramesonephric duct. We use the term mesonephric for Wolffian and paramesonephric for müllerian ducts, as preferred by embryologists. The splitting occurs at the 7th week [1]. The division may be short, or it may be extensive and bilateral [1]. The duplicated paramesonephric duct runs parallel to the normal tube and may fuse with it on one or both ends. In the radiologic literature [2], the duplication of the paramesonephric duct means either failure of fusion (types II, III, IV) or failure of septal resorption (types V or VI). True duplications of the mesonephric and paramesonephric ducts are not mentioned.

Clinical manifestations include incidental findings, as in our case; parauterine pelvic mass; uterine diverticula; accessory or rudimentary horn of the uterus; accessory tube; renal and ureteric abnormalities; or a combination of these. Mesonephric and paramesonephric duct duplications may coexist in the same patient. Histology will differentiate between the two.

Cervical diverticula are occasionally seen, but true uterine diverticula are extremely rare in nonpregnant women [3]. They represent localized duplication of the distal paramesonephric duct and may mimic uterine sacculation of pregnancy. Most of the accessory diverticula and tubes are a portion of the epoophoron, which is a mesonephric duct remnant [1]. The most common complications are dysmenorrhea, infection, and ectopic pregnancy. Ectopic pregnancy may mimic abdominal pregnancy, has a 70% chance of rupture, and does not respond to induction of labor. Saharan and Parulekar [4] described a patient with a rudimentary horn of the uterus and an anomalous tubular structure on the right, where a normal ureter is expected. The right kidney and ureter were absent. The diagnosis of persistent mesonephric duct was confirmed at surgery and by biopsy.

Our presentation has two drawbacks. First, the status of the right kidney and ureter are unknown because evaluation of the urinary tract was not done. Second, there was neither surgical nor biopsy correlation because these were not indicated. True duplications are documented in the anatomic, pathologic, surgical, and gynecologic literature, but we did not find any references in the available English-language radiologic literature. The diverticula and accessory duct are compatible with both mesonephric and paramesonephric duct. On the basis of the course of the additional tube, we believe that our case is a true duplication of the mesonephric duct.


References
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 References
 

  1. Gray SW, Skandalakis JE. Embryology for surgeons. Philadelphia, PA: W. B. Saunders, 1972:596 -597, 640, 651
  2. Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology 2004;233 : 19-34[Abstract/Free Full Text]
  3. Engel G, Rushovich AM. True uterine diverticulum. A partial mullerian duplication? Arch Pathol Lab Med1984; 108:734 -736[Medline]
  4. Saharan SP, Parulekar SV. Hemihaematometra with persistent underdevelped Wolffian duct. J Posgrad Med (serial online) 1993 (cited 2007 Dec 19); 39:98 . http://www.jpgmonline.com/text/asp?1993/39/2/98/623

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