Vesicovaginal reflux: A case report

Vesicovaginal reflux is a common cause of urinary incontinence in girls. A micturating cystourethrogram, which is the diagnostic investigation of choice, can demonstrate retrograde filling of the vagina during micturition and the complete emptying of the vagina at the end of micturition. Vesicovaginal reflux is a rare cause of gross hydrocolpos occurring without any anatomical obstruction. The condition may be associated with functional voiding disturbances.


Introduction
Hydrocolpos is commonly due to an anatomical obstruction such as imperforate hymen, vaginal septum or hypoplastic vagina.Gross distention of the vagina due to refluxed urine has been rarely described.Vesicovaginal reflux (VVR) is a common entity known to be associated with physiologic and pathologic incontinence in the pediatric age group.We report one such case of VVR with classical manifestations.

Case Report
A 14-year-old adolescent, weighing 45 kg, with a normal menstrual history presented with urinary incontinence since childhood.Clinical examination revealed normal external genitalia.There was continuous dribbling of urine from the vagina.On limited per vaginal examination, the introitus admitted one finger and revealed a ballooned-out vagina.Renal function tests and blood counts were within normal limits.Urine examination revealed numerous pus cells, red blood cells and epithelial cells.There was significant bacteriuria (> 1 00 000 colony-forming units/ ml); Escherichia coli was the organism isolated.Urodynamic study demonstrated interrupted voiding flow curves.Ultrasonography of the abdomen and pelvis revealed a grossly distended fluid-filled vagina that was suggestive of hydrocolpos [Figures 1A, B].The uterus, both ovaries and the urinary bladder were normal [Figure 1C].Postmicturition study showed complete evacuation of the vaginal fluid and postvoid residual urine of 50 ml in the urinary bladder [Figure 1D].The ureteric jets on both sides were normally seen within the bladder.No obvious reproductive tract abnormalities were seen.An intravenous

Abstract
Vesicovaginal reflux is a common cause of urinary incontinence in girls.A micturating cystourethrogram, which is the diagnostic investigation of choice, can demonstrate retrograde filling of the vagina during micturition and the complete emptying of the vagina at the end of micturition.Vesicovaginal reflux is a rare cause of gross hydrocolpos occurring without any anatomical obstruction.The condition may be associated with functional voiding disturbances.

Discussion
Even though VVR is commonly encountered, it is an uncommon cause of hydrocolpos.Vesicovaginal reflux causes retrograde filling of the vagina during micturition.It can occur in both, the supine and the upright positions. [1]rinary incontinence, recurrent urinary tract infection (UTI), wetting, vulvovaginitis, irritation of the genitalia, bad smell and vaginal discharge may be the various presentations. [1,3,5]he UTI may be real or due to contamination of urine by the vaginal flora.The condition is common in prepubertal children; however, it may also be seen in postpubertal girls and women. [3]The vaginal distention may be complete, partial or minimal; gross distention is relatively uncommon. [4]The urogenital tract anatomy is usually normal for age . [3,4]][7] The diagnosis of VVR is indicated by resolution of the hydrocolpos on a postvoid USG and can be confirmed  with a voiding cystourethrogram, which shows gradual distension of the vagina during micturition due to its retrograde filling as the bladder empties.A wide bladder neck, as seen in our patient, a spinning top urethra or lowbladder volumes may be the associated functional voiding disturbances. [1,8,9]oss hydrocolpos makes the present case unusual.Absence of hydrometra and a normal menstrual history ruled out an imperforate hymen.The fluid-filled vagina seen posterior to the distended urinary bladder could have been confused with a distended rectum on USG; however, this was ruled out on seeing the cervix suspended at its upper end.Instructions on proper voiding form a key element in the management of VVR. [3]

Figure 1 (
Figure 1(A-D): USG pelvis (A) shows a grossly distended fluidfilled vagina (arrow), posterior to the urinary bladder suggestive of hydrocolpos.3D reformatted image (B) demonstrates a grossly distended, fluid-filled vagina, suggestive of hydrocolpos; the cervix (CX) is suspended at its upper end, posterior to the urinary bladder (UB).USG pelvis (C) shows a normal uterus and cervix (note the distended vagina -three horizontal arrows).Postmicturition USG (D) shows complete evacuation of the vaginal fluid (black arrow) and a urinary bladder post-void residue

Figure 3 :
Figure 3: Sagittal reformatted CT scan of the pelvis shows a contrastfilled vagina, separate and posterior to the urinary bladder, without any anomalous connection/extravasation