Colpolithiasis or vaginal calculi are a rare and unusual finding. They are classified as either primary or secondary vaginal stones, depending on the absence or presence of a foreign body in the vagina, which acts as a nidus for the formation of the secondary calculi.
Most of the primary vaginal calculi are believed to originate from the stasis of urine in the vagina, whereas secondary vaginal calculi are the result of crystallization of urinary constituents around a foreign body in the vagina.An extremely rare combination of OHVIRA syndrome associated with primary vaginal calculus.
Case:A 50 years-old unmarried lady, with primary amenorrhoea, presented in our out-patient clinic with mild pain in the lower abdomen of one week duration which was initially associated with enteritis. She had been treated with a course of antibiotics in a private clinic. Radiological investigations done in the private clinic revealed a calculus in the pelvis which was misdiagnosed as bladder calculus. In view of persistent lower abdominal pain, the patient was referred for gynecological opinion. She was a farmer by occupation, moderately built and nourished, with normal secondary sexual characteristics.
On local examination, the clitoris, urethral opening, labia majora and minora were normal, but the vaginal opening was absent. On rectal examination a stony-hard globular mass of size around 6x5 cm was felt anterior to the rectum, it was fixed and non-tender.
Findings: A computerized tomography scan showed colpolithiasisa laminated oval calcified mass of size 5.1x4.8x3.1cm, located in the pelvis, posterior to the urinary bladder and inferior to the uterus, possibly in the vagina. Vagina was not visualized below the calculus. It also revealed that the right kidney was absent. Left kidney and ureter were normal. She had a unicornuate uterus with normal left ovary and fallopian tube ; right ovary was small in size. Correlative MRI showed the same findings
Diagnosis and treatment: She was diagnosed with OHVIRA syndrome with colpolithiasis. Considering the age of the patient, she was counselled for total abdominal hysterectomy along with the removal of the calculus. Intraoperative findings revealed left unicornuate uterus with normal left tube and ovary. The right Wolffian duct and Mullerian duct components, that is right kidney and ureter, right horn of uterus, fallopian tube and round ligament were absent Total abdominal hysterectomy along with left salpingo-oophorectomy was performed. The vault of vagina was distended with the stony hard mass. The vault was opened and a calcified dark brown colored, vaginal stone of 6x5cms was enucleated from the upper vagina and removed. The upper vagina (approximate length 4 cm) was well developed and ended as a blind pouch. There were no fistulous openings identified in the vagina. Right ovary could not be visualized, though the MRI showed it was present and small in size. Upper vagina was obliterated with three purse string sutures, vault was closed, and rest of the abdomen was closed in layers.
Post-operative period was uneventful. On her first follow-up visit after four weeks she remained asymptomatic. Histopathology of the specimen showed endometrium in proliferative phase, cervix had features of polypoidal endocervicitis and normal left ovary. Myometrium and left fallopian tube were unremarkable. The stone weighed 54.0229gms. Chemical analysis of the calculus showed calcium-magnesium oxalate which is of hematic origin.
Patients with comorbidities and who are immobile for prolonged periods, may also have difficulty in expressing their symptoms contributing to misdiagnosis. Such delay in reaching the correct diagnosis allows the calculus to grow to a fairly large size, that may require surgical intervention at a later date.