Central Medical Journal of Obstetrics and Gynecology

Case Report *Corresponding authors William James English, Department of Academic Surgery, Royal London Hospital, Whitechapel, London, An Unusual Case of Vaginal E1 1BB, UK, Tel: 07763387896; Email: Submitted: 10 March 2017 Discharge Accepted: 18 April 2017 Published: 20 April 2017 William English1*#, Wei Shen Tan1,2#, Nataly Atalia4, James ISSN: 2333-6439 1,3 Green Copyright 1 Department of Urology, Whipps Cross University Hospital, Barts Health NHS Trust, © 2017 English et al. London, UK 2Division of Surgery & Interventional Science, University College London, London, UK OPEN ACCESS 3Department of Health and Social Care, London Southbank University, London, UK 4Fertility Unit, Holly House Hospital, London, UK Keywords #Both Authors contribute equally • Complications • Management Abstract • In vitro fertilisation • Trauma We present a case of unusual vaginal discharge in a young woman following • Ureteric injury ultrasound guided egg collection for IVF (in vitro fertilisation) who attended A&E with low abdominal pain and clear discharge. After CT intravenous urogram (IVU) a right-sided ureteric injury was identified and treated with insertion of a JJ stent. She recovered well with no immediate or long-term complications. She had a repeat retrograde study of her ureters that demonstrated no leak.

INTRODUCTION The process of IVF involves the harvesting of eggs and through the vaginal wall on the right originating from the right distal ureter (Figure 1). then artificially fertilising them before re-implantation into The patient underwent a right JJ stent insertion of the right organsthe uterus. [1] The commonest complications associated with egg ureter. Retrograde studies demonstrated extravasation from the retrieval include: bleeding, infection and damage to surrounding[2]. right vesicoureteric junction. She was discharged with a catheter. and the incidence of severe complications such as She returned for the removal of her stent five weeks later. intraperitoneal bleeding or ovarian abscess formation is low Retrograde studies confirmed no further contrast extravasation Other complications are associated with anaesthesia and the use in the right ureter after stent removal. She then proceeded with of human chorionic gonadotrophin (hCG) to stimulate ovulation herDISCUSSION IVF treatment. leadingCASE PRESENTATIONto ovarian hyperstimulation syndrome.

Complications following transvaginal egg retrieval are rare A 26 year old lady with primary infertility from polycystic and most commonly include bleeding or infection. More serious ovary syndrome (PCOS) presented to the Emergency Department guidedwith severe egg collectionlower abdominal procedure pain, under new generalclear vaginal anaesthetic discharge for and difficulty micturating after having had an ultrasound (US) in IVF two days previously. The procedure was made difficult by very mobile ovaries requiring repeated needle puncturing of the ovaries. She has no other past medical history. On examination, her abdomen was soft with mild tenderness suprapubically. Her observations were stable and vaginal examination was unremarkable. An abdominal ultrasound revealed enlarged ovaries consistent with previous ovarian stimulation, a normal uterus Figure 1 CT Intravenous urogram demonstrating contast medium and a distended bladder without any evidence of free fluid or vagina. collection in the pelvis. A CT IVU demonstrated free extravasated leak through a fistula between the right vesical ureteric junction and contrast pooling in the area of posterior fornix of vagina, tracking

Cite this article: English W, Tan WS, Atalia N, Green J (2017) An Unusual Case of Vaginal Discharge. Med J Obstet Gynecol 5(2): 1100. English et al. (2017) Email: Central

ACKNOWLEDGMENTS complications, which are rare, include intraperitoneal bleeding vasculatureand ovarian or abscess the urinary formation. and gastro-intestinal Other complications tract [1,3] include. damage to surrounding intra-abdominal structures such as major CONFLICTWe would OFlike INTERESTto thank the patient for the use of her images

There are very [4] few reports of ureteric injury[5] and following uro- None of the contributing authors have any conflict of interest, transvaginal egg retrieval. Other case reports have demonstrated retroperitoneum [4]. inincluding the manuscript. specific financial interests or relationships and fistula formation , ureteric obstruction affiliations relevant to the subject matter or materials discussed REFERENCES The mechanism of injury appears to be the result of any of a 1. Siristatidis C, Chrelias C, Alexiou A, Kassanos D. Clinical complications series of possibilities; hyper-mobile ovaries, abnormal anatomy (possibly secondary to previous infection of pelvic inflammation), the ureters using ultrasound. after transvaginal oocyte retrieval: a retrospective analysis. J Obstet the natural location of the ureters and the difficulty in identifying 2. Gynaecol. 2013; 33: 64-66. Aragona C, Mohamed MA, Espinola MS, Linari A, Pecorini F, Micara Ureteric injury during IVF treatment is potentially under G, et al. Clinical complications after transvaginal oocyte retrieval in reported and most patients are asymptomatic. We believe in the 3. 7,098 IVF cycles. Fertil steril. 2011; 95: 293-294. case reported, the patient was symptomatic because of urinary El-Shawarby S, Margara R, Trew G, Lavery S. A review of complications leak when the bladder is distended with urine and symptoms following transvaginal oocyte retrieval for in-vitro fertilization. Hum stopped following catheterisation to drain the bladder and JJ 4. Fertil (Camb). 2004;7:127-133. stent insertion which may have sealed the defect by tamponade. von Eye Corleta H, Moretto M, D’Avila AM, Berger M. Immediate This case report demonstrates the diagnosis of ureteric injury in ureterovaginal fistula secondary to oocyte retrieval--a case report. a patient presenting with abdominal pain and vaginal discharge 5. Fertil steril. 2008; 90: 2006. e1-3. should make up part of the differential diagnosis as if treated in a Miller PB, Price T, Nichols JE Jr, Hill L. Acute ureteral obstruction time appropriate manner can be managed successfully. following transvaginal oocyte retrieval for IVF. Hum Reprod. 2002;17:137-138.

Cite this article English W, Tan WS, Atalia N, Green J (2017) An Unusual Case of Vaginal Discharge. Med J Obstet Gynecol 5(2): 1100.

Med J Obstet Gynecol 5(2): 1100 (2017) 2/2