Open Journal of Obstetrics and Gynecology, 2011, 1, 213-216 OJOG
doi:10.4236/ojog.2011.14041 Published Online December 2011 (http://www.SciRP.org/journal/ojog/).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG
Non-Communicating inactive rudimentary horn of the uterus
presenting with dysmenorrhoea—a case report of successful
laparoscopic excision
Rachana Dwivedi1, Keerthi Perera2, Padma Eedarapalli1
1The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK;
2Poole Hospital NHS Foundation Trust, Poole, UK.
Received 7 September 2011; revised 17 October 2011; accepted 27 October 2011.
ABSTRACT
Uterine developmental abnormalities can cause both
obstetric and gynaecological complications. Non-func-
tioning rudimentary uterine horn is a rare cause of
dysmenorrhoea which usually starts after menarche.
Cases with lateral/inferior arrangement of blood su-
pply to the functioning rudimentary horn and lapa-
scopic removal have been described in literature. Ours
is a unique case of non-functioning rudimentary horn
with an unusual medial arrangement of vasculature
successfully treated by laparoscopic excision. We also
present a brief review of the literature. The patient
presented with irretractable dysmenorrhoea despite
hormonal manipulation and analgesics. Following the
diagnosis using laparoscopy and hysteroscopy and
MRI, the left sided non-communicating rudimentary
horn with inactive endometrium was removed lapa-
roscopically. Her symptoms were r esolved and this was
followed by successful pregnancies. Diagnosis of ru-
dimentary horn with inactive endometrium is diffi-
cult. Ultrasound is unreliable. MRI, 3D CT scan and
3D ultrasound are gaining popularity. Accurate, prior
identification of the type using laparoscopy and hys-
teroscopy if necessary is essential. This helps in sur-
gical planning. The laparoscopic approach is increa-
singly being used to resect these horns due to its sa-
fety and merits.
Keywords: Dysmenorrhoea; Rudimentary Horn; Lapa-
roscopic Excision
1. INTRODUCTION
Congenital uterine anomalies result from arrested de-
velopment of one or both of the Mullerian ducts and/or
their defective fusion. In 80% - 90% of cases, there is no
communicating channel between the two uterine cavi-
ties [1]. There are many cases reported with non-commu-
nicating rudimentary horn and the functioning endome-
trium associated with various complications such as dys-
menorrhoea, adenomyosis, ectopic pregnancy and haema-
tometra [2,3]. There are also several in literature, treated
with laparoscopic excision where the blood supp ly of the
rudimentary horn was either lateral or inferior [4]. How-
ever, to our knowledge, there are no case reports of uni-
cornuate uterus and a non-communicating rudimentary
horn with an inactive endometrium presenting with uni-
lateral dysmenorrhoea. Moreover, none so far have de-
scribed a medial arrangement of vasculature.
We report a case of an 18 year old girl who presented
with primary cyclic spasmodic dysmenorrhoea which was
relieved after laparoscopic excision of type 3 rudimen-
tary horn. The horn was non-communicating with a well
developed horn on the other side. The vessels were ar-
ranged medially and the endometrium was non-func-
tioning.
2. CASE REPORT
The nulliparous g irl was first referred to paediatrician s at
the age of 14 for left loin pain which settled in 2 days.
She presented a year later with similar pain which was
thought to be due to renal co lic. An Ultrasound scan and
an X-ray were unremarkable. Two years later she pre-
sented to gynaecologists for pelvic pain and cyclical left
sided dysmenorrhoea which did not respond to analge-
sics. Clinical examination elicited tenderness in the left
iliac fossa. Repeat ultrasounds and X-Rays were normal
and the pain settled on minipill.
She presented again to gynaecologists with cyclical left
sided dysmenorrhoea despite minipill, tricycling com-
bined pill and d epot provera. On laparoscopy, the uterine
fundus appeared broad. The right tube and ovary were
normal. The left tube had a small 2 cm sized swelling
near the isthmic end but not continuous with the fundus

R. Dwivedi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 213-216 214
(Figure1). This was confirmed with methylene blue dye
test. There was no evidence of endometriosis. A rudi-
mentary uterine horn was suspected. She subsequently
had a hysteroscopy which confirmed the fully developed
right horn with a single right sided tubal ostium. Mag-
netic resonance imaging (MRI) further confirmed this
finding and detected a 1 cm sized non-communicating
rudimentary horn with endometrial lining on the left side
(Figure 2). Renal ultrasound excluded any urinary tract
abnormality. She was offered excision of the left horn
and fallopian tube laparoscopically. This was carried out
successfully through 3 ports using tripolar scissors. The
arterial supply coursed medial to the rudimentary horn
(Figure 3). The left hemi uterus was only loosely atta-
ched to the right sided well developed horn. The left round
and utero-ovarian ligaments were diathermied and tran-
sected. After identification of the ipsilateral ureter, the
uterine vessels on the medial side of this horn (to the left
of the right horn) was then similarly cauterised and cut
(Figure 4). The patient recovered well from the opera-
tion and was discharged home within 24 hours. Histolo-
gy showed a normal fallopian tube, and the rudimentary
uterine structure measured 35 mm× 20 mm × 15 mm
with a lumen lined by inactive endometrium.
Figure 1. Laparoscopy demonstrating the rudimentary left ute-
rine horn attached to the left fallopian tube.
Figure 2. MRI Images of Noncommunicating rudimentary horn.
Figure 3. Laparoscopic excision of the left rudimentary horn
and fallopian tube demonstrating the medial arrangement of
vasculature.
Figure 4. Excised rudimentary horn.
Although her left sided cyclical dysmenorrhoea reso-
lved postoperatively, she continued to have mild cyclical
central dysmenorrhoea. She was content to manage this
with minipill. Subsequently she had successful pregnan-
cy with an emergency caesarean section for obstetr ic rea-
sons and is currently pregnant with her second child (at
the time of submission of this paper).
3. DISCUSSION
The incidence of Mullerian anomalies in the reproduc-
tive age group varies from 0.50% - 017%. The incidence
of unicornuate uter us is 2. 5% - 13.2% [ 5] . The fre quency
of rudimentary horn is extremely rare at 1:100,000. In
80% - 90% cases there is no communication with the
other horn. Rudimentary horn could be either firmly atta-
ched to the unicornuate uterus or separated by a loose
band of tissue. The American Society for Reproductive
Medicine (ASRM) [6] divides this into 4 subtypes: Fig-
ure 1 unicornuate uterus with a communicating rudi-
mentary horn; Figure 2 and 3 with a non-communicat-
ing horn, with or without cavity and in Figure 4, an iso-
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R. Dwivedi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 213-216 215
lated unicornuate uterus.
Women with obstructive uterine anomalies usually pre-
sent with chronic cyclic or continuous pelvic pain. The
presentation can be delayed with increasing severity of
dysmenorrhoea, with each subsequent menstrual period
as a common feature. The symptoms may be severe e-
nough to interfere with quality of life and may not res-
pond to medication. Unlike in obstructive uterine ano-
malies where symptoms are caused by the accumulation
of blood in the rudimentary horn, disordered arrange-
ment of uterine musculature and abnormal contraction
are thought to be the cause in cases such as ours with
inactive endometrium [7]. Unequal development of Mu-
llerian system gives rise pain on one side of the pelvis.
Torsion of the rudimentary horn has also been reported.
Other complications include endometriosis and primary
infertility. Anomalies of the urinary system are usually
associated with uterine developmental abnormalities due
to their close embryological origins. Endometriosis re-
sults from retrograde menstruation from the functioning
endometrial cavity through the ipsilateral fallopian tube.
Obstetric complications such as rupture uterus, recurrent
miscarriages, premature labour and malpresentation can
also occur [8].
A high index of suspicion for Mullerian duct abnor-
mality is therefore needed in teenagers with dysmenor-
rhoea to prevent delays in diagnosis [9]. Ultrasonogra-
phy including hysterosonography is not specific in non-
functioning uterine horns as the detail of adnexa is in-
sufficient. In a recent review of the literature, the sensi-
tivity of ultrasonography even in cases with functioning
horns was only 26%. MRI is much more accurate and
detected all cases in these series and is considered to be
the gold standard [10]. 3D CT scanning has been used in
some cases. 3D ultrasound also may also have a future
role. An early recourse to laparoscopy combined with
hysteroscopy is required to confirm the diagnosis most
cases.
Resection not only offers symptomatic relief in cases
unresponsive to medication, it also prevents the possibi-
lity of pregnancy in the rudimentary horn due to trans-
peritoneal migration of sperm or fertilised ovum. Accu-
rate diagnosis of the anomaly is required prior to exci-
sion to decide on the precise surgical approach as in so-
me cases the two horns are firmly attached. This requires
difficult dissection to develop a plane between the hemi
uteri. If the other tube is normal, the ipsilateral fallopian
tube should be removed to prevent ectopic pregnancy. If
the other tube is damaged, microsurgical transposition of
the ipsilateral tube may need to be considered [11]. Al-
though laparotomy was used traditionally, there are seve-
ral publications of the laparoscopic removal of the rudi-
mentary horn [10]. This follows a similar trend in other
types of gynaecological surgery. Most cases are amena-
ble to laparoscopic management and this is preferred to
prevent adhesions and damage to the myometrium of the
well developed horn. Rudimentary horn attached to the
unicornuate uterus by a band of tissue, as in our case, is
relatively easy to dissect. Minimally invasive, with well
established safety profile, laparoscopic approach has other
advantages such as shorter hospital stay and quicker re-
turn to activities [12]. Aberrant blood vessels and uro-
logical anomalies increase the risk of bleeding and ina-
dvertent injury. Review of MRI scans with radiologists
prior to surgery allows selected cases to be referred to
advanced laparoscopic surgeons.
REFERENCES
[1] Dadhwal, V., Mittal, S., Kumar, S. and Barua, A. (2000)
Hematometra in postmenarchal adolescent girls: A report
of two cases. Gynecologic and Obstetric Investigation,
50, 67-69. doi:10.1159/000010284
[2] Chakravarthi, S. and Chin, K. (2003) Rudimentary uter-
ine horn: Management of a diagnostic enigma. Acta Ob-
stetricia et Gynecologica Scandinavica, 82, 1153-1154.
doi:10.1046/j.1600-0412.2003.00234.x
[3] Goel, P., Aggarwal, A., Devi, K., Takkar, N., Saha, P.K.
and Huria, A. (2005) Unicornuate with non-communi-
cating rudimentary horn different clinical presentations.
The Journal of Obstetrics & Ganecology of India, 55,
155-158.
[4] Falcone, T., Gidwani, G., Paraiso, M., Beverly, C. and
Goldberg, J. (1997) Anatomical variation in rudimentary
horns of a unicornuate uterus: Implications for laparo-
scopic surgery. Human Reproduction, 12, 263-265.
doi:10.1093/humrep/12.2.263
[5] Green, L.K. and Harris, R.E. (1976) Uterine anomalies:
Frequency of diagnosis and associated obstetric compli-
cations. Obstetrics Gynecology, 47, 427-429.
[6] Buttram, V.C. Jr. and Gibbons, W.E. (1979) Mullerian
anomalies: A proposed classification (an analysis of 144
cases). Fertility and Sterility, 32, 40-46.
[7] Jeffcoate, N. (2006) Malformation and maldevelopments
of the genital tract: In principles of gynaecology. The 4th
Edition, Butterworth & Co Ltd, London, 138.
[8] Atmaca, R., Germen, A.T., Burak, F. and Kafkasli, A.
(2005) Acute abdomen in a case with noncommunicating
rudimentary horn and unicornuate uterus. Journal of the
Society of Laparoendoscpic Surgeons, 9, 235-237.
[9] Badawy, S.Z.A. and Montgomery, S. (2009) Severe pri-
mary dysmenorrhoea due to functioning noncommunica-
timg rudimentary horn. Journal of Gynecologic Surgery,
25, 23-27. doi:10.1089/gyn.2009.B-02330
[10] Spitzer, R.F., Kives, S. and Allen, L.M. (2009) Case se-
ries of laparoscopically resected noncommunicating
functional uterine horns. Journal of Pediatric and Ado-
lescent Gynecology, 22, E23-E28.
doi:10.1016/j.jpag.2007.12.001
[11] Gold Berg, J.M. and Friedman, C.I. (1988) Microsurgical
fallopian tube transposition with subsequent term preg-
nancy. Fertility and Sterility, 50, 661-662.
C
opyright © 2011 SciRes. OJOG

R. Dwivedi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 213-216 216
[12] Liatsikos, S.A., Tsikouras, P., Souftas, V., Ammari, A.,
Prassopoulos, P., Maroulis, G. and Liberis, V. (2010) Di-
agnosis and laparoscopic management of a rudimentary
uterine horn in a teenage girl, presenting with hema-
tometra and severe endometriosis: Our experience and
review of literature. Minimally Invasive Therapy and Al-
lied Technologies, 19, 241-247.
doi:10.3109/13645701003644491