Concurrent imperforate hymen and
transverse vaginal septum: A rare
presentation and management with
minimal invasive techn...
Case Report
Concurrent imperforate hymen and transverse
vaginal septum: A rare presentation and
management with minimal in...
46%of vaginal septa occurinthe upper vagina,40% in themiddle
vagina, and 14% in the lower vagina.2
2. Case report
This 13-...
considered the gold standard for diagnosis.4
But MRI could not
differentiate transverse vaginal septum from vaginal agenes...
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Concurrent imperforate hymen and transverse vaginal septum: A rare presentation and management with minimal invasive technique

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A 13 year old girl not attained menarche presented as a case of acute abdomen; she had a mass per abdomen, on ultrasound diagnosed as haematometra and hematocolpus; clinically had an imperforate hymen; further evaluation by MRI revealed a high vaginal cause of obstruction which cannot be differentiated as vaginal atresia or a combination of transverse vaginal septum and imperforate hymen; operative findings showed a imperforate hymen with a patent lower vagina and a transverse vaginal septum separating upper and lower vagina; surgical correction done and drained 1000 ml of blood and post operatively patient is followed up for a month and bleeding through vagina during the next cycle is noted showing the patent vagina. This is a first case of concurrent transverse vaginal septum and imperforate hymen without any other genitourinary anomalies in literature.

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Concurrent imperforate hymen and transverse vaginal septum: A rare presentation and management with minimal invasive technique

  1. 1. Concurrent imperforate hymen and transverse vaginal septum: A rare presentation and management with minimal invasive technique.
  2. 2. Case Report Concurrent imperforate hymen and transverse vaginal septum: A rare presentation and management with minimal invasive technique Sushma Meda a, *, Venkata Sujatha Vellanki b , Rajesh Kaul c , Radhika Pentyala d , Venkat Kishan Tatikonda e a Senior Resident Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, India b Associate Professor Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, India c Professor and Head of Department of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, India d Senior Resident Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, India e Consultant Radiologist, Department of Radiology, Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, India a r t i c l e i n f o Article history: Received 10 October 2012 Accepted 25 February 2013 Available online 4 March 2013 Keywords: Transverse vaginal septum Imperforate hymen Haematocolpos Haematometra a b s t r a c t A 13 year old girl not attained menarche presented as a case of acute abdomen; she had a mass per abdomen, on ultrasound diagnosed as haematometra and hematocolpus; clini- cally had an imperforate hymen; further evaluation by MRI revealed a high vaginal cause of obstruction which cannot be differentiated as vaginal atresia or a combination of transverse vaginal septum and imperforate hymen; operative findings showed a imper- forate hymen with a patent lower vagina and a transverse vaginal septum separating upper and lower vagina; surgical correction done and drained 1000 ml of blood and post operatively patient is followed up for a month and bleeding through vagina during the next cycle is noted showing the patent vagina. This is a first case of concurrent transverse vaginal septum and imperforate hymen without any other genitourinary anomalies in literature. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction The transverse vaginal septum is one of the rarest anomalies of the female genital tract, with a reported incidence of one in 72,000. Transverse vaginal septum occurs because of a defect in vertical fusion during embryological development of the vagina.1 The complete transverse vaginal septum may be located at variouslevels(low,middle,orhigh)inthevagina.Approximately * Corresponding author. Fax: þ91 08682 272829. E-mail address: sushma.libran@yahoo.com (S. Meda). Available online at www.sciencedirect.com journal homepage: www.apollomedicaljournal.net a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 5 6 e5 8 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.02.008
  3. 3. 46%of vaginal septa occurinthe upper vagina,40% in themiddle vagina, and 14% in the lower vagina.2 2. Case report This 13-year-old girl initially presented to the casuality as an acute abdomen. On abdomen examination she had a tender mass in the right lumbar region. She has not attained menarche. There is no history of cyclic abdominal pain. No family history of congenital anomalies. Her mother has attained menarche at age 12. On general examination Sec- ondary sexual characteristics are present with tanner’s stage IV breast and stage III pubic hair. Local examination showed normal labia majora and minora. On separation of labia minora imperforate hymen is detected. There is no visible bulge or bluish discolouration of hymen. On rectal examina- tion a bulge is felt anteriorly only in the upper part of vagina where as the lower vagina was free. On ultrasound examination mass per abdomen is found to be enlarged uterus filled with blood i.e. haematometra and below it ‘there is dilated upper portion of vagina and both the cavities are freely communicating through a patent cervix. The dilated portion of vagina was at a significant distance from the imperforate hymen suggesting a high cause of cryptomenorrhea. Further evaluation by MRI (Fig. 1) confirmed ultrasound findings but could not differentiate vaginal atresia or a transverse vaginal septum. There were no other associ- ated genitourinary anomalies seen. All other investigations are within normal limits. Surgery is performed under general anaesthesia. Cathe- terization of bladder with pediatric Foley’s done. On the hymen, midway between urethral meatus and fourchette, a Veress needle was introduced to drain the haematocolpos (Fig. 2). Incision was made around the Veress needle on the hymen. A patent vagina is visualised. A transverse vaginal septum was noted (Fig. 3a, b) between the upper and middle one third of vagina which was excised and about 1000 ml of blood was drained. Foley’s catheter 16 no. was kept in vagina above the level of the septum and inflated with 30 ml of saline which was kept (Fig. 4) for a month till her next menstrual cycle to maintain the patency of the vagina. She was followed for six months and she had 30 day regular cycles. Vaginal examination showed a patent vaginal canal after 6 months. 3. Discussion Imperforate hymen and transverse vaginal septum are known causes of haematometra and haematocolpos. However, the concurrent occurrence of the two abnormalities is unique.3 The differential diagnosis of primary amenorrhea, pelvic pain, and pelvic mass in pubertal developmental stage in- cludes imperforate hymen, transverse vaginal septum, longi- tudinal vaginal septum, vaginal agenesis, and cervical atresia. Imperforate hymen must be differentiated from a low trans- verse vaginal septum; this can be accomplished with the Valsalva maneuver. Imperforate hymen should bulge with Valsalva and transverse vaginal septum should not. Magnetic resonance imaging (MRI) may also identify if a cervix is pre- sent, differentiating a high vaginal transverse septum from cervical atresia. MRI will delineate these abnormalities and is Fig. 1 e MRI showing haematometra and haematocolpos with obstruction at high vagina. Fig. 2 e Veress needle used to drain the haematocolpos and guide the catheter. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 5 6 e5 8 57
  4. 4. considered the gold standard for diagnosis.4 But MRI could not differentiate transverse vaginal septum from vaginal agenesis as in our case the cervix was visualized and cervical atresia was ruled out but a patent vaginal wall could not be visualized due to imperforate hymen. Severe vaginal stenosis is a potentially disabling complication of transverse vaginal septum resection due to the constriction of the resulting cir- cular scar5 hence the use of Foley’s catheter to prevent ste- nosis has been described.6 We used this method to prevent stenosis in our patient. Although Deligeoroglou et al recently reported a case of combined unicornuate uterus, imperforate hymen, and transverse vaginal septum,7 the case findings suggest the possibility of agenesis of one-half of the para- mesonephric ducts, resulting in a unicornuate uterus. To our knowledge ours is the first case to present with combined imperforate hymen and transverse vaginal septum without other anomalies and treated at one sitting with minimal invasive technique using Veress needle and Foley’s catheter with minimal disruption to the hymen. 4. Conclusion Our patient though presenting with a very rare combination of mullarian anomalies could be managed with minimal inva- sive modalites using Veress needle and Foley’s catheter to prevent stenosis with early return to normal activities. This method may be considered to other invasive techniques in young girls. Conflicts of interest All authors have none to declare. Consent Written informed consent was obtained from the patient’s parents as she is a minor for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal. r e f e r e n c e s 1. Al-Abdulhadi F, Diejomaoh MF, El Biaa A, et al. Excision of high vaginal septum. Arch Gynecol Obstet. 2010;281:955. 2. Breech Lesley L, Laufer Marc R. Mullerian anomalies. Obstet Gynecol Clin North Am. 2009;36:47e68. 3. Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg. 1999;34(10):1555e1556. 4. Burgis J. Obstructive Mullerian anomalies: case report, diagnosis, and management. Am J Obstet Gynecol. 2001;185:338. 5. Lacy Judith, Correll Gretchen R, Walmer David K, Thomas M. Simple vaginal mold for use in the postoperative care of patients with a transverse vaginal septum. Fertil Steril. May 2007;87(5):1225e1226. 6. Gezginc Kazım, Yazıcı Fatma, Karatayl Rengin, Acar Ali. A new technique for the treatment of transverse vaginal septum by Foley catheter. J Pediatr Adolesc Gynecol. 2011;24:322e325. 7. Deligeoroglou E, Deliveliotou A, Makrakis E, Creatsas G. Concurrent imperforate hymen, transverse vaginal septum, and unicornuate uterus: a case report. J Pediatr Surg. 2007 Aug;42(8):1446e1448. Fig. 3 e a, b Transverse vaginal septum. Fig. 4 e Foley’s cateter inserted beyond the transverse vaginal septum. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 5 6 e5 858
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