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.

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

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. 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. 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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