Concurrent imperforate hymen and transverse vaginal septum: A rare

presentation and management with minimal invasive technique.

Case Report

Concurrent imperforate hymen and transversevaginal septum: A rare presentation andmanagement with minimal invasive technique

Sushma Meda a,*, Venkata Sujatha Vellanki b, Rajesh Kaul c,Radhika Pentyala d, Venkat Kishan Tatikonda e

aSenior Resident Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of

Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, IndiabAssociate Professor Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of

Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, IndiacProfessor and Head of Department of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology,

Kamineni Institute of Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, IndiadSenior Resident Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Kamineni Institute of

Medical Sciences (Sreepuram), Narketpally, Nalgonda 508254, Andhra Pradesh, IndiaeConsultant 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 fusionduringembryologicaldevelopmentof thevagina.1

The complete transverse vaginal septum may be located at

various levels (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.apol lomedical journal .net

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 5 6e5 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

46%ofvaginal septaoccur in theupper 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 byMRI (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 6e5 8 57

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 presentingwith 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 highvaginal septum. Arch Gynecol Obstet. 2010;281:955.

2. Breech Lesley L, Laufer Marc R. Mullerian anomalies. ObstetGynecol Clin North Am. 2009;36:47e68.

3. Ahmed S, Morris LL, Atkinson E. Distal mucocolpos andproximal hematocolpos secondary to concurrent imperforatehymen 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 ofpatients with a transverse vaginal septum. Fertil Steril. May2007;87(5):1225e1226.

6. Gezginc Kazım, Yazıcı Fatma, Karatayl Rengin, Acar Ali. A newtechnique for the treatment of transverse vaginal septum byFoley 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. 2007Aug;42(8):1446e1448.

Fig. 3 e a, b Transverse vaginal septum.

Fig. 4 e Foley’s cateter inserted beyond the transverse

vaginal septum.

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