About the Journal | Editorial Board | Instructions to Contributors | Submission & Review | Advertise with Us | Subscribe to E- Alerts
Sitemap | Feedback
Advanced search
Journal of Case Reports
An Unusual Case of Low Transverse Vaginal Septum
Chetana Ratnaparkhi1, Nakul Gawade1, Avinash Dhok1, Anuja Bhalerao2, Vikrant Bhende1 
Departments  of  1Radiodiagnosis  and  2Obstetrics  and  Gynaecology, NKP  Salve  Institute  of  Medical  Science  and  Lata  Mangeshkar  Hospital, Hingna  Road,  Nagpur, 440019. Maharashtra, India. 
Corresponding Author:
Dr. Nakul  Gawade 
Email: nakulgawade07@gmail.com
Received: 12-DEC-2016 Accepted: 27-NOV-2017 Published Online: 20-DEC-2017
DOI: http://dx.doi.org/10.17659/01.2017.0109
Abstract
Background: The complete or imperforate transverse vaginal septum is a rare anomaly of the female reproductive tract. Its site varies in the vaginal canal. The common sites are upper and middle third of the vagina, the low transverse vaginal septum is very rare. It is found in association with urological anomalies and anorectal malformation as well as other Mullerian anomalies especially bicornuate uterus. Case Report: We report a case of a 13-year-old girl with hematometra, hematocolpos and hematosalpinx due to an imperforate complete low vaginal septum. Conclusion: Hematosalpinx presence adversely affects the fertility and obstetric outcomes in the patient. MRI is important diagnostic modality that helps in deciding the management and so as predicting future outcome. 
Keywords : Transverse Vaginal Septum, Hematometra, Hematocolpos, Hematosalpinx, Magnetic Resonance Imaging.
6go6ckt5b8|3000F7576AC3|Tab_Articles|Fulltext|0xf1ff64811e0000004707000001000800
6go6ckt5b5idvals|813
6go6ckt5b5|2000F757Tab_Articles|Fulltext
Introduction 

Transverse  vaginal  septum  is  a  vertical  fusion  defect  of  the  Mullerian  ducts  that  develops  due  to  failure  of  resorption  of  the  tissue  between  the  vaginal  plate,  originating  from  the  urogenital  sinus  and  the  caudal  aspect  of  the  fused  Mullerian  ducts.  Normally this resorption occurs around the fifth month of gestation. The prevalence  of  transverse  vaginal  septum  is  reported  to be 1  in  30,000  to  1 in  84,000 [1] and it was  first  described  by  Delaunay  in  1877 [2]. 

A  transverse  vaginal  septum  results  in  reduced  functional  length  and  in  most  situations  outlet  tract  obstruction  resulting  in  hematometra  and  hematocolpos  and  rarely  hematosalpinx.  Upper  vaginal  septa  are  most  common  (46%  of  cases)  followed  by  the  mid (40%  of  cases)  or  lower  (14%  of  cases)  vagina  [3].

MRI  is  important  in  diagnosing  the  complications like  hematometra,  hematocolpos  and    hematosalpinx   more  accurately  than  any  other  imaging  modality  and  helps  in  deciding  the  management  and  predicting  future  outcome.  Introduction  of  ultrasound  jelly  in  the  introitus  better  delineates  transverse vaginal  septum  and  jelly  itself  serves  as  a  contrast.  Here  we  present  the  case  of  complete  or  imperforate  transverse  vaginal  septum  which  is  a  rare  anomaly  of  the  female  reproductive  tract.

Case Report

A  13  year  old  pre-menarchial  girl  presented  to  the  emergency  department  with  history  of  episodic,  colicky  abdominal  pain  since  last three  months. Abdominal pain was accompanied by distension of the lower abdomen. No significant history of drug intake/medication by mother during pregnancy or congenital anomalies in family was elicited. On local examination external genitalia were normal.

Per-speculum examination showed small  opening 2  cm  from  urethra. On  per  rectal  examination  cervix  and  uterus  were  felt,  right  adnexa  was  free  and  mass  was  felt  in  left  adnexa  extending  upto  midline,  which  was  firm  in  consistency. On  ultrasound  (US)  the  uterus  and  cervix  appeared  to  be  distended  with  fluid  suggesting  hematometra  and  hematocolpos.  Both ovaries were seen.  Bilateral kidneys and ureters  and  bladder  were  normal.  Patient was advised Magnetic Resonance Imaging (MRI)  for  further  evaluation. MRI  pelvis  was  done  with  and  without  ultrasound  jelly  in  introitus.  The jelly  serves  as  contrast  and  better  delineates  the  septum.  MRI  pelvis  shows  a  low  transverse  vaginal  septum  resulting  into  hematometra,  hematocolpos  and  bilateral  hematosalpinx.  The  distance  between  the  lower  end  of  the  vagina  and  the  introitus  was   15 mm. Thickness  of  the  septum  was  two  mm. 

A  vaginoplasty  was  being  planned,  but   there  was  a  spontaneous  rupture  of  the  septum. The ruptured  contents  were  tarry  and  foul  smelling. A  post-rupture  follow  up  MRI  was  also  done  in  which  the  hematometra  and  hematocolpos  were  partially  relieved  but  hematosalpinx  was  persistent. After spontaneous rupture, patient  was  started  on  progesterone. A  thorough  vaginal  examination  was  done  under  general  anaesthesia  which  showed  ruptured  septum, hence  a  definitive  resection  and  vaginoplasty (Z  plasty)  was  planned  and  performed  at  a  later  date. A  vaginal  mould  of  two  cm  diameter  and  four  cm  length  was  placed  in  the  vagina  to  maintain  patency  and  improve  functional  capability.



Discussion

In  complete  vaginal  septum,  the  menstrual  blood  accumulates  resulting  in  hematocolpos  and  hematometra,  rarely  hematosalpinx  may  result. These  patients  usually  present  at  adolescence  with  cyclic  lower  abdominal  pain  and  occasionally  with  a  lower  abdominal  mass   (hematometra).  An  incomplete  septum  allows  partial  flow  of  menstrual  blood,  and  these  patients  present  with  dysmenorrhea,  hypo-menorrhea,  dyspareunia  and  foul-smelling  vaginal  discharge. As per the classification  of  vaginal  anomalies  by American  Society  of  Reproductive  Medicine,   transverse  vaginal  septum  is class I which says transverse  vaginal  septum  is  a  vertical  fusion  defect  of  the  Mullerian  ducts  that  develops  due  to  failure  of  resorption  of  the  tissue  between  the  vaginal  plate  and  the  caudal  aspect  of  the  fused  Mullerian  ducts.  Normally this resorption occurs  around  the  5th  month  of  gestation. A  transverse  vaginal  septum  results  into  two  segments  of  vagina,  reducing  its  functional  length  and  cause  outlet  tract  obstruction  in  most  cases [4].

Patients  often  present  at  menarche  with  cyclic  pelvic  pain  and  primary  amenorrhea  due  to  obstructed  menses.  Incomplete  (perforated)  septum  may  manifest  even  later,  with  dyspareunia  and  dysmenorrhea [5,6]. Patients  with  imperforate  transverse  vaginal  septum  generally  have  a  normal  upper  genital  tract  and  therefore  do  not  have  reduced  fertility. 

In our case hematometra and hematocolpos were seen on ultrasound however hematosalpinx and the exact location and thickness of septum were not satisfactorily seen, hence an MRI was done. MRI revealed a well-defined 2 mm thick septum. The septum was exceptionally well demarcated on T2 weighted images due to the use of ultrasound jelly. The septum is seen as a hypo-intense band of tissue in between the hyper-intense collection internally and ultrasound jelly externally. MR  imaging  was  also useful  in  depicting  the  pelvic  anatomy  further  aiding  in  the  selection  of  the  appropriate  management [7]. Management depends on the  thickness  and  position   of  the  septum [8]. 

Transverse vaginal septum  adversely  affects  the  fertility  and  obstetric  outcomes  in  the  patient,  however  early  an  intervention  can  lead  to  a  better  outcome. Ultrasound  helps  in  localization  and  characterization  of  the  lesion  but  MRI  is  important  in confirming  the  vaginal  septum  and  its  related  complications  more  accurately  than  any  other  imaging  modality  and  helps  in  deciding  the  management  and  so  as  predicting  future  outcome.  Introduction  of  ultrasound  jelly  in  the  vagina/introitus  for  better  delineation  of  the  septum  seems  promising. This is especially useful  when  the  septum  is very  thin.

Conclusion

Whenever a female in the pre-menarchal age presents  to  the  emergency  department  with  history  of  episodic,  colicky  abdominal  pain  with  distension  of  the  lower  abdomen a possibility of transverse vaginal septum should always be borne in mind.   

Contributors: CR: manuscript writing, literature review; NG, AD, VB: manuscript editing, literature review; AB: critical inputs into the manuscript, and patient management. NG will act as guarantor. All authors approved the final version of this manuscript.
Funding: None; Competing interests: None stated.

References
  1. Caloia DV, Morris H, Rahmani MR. Congenital transverse vaginal septum: vaginal hydrosonographic diagnosis. Journal of Ultrasound in Medicine, 1998;17:261-264.
  2. Delaunay. Etude sur le cloisonnement transversal du vagin complet et incomplete d'origine congenital, Thesis, Paris 1877.
  3. Rock JA, Lesley LB. Surgery for anomalies of the mullerian ducts. In: Rock JA, Jones HW, Te Linde RWTLsog, eds. Te Linde's Operative Gynecology. 10th ed. Philadelphia, London: Lippincott Williams and Wilkins; 2008. pp. 539-584. 
  4. Junqueira BL, Allen LM, Spitzer RF, Lucco KL, Babyn PS, Doria AS. Müllerian duct anomalies and mimics in children and adolescents: Correlative intraoperative assessment with clinical imaging. RadioGraphics, 2009;29:1085-1103.
  5. Laufer MR, Goldstein DP, Hendren WH. Structural abnormalities of the female reproductive tract. In: Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and adolescent gynecology. 5th ed. Boston, Mass: Lippincott Williams & Wilkins, 2005; 362-416.
  6. Edmonds DK. Rokitansky syndrome and other Mullerian anomalies. In: Balen AH, Creighton SM, Davies MC, MacDougall J, Stanhope R, eds. Paediatric and adolescent gynaecology. Cambridge, England: Cambridge University Press, 2004;267-274. 
  7. Lopez C, Balogun M, Ganesan R, Olliff JF. MRI of vaginal conditions. Clin Radiol. 2005;60:648-662. 
  8. Burgis J. Obstructive Müllerian anomalies: case report, diagnosis, and management. Am J Obstet Gynecol. 2001;185:338-344. 
Article Options
FULL TEXT
ABSTRACT
PDF
PRINTER FRIENDLY VERSION
Search PubMed for
Search Google Scholar for
Article Statistics
CITE THIS ARTICLE
Ratnaparkhi C, Gawade N, Dhok A, Bhalerao A, Bhende VAn Unusual Case of Low Transverse Vaginal Septum.JCR 2017;7:400-403
CITE THIS URL
Ratnaparkhi C, Gawade N, Dhok A, Bhalerao A, Bhende VAn Unusual Case of Low Transverse Vaginal Septum.JCR [serial online] 2017[cited 2024 Mar 29];7:400-403. Available from: http://www.casereports.in/articles/7/4/An-Unusual-Case-of-Low-Transverse-Vaginal-Septum.html
Bookmark and Share