J Pediatr Adolesc Gynecol (2009) 22:157e161
Original Study
Treatment of Patients with a Congenital Transversal Vaginal
Septum or a Partial Aplasia of the Vagina. The Vaginal
Pull-through Versus the Push-through Technique
Chantal van Bijsterveldt, MD and Wim Willemsen, MD, PhD
Department of Obstetrics & Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
Abstract. Study Objective: The aim of this study is to de-
scribe the different modalities of congenital obstructing
vaginal malformations and the evaluation of techniques to
solve the problem.
Design: A retrospective study.
Setting: The University Hospital Nijmegen, the
Netherlands.
Participants: The medical records of 18 patients with
congenital obstructive malformations of the vagina oper-
ated on by one gynecologist were retrospectively reviewed.
The conditions were classified in three groups: group I with
one uterus and vagina and with a transverse vaginal septum,
group II with a partial vaginal agenesis and group III with
a double genital system and a septum with occlusion of one
vagina.
Main outcome measures: Operating technique used,
mold treatment after surgery, menstruation outflow, the pos-
sibility of having intercourse and the need for additional
surgery.
Results: 18 patients were evaluated. Of 10 patients in
group I, 8 patients were treated with the pull-through tech-
nique and 2 patients with the push-through technique. Four
of the patients with a pull-through operation did not get
mold treatment; of these patients, 3 needed repeat surgery
because of the tendency for constriction. Of 4 patients in
group II, 1 patient was treated with the pull-through tech-
nique and 3 with the push-through technique. The patient
with the pull-through technique needed repeat surgery
because of constriction. There was no mold treatment after
the first procedure. Group III were 4 patients all treated
with the pull-through technique. None of them received
mold treatment, and none of these patients needed repeat
surgery.
Conclusions: The push-through method is a good surgi-
cal technique for the patients in whom problems of con-
striction after surgery are expected and for patients with
difficulties during surgery. Mold treatment is recommended
Address correspondence to: Chantal van Bijsterveldt, MD, Dept
Ob Gyn, UMCN St Radboud, PO Box 9101 6500 HB Nijmegen,
The Netherlands; E-mail: chant1@hotmail.com
Ó 2009 North American Society for Pediatric and Adolescent Gynecology
Published by Elsevier Inc.
after surgery in patients with a thick transversal vaginal
septum or a partial vaginal aplasia.
Key Words. Vaginal septum—Vaginal aplasia—
Pull-through technique—Push-through technique—
Mold treatment
Introduction
Congenital obstructing vaginal malformations arrest
the outflow of menstrual blood and cause hematocol-
pos, possible hematometra and hematosalpinges.
Incomplete occlusion of the vagina in a double genital
system can lead to retention of secretions, vaginal dis-
charge, pain in the lower abdomen or complaints at
intercourse. These obstructing anomalies are either
longitudinal or transverse in origin.1 The longitudinal
vaginal septum is caused by incomplete disappear-
ance of the partition between the fused Müllerian
ducts. The transverse vaginal septum is the result of
failure of absorption of the tissue between the vaginal
plate and the caudal end of the fused Müllerian ducts.2
It may be located in the lower, middle, or upper part
of the vagina. Gynecological examination and ultraso-
nography will often reveal the diagnosis. High trans-
verse septa can be confused with partial aplasia of
the vagina. MRI is a reliable method for evaluating
the anomaly especially in a patient with a doubtful di-
agnosis. When the congenital vaginal occlusion had
a thickness of less than 1 cm, we called it a septum.
When the occlusion more than 1 cm in thickness, it
was called a partial aplasia of the vagina. The MRI
can be helpful for planning surgical treatment, but
should be reserved for more complex cases.3 With
the MRI, the thickness of a vaginal septum can be
measured, as well as, in the case of a partial vaginal
1083-3188/09/$36.00
doi:10.1016/j.jpag.2008.02.008
158 van Bijsterveldt et al: Treatment of Congenital Transversal Vaginal Septum or Partial Vaginal Aplasia

aplasia, how many centimeters of the vagina are miss-

ing (Fig. 1).

Materials and Methods

During the pull-through technique, vaginally, a little

opening is made in the septum, and a catheter is
brought up until the balloon at the tip of the catheter
is behind the septum (Fig. 2). The balloon is then
filled with saline and by pulling at the catheter the
vaginal septum is brought to tension towards the vag-
inal introitus. The surgical approach is now easier and
the septum can be removed. The pull-through tech-
nique was reserved for patients whom we expected
to have a simple vaginal obstruction. Surgical treat-
ment of high and thick septa and also of partial vag-
inal agenesis is technically more difficult and can
cause vaginal constriction afterwards with the need
for re-operation. For this reason and also because
the pull-through operation technique itself is more
complex, in these cases another method of surgery
is done in patients with obstructive genital anomalies.
We call it the push-through operating technique
(Fig. 3). During this surgical procedure the thick sep- Fig. 1. MRI of partial vaginal aplasia.
tum is approached both abdominally and vaginally.
Abdominally, after opening the serosa between blad- having painless intercourse, and the need of re-opera-
der and uterus, the upper vagina is opened and blood tion were registered.
is removed (Fig. 4). With a blunt object (we used
a sterile marble), the septum can be brought to tension
abdominally towards the vaginal side (Fig. 5). Now Results
the surgical approach of the septum is easier and the
view is much better, so that the septum can be re- The mean age of the 18 patients at time of operation
moved appropriately. After mobilization of the vagi- was 22.2 years. This mean age is relatively high. The
nal mucosa the wound can be closed without reason is probably that in some cases the anomaly was
tension. The suture line will be approximately in the discovered relatively late and that some women did
middle where the septum of the vagina or aplastic va- not want surgery when they were younger (no inter-
gina was. Especially in patients with a thick septum of course, no complaints). Nine patients were younger
the vagina or a partial vaginal aplasia, mold treatment than 20 years old at time of surgery. The other 9 pa-
is recommended after surgery. tients were 20e44 years old. Table 1 gives an over-
Eighteen females with an obstructing malformation view of patients and their treatment.
of the vagina had surgery and were evaluated at the Nine out of the 18 patients did not need mold treat-
university hospital of Nijmegen in the Netherlands, ment after surgery and had a good outcome without
between 1970 and 2005. The patients were classified the need of re-excision. A good outcome is defined
in three groups : as: there is menstruation outflow and the possibility
of having painless intravaginal intercourse.
Group I one uterus and one vagina with a transverse
vaginal septum (10 patients). Group I: one uterus and one vagina with
Group II partial vaginal agenesis (4 patients). a transverse vaginal septum
Group III double system with a vaginal septum and 4 patients with a good outcome with the pull-through
occlusion of one vagina (4 patients). technique without mold treatment, no re-excision
The hospital records of these females were thor- needed.
oughly reviewed to obtain data about diagnosis, age
at the time of treatment, operating technique used Group II: partial vaginal agenesis
and outcome. In the follow-up period (which was at 1 patient with a good outcome with the push-through
least 2 years after surgery) the time of treatment with technique without mold treatment, no re-excision
a mold, outflow menstrual blood, the possibility of needed.
 van Bijsterveldt et al: Treatment of Congenital Transversal Vaginal Septum or Partial Vaginal Aplasia
Fig. 2. The pull-through technique.
Group III: double system with a vaginal septum
4 patients with a good outcome with the pull-through
technique without mold treatment, no re-excision
needed.
Four patients did not get mold treatment after the
first surgery but needed repeat surgery after a few
months because of the tendency of constriction. All
four had a good outcome after mold treatment follow-
ing the second procedure.
Group I: one uterus and one vagina with
a transverse vaginal septum
Two patients with the pull-through technique plus one
patient with the push-through technique without mold
treatment, needed re-excision because of tendency of
constriction.
All three patients used mold treatment for 6 weeks
after second procedure.
Group II: partial vaginal agenesis
one patient with the pull-through technique without
mold treatment needed re-excision because of
159
tendency of constriction. The patient had 3 months
of mold treatment after second procedure.
The other patients, who received mold treatment
after their first surgery, used the mold 2 months to 1
year in one case. Patients who had intravaginal inter-
course regularly and soon after surgery needed mold
treatment during a shorter time than the patients
who did not have intravaginal intercourse on a regular
basis. All patients had a good outcome.
Group I: one uterus and one vagina with
a transverse vaginal septum
Two patients with the pull-through technique, 2 and 6
months of mold treatment, respectively. 1 patient with
the push-through technique and 2 months of mold
treatment.
Group II: partial vaginal agenesis
Two patients with the push-through technique, 2
months and 1 year of mold treatment.
In the five cases in which the push-through
technique was used, the mold treatment lasted
160 van Bijsterveldt et al: Treatment of Congenital Transversal Vaginal Septum or Partial Vaginal Aplasia

Fig. 3. The push-through technique.

6 weeks in one case, 2 months in two cases, 1 year in recommended in these cases because of the simplicity
one case, and one case did not need mold treatment of the anomaly and its correction.
at all. The outcome of the push and the pull-through
method is probably positive because the patient
Discussion

The obstruction of menstrual outflow due to congeni-

tal vaginal anomalies is a surgical challenge. We de-
scribe 18 patients with these problems. Two surgical
procedures and the results are described.
As mentioned, a good outcome is defined as: there
is menstruation blood outflow and the possibility of
having painless intravaginal intercourse. Of the 18 pa-
tients, 14 had a good outcome after their first surgery.
Four patients needed a second surgical procedure be-
cause of the tendency of constriction of the vagina.
Remarkably three out of these four occurred in group
I (patients with a transverse vaginal septum). The rea- Fig. 4. Abdominally, the vagina is opened and blood is
son for that could be that mold therapy was not removed.
 van Bijsterveldt et al: Treatment of Congenital Transversal Vaginal Septum or Partial Vaginal Aplasia 161

Table 1. Pull-through and Push-through Surgery in Patients

(N 5 18)

Technique Total Group I Group II Group III

Pull-through 13 8 1 4
Push-through 5 2 3 0
Repeat surgery 4 3 1 0
after few months
Group I: One uterus and one vagina with a transverse vaginal septum.
Group II: Partial vaginal agenesis.
Group III: Double system with a vaginal septum.

group of patients in whom problems of constriction

Fig. 5. With a blunt object, the septum can be brought to
tension abdominally towards the vaginal side.
selection was made before surgery. The patients in the
group with the push-through method had high and
thick vaginal septa or a partial vaginal aplasia and
these vaginal reconstructions could easily constrict
after pull-through procedure. That is why the push-
through method seems to be the best solution in these
cases and indeed they have a good outcome.
It could be possible to do this procedure laparos-
copically in the future, but at this point the surgical
materials are not optimal for practice.
In conclusion it can be said that the push-through
method is a good surgical technique for a special
after surgery and difficulties during surgery are
expected. Mold treatment should be recommended af-
ter surgery in patients with a thick transversal vaginal
septum or a partial vaginal aplasia.
References
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clinical implications and fecundity in females with obstruct-
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2003; 16:307
2. Crosby WM, Hill EC: Embryology of the Müllerian duct
system. Obstet Gynecol 1962; 20:507
3. Troiano RN, McCarthy SM: Mullerian duct anomalies:
imaging and clinical issues. Radiology 2004; 233:19