CASE 42

The Case
• 12 year old, Nulligravid, Chief complaint: vulvar pain

• 2 weeks PTA constipation relieved by Glycerin

suppository. 5 days anal pain with constipation, lactulose
was added. Few hours, loose stools with hypogastric pain
(6/10) intermittent

• Gyne History The patient has not had her menarche.

Denies coitarche.

• PE: Tanner Stage 3: Dark, coarse, curled hair sparsely

distributed over mons , Elevated breast and papilla,
increased areola diameter, without separation of breast
and areola
Pelvic Exam
• On genital
examination, there was
no obvious vaginal
orifice and a thin,
bulging, blue perineal
membrane at the
inferior limit of a
palpable, fluctuant
mass (hematocolpos)
Give FOUR Differentials

• Imperforate Hymen

• Transverse Vaginal Septum

• Mullerian Agenesis

• Androgen Insensitivity Syndrome

 Hymen

• A membranous vestige of the junction between the

sinovaginal bulbs and the urogenital sinus

• It generally becomes perforate during fetal life to establish

a con- nection between the vaginal lumen and the
perineum.
 Imperforate Hymen
• Most frequent obstructive anomaly of the female genital
tract (1 in 1000 live-born females )

• Failure of dissolution of the hymenal membrane during late

fetal development

• Usually sporadic, some cases are reported to be familial

• Examination of first-degree relatives/female siblings of

affected individuals has been recommended.
 Imperforate Hymen

Adolescent Abdominal pain Voiding symptoms

No menarche No introitus
Transverse Vaginal Septum

• Transverse vaginal septa are believed to arise from failed

müllerian duct fusion or failed canalization of the vaginal
plate

• The anomaly is uncommon, and Banerjee (1998) reported

an incidence of 1 in 70,000 females.

• Transverse vaginal septum can develop at any level within

the vagina but is more common in the upper portion. This
corresponds to the junction between the vaginal plate and
the caudal end of the fused müllerian ducts
Transverse Vaginal Septum

• 46 percent of septa were

located in the upper vagina,
35 percent in the middle,
and 19 percent in the lower
vagina.

• Typically, a septum is thin

(average thickness of 1 cm),
but Rock (1982) reported
septal thicknesses up to 5
to 6cm
IMPERFORATE HYMEN TRANSVERSE VAGINAL
SEPTUM
Present at the expected time of menarche
Cyclic perineal, pelvic or abdominal pressure or pain
Age-appropriate secondary sexual development
No obvious vaginal orifice Normal vaginal orifice
Thin, often bulging, blue Pelvic mass resulting from
perineal membrane at the hematometra and
inferior limit of a palpable, hematosalpinges.
fluctuant mass
Palpable hematocolpos in
the proximal vaginal
segment above the
obstruction
IMPERFORATE HYMEN TRANSVERSE VAGINAL
SEPTUM
Present at the expected time of menarche
Cyclic perineal, pelvic or abdominal pressure or pain
Age-appropriate secondary sexual development
No obvious vaginal orifice Normal vaginal orifice
Thin, often bulging, blue Pelvic mass resulting from
perineal membrane at the hematometra and
inferior limit of a palpable, hematosalpinges.
fluctuant mass
Palpable hematocolpos in
the proximal vaginal
segment above the
obstruction
Give Two Diagnostic Tools To
Differentiate these conditions

1. Ultrasound ( Transrectal )

2. Magnetic Resonance Imaging ( MRI )

 Transverse Vaginal Septum

• The diagnosis is suspected when an

abdominal or pelvic mass is palpated or when
a foreshortened vagina and inability to identify
the cervix is encountered.

• Diagnosis is confirmed by either sonography

or magnetic resonance (MR) imaging.
Transverse Vaginal Septum
• Magnetic resonance
imaging

• to determine the
septal thickness and
depth

• may identify whether a

cervix is present, and
thereby allow
differentiation of a high
vaginal septum from
cervical agenesis.
 The Case
Small anteverted uterus
Thin endometrium (0.44cm)
Unremarkable bilateral
ovaries.
Unremarkable cervix.

The vaginal canal is dilated

containing heterogenous
echoes measuring
8.52x6.23x7.22 cm
(200.43cc), exhibiting no color

TR - UTZ flow on color mapping,

consider hematocolpos.
What is the management
of this case?
Hymenectomy
Hymenectomy
• Informed consent

• Anesthesia

• A day surgery procedure using

general anesthesia.

• Patient Positioning

• The patient is placed in the dorsal

lithot- omy position, the bladder
is drained, and a sterile perineal
prep is performed.
Hymen Incision
• To avert injury to the urethra
anteriorly and to the rectum
posteriorly, the surgeon
avoids creating pure vertical
and horizontal incisions.

• A cruciate incision is made

anteroposteriorly from 10 to
4 and from 2 to 8 o’clock
into the hymeneal
membrane
Hymen Incision
• The hymeneal leaflets are
then sharply trimmed from
the hymeneal ring.

• The leaflets should not be

excised too closely to the
vaginal epithelium.

• This avoids increased

scarring at the hymeneal
ring.
Irrigation

• The vagina is copiously

irrigated using a sterile saline
solution with either a red
rubber catheter or bulb
syringe.
Suturing

• The cut edges of the leaflet

bases are then oversewn with
interrupted sutures using 3- or
4-0 delayed-absorbable suture,
thus creating a ring of sutures

• A running interlocking suture

line is avoided to minimize
circumferential narrowing of the
introitus
 Management - Imperforate
Hymen
• Intraoperative evaluation or
manipulation of the upper
vagina, cervix, and uterus is
discouraged as the walls of
these organs may have been
thinned by hematocolpos or
hematometra and may be at
greater risk for perforation.
 Management - Imperforate
Hymen
• Laparoscopy may be performed
concurrently with hymenectomy to exclude
endometriosis.

• Importantly, clinicians should avoid needle

aspiration of a hematocolpos for diagnosis
or treatment.

• Aspiration may seed the retained blood

with bacteria and increase infection risks
 Management - Imperforate
Hymen
• POST OPERATIVE CARE

• Oral analgesics and topical anesthetics such as 2-percent

lidocaine jelly.

• Local wound care includes twice-daily sitz baths.

• The patient is counseled that retained fluid may continue

to drain from the uterus and vagina for several days
following the procedure.

• The patient is seen 1 to 2 weeks following surgery, at

which time the introitus is inspected for patency and
assessment of healing.
 Management -
Transverse Septum
• Surgical repair technique is dependent
upon septal thickness, and skin grafts may
occasionally be necessary to cover the
defect left by excision of very thick septa.

• Smaller septa may be removed by

excision followed by end-to-end
anastomosis of the upper and lower
vagina).
 Management -
Transverse Septum
• Alternative to excision with end-to-end
anastomosis, Garcia (1967) reported a Z-
plasty technique that may minimize scar
formation.

• Sanfilippo (1986) recommends laparoscopy

con- currently with transverse vaginal septum
excision because of the high rate of
endometriosis due to retrograde menstruation
from outflow tract obstruction.
 Longitudinal Vaginal
Septum
• Obstructed hemivagina is almost
universally associated with ipsilateral
renal agenesis.

• Together obstructed hemivagina with

ipsilateral renal agenesis has been
labeled OHVIRA syndrome.( Obstructed
Hemivagina with Ipsilateral Renal
Agenesis )
CASE 42