Surgical management of a transverse vaginal septum: About a rare case

Abstract

Introduction

The transverse vaginal septum is a rare anomaly of the müllerian ducts whose pathophysiology is linked to a defect in the resorption of the embryological tissue located between the vaginal dome and the caudal terminal part of the fused müllerian ducts.

Case presentation

We report a rare case of a permeable transverse vaginal septum in a 41-year-old patient, who consulted for cyclic pelvic pain.

Discussion

The vaginal septum is a rare anomaly of the Müllerian ducts whose approximate frequency is around 1/70,000 women. The vaginal septum can be permeable or impermeable and can affect all levels of the vagina. The combination of conventional ultrasound and MRI confirms the diagnosis of these abnormalities. The treatment is surgical and must be implemented quickly. Several surgical techniques have been described, the simplest of which is the “crevice” technique.

Conclusion

The combination of conventional ultrasound and MRI is useful in confirming the diagnosis of these abnormalities. Surgical treatment should always be well planned. The risks of postoperative stenosis and the impact on the upper genital tract must be taken into account.

Highlights

• •The transverse vaginal septum is a rare anomaly of the müllerian ducts, it can be permeable or impermeable and can affect all levels of the vagina.
• •The combination of conventional ultrasound and MRI is useful in confirming the diagnosis.
• •Surgical treatment should always be well planned. The risks of postoperative stenosis and the impact on the upper genital tract must be taken into account.

1. Introduction

The vaginal septum is formed by the absence of resorption of the boundary between the Müller ducts and the urogenital sinus. This anomaly will divide the vagina into two segments, reducing it to its functional part. The vaginal septum can be permeable or impermeable and can affect all levels of the vagina [1]. The vaginal septum have a variable thickness, greater when higher up, especially at the level of their insertion base, but always less than one centimeter. Their seat is also variable: slightly above the hymen or in the upper third of the vagina, often surmounted by a narrow vaginal vault, funnel-shaped, devoid of real vaginal cul-de-sac. The transverse partitions can be multiple and staged [1,2]. The work has been reported with respect to the SCARE 2020 criteria [3].

2. Observation

M.L. aged 41, single, never have been pregnant, with no particular personal or family history. She presented since the menarche cyclic pelvic pain without associated urinary or digestive signs, her menstrual cycle was regular marked by hypomenorrhea lasting a maximum of two days since menarche.

The gynecological examination showed the presence of a taut and microperforated vaginal diaphragm, bulging and bluish, located 3 cm from the vaginal orifice. On digital rectal examination, there was a very painful renitent retro-uterine mass.During menstruation, the patient was re-examined; low-abundance blackish blood was observed through the microperforation of the vaginal septum.

The pelvic ultrasound showed the existence of an enlarged, globular uterus with a hematometry and a cystic mass in the cervical region, hypoechoic, oblong measuring 10 cm in diameter (Fig. 1). A pelvic MRI was performed revealing an enlarged uterus of 146 mm long axis site of a hematometry. It confirmed the existence in the cervical region of a real cystic mass measuring 12 cm. The uterine cavity is normal in appearance with no internal septum (Fig. 2).

Fig. 1.

Enlarged, globular uterus with hematometry and a cystic mass in the cervical region, hypoechoic, oblong measuring 10 cm in diameter.

Fig. 2.

Enlarged uterus with a long axis of 146 mm, site of a hematometry with the presence in the cervical region of a cystic mass measuring 12 cm.

The patient underwent surgical repair using the crevice technique, which consists of making an incision on a permeable annular diaphragm from the orifice to the deep vaginal base. Submucosal dissection on both sides and transverse tension will make it possible to obtain a diamond shape. There is no suture and this process requires progressive re-epithelialization (Fig. 3).

Fig. 3.

The stages of the crevice technique:

(a) an incision on the annular permeable diaphragm from the orifice to the deep vaginal base.

(b) Submucosal dissection on both sides and transverse tension will make it possible to obtain a diamond.

(c) incision made all around the diaphragm and allowing its collapse.

(d) the placement of a mold which must be removed several times in the 1st postoperative period.

Postoperatively, to avoid a possible vaginal stenosis a vaginal mold was placed with permanent application during hospitalization, then non-permanently for 4 to 6 months.

The prognosis immediately after the surgical treatment was satisfactory with a disappearance of pelvic pain and an improvement in the quality of sexual intercourse (Fig. 4).

Fig. 4.

Postoperative image after reepithelialization.

3. Discussion

The vaginal septum is a rare anomaly of the Müllerian ducts whose approximate frequency is around 1/70,000 women. The pathophysiology most often put forward is the lack of resorption of the embryological tissue located between the vaginal dome and the caudal terminal part of the fused Müllerian ducts. This explains that the partitions can be located at all levels, that their thickness can also be variable (around 1 cm) [2].

Concerning the impermeable partitions, the clinical manifestations can occur as soon as they awaken pre-pubertal hormonal with the accumulation of cervical mucus, putting tension on the vaginal cavity whose painful symptomatology will depend on the level of the partitions and the dimensions of this blind vaginal cavity. In this situation, the most frequent and most obvious symptomatology remains the appearance of the first menstrual period with menstrual pain severe enough to lead the young girl to consult. In the situation of an incomplete or in any case permeable transverse vaginal septum, the menstrual symptomatology will depend on the pertuis of permeability but one can also discover this lesion in the context of primary infertility. The level of the transverse septum can also lead to confusion with the presence of a good-sized vaginal cavity ending in a slit that can be considered a cervical abnormality [4].

Radiological examinations provide diagnostic confirmation and look for associated complications. Pelvic ultrasound, because of its ease of access, is the most suitable and least invasive examination for making the diagnosis quickly. It appreciates the retention volume in the uterine cavity and its extension into the adjacent fallopian tube. It looks for bifidity of the genital tract and association with renal agenesis [5].

MRI is one of the radiological examinations offered in the context of these malformations. Its possibilities of study in the multiple planes of space and its excellent definition of contrasts, compared to computed tomography, accurately differentiate uterine anomalies. Many authors agree on the usefulness of MRI in the context of utero-vaginal malformations and in the joint search for endometriosis. Thus, the ideal combination seems to be conventional ultrasound and MRI when it is accessible [6,7].

Laparoscopy usually precedes the surgical procedure. It shows a brioche appearance: the vaginal tube distended by hematocolpos topped by a normal or rounded, globular uterus, blown by hematometry [8]. It perfectly specifies the impact upstream: hematometry, hematosalpinx, tubal reflux of menstruation blood, hematic deposits, endometriotic grafts, pelvic adhesions. In case of voluminous hematocolpos, it will be undertaken secondarily after debridement of the latter, making it possible to control the quality of the emptying. Laparoscopy is not essential if an MRI has been performed previously [9].

The Treatment is surgical and must be quickly implemented. In the case of the presence of a diaphragm with complete menstrual retention, it will be necessary to perform an urgent rapid incision of the vaginal membrane in order to be able to evacuate a hematocolpos more or less associated with hematometry and hematosalpinx. Surgical restorative treatment must be carried out in a second step in order to recover an almost normal upstream vaginal cavity [1].

Several surgical techniques have been described; the crevice procedure is the simplest technique, which consists of making an incision on a permeable annular diaphragm from the orifice to the deep vaginal base. Submucosal dissection on both sides and transverse tension will result in a diamond shape. This incision can be made all around the diaphragm and allow it to collapse. There is no suture and this procedure requires progressive re-epithelization. It requires the placement of a mold that must be removed several times in the first postoperative period in order to eliminate secretions and the appearance of clots. Thereafter, this change can be made once a week under aseptic control, with the expectation of re-epithelization after one to one and a half months. [2].

The sliding technique of a mucous bridge or Y—V procedure which requires the realization of a triangular mucous flap at the vaginal base. This triangle will be drawn on the caudal part of the diaphragm. A submucosal dissection is performed to obtain a triangular flap. The incision will be extended from the base of the V to form an inverted Y. Along the cranial base of the diaphragm, this incision collapses the conjunctive and fibrous lamina, making it possible to collapse the diaphragm and to separate the banks by forming a V. This will be filled by the previously dissected mucous flap, at the aid of stitches (slow resorption threads type 3/0). In this case, the difficulty will be to preserve mucosal continuity by not releasing the sutures [2].

Z-plasty is a seemingly complex technique whose principle is to change the axis of the mucosa-fibroconjunctive layer of the diaphragm. This transverse axis will be transformed into a vertical axis. This technique requires good exposure by divergent traction of the free part of the diaphragm. There are several advantages to this technique, the most obvious of which is the tension-free suture. The absence of mucoconjunctive detachment allows a solidity of the sutures which are taken in the same plane. The disadvantage is the difficulty of dissection depending on the height of the vaginal septum [2].

The main risk of surgical management remains failure by recurrent stenosis, hence the importance of follow-up and preventive postoperative treatment. Different devices have been put in place to overcome this problem, in particular with the introduction of a specific intravaginal mold 3 nights a week for 4 to 6 months. The application of hyaluronic acid has shown its success in preventing recurrent stenosis [10].

4. Conclusion

The clinical examination, the symptomatology of these malformations are not contributive and difficult in young virgin patients for whom appendicitis or urological pathologies are more often evoked. The combination of conventional ultrasound and MRI is useful in confirming the diagnosis of these anomalies both in the uterine morphological study and in the search for complications. Surgical treatment should always be well planned. Indeed, the risks of postoperative stenosis and the impact on the upper genital tract must be taken into account. A good knowledge of this type of surgery should be able to reduce these frequent problems forcing patients to undergo many surgeries very often.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

I swear that this work has been exempted from ethics approval by my institution, as dissemination of research results does not identify specific individuals.

Funding

We have no sources of funding.

Author contribution

El Abbassi Imane: Corresponding author and writing the paper.

Bensouda Mohamed El Mehdi: writing the paper.

Jalal Mohammed: study concept.

Lamrissi Amine: study concept and operating surgeon.

Bouhya Said: correction of the thesis.

Guarantor

El Abbassi Imane

Research registration number

2464

Conflict of interest statement

The authors declare that they have no conflict of interest.