Secondary vaginal atresia following caesarean section: an unreported entity

Abstract

Postpartum genital tract adhesions are infrequent and exact incidence is not reported. Severe dystocia, obstructed labour and frequent pelvic examinations have been proposed as possible causes of vaginal adhesion following vaginal delivery. Atresia/adhesions of vagina following caesarean section is very rare. Here, we report a rare case of 21-year-old P1L1 woman presenting with secondary amenorrhoea associated with cyclical abdominal pain following caesarean section. Per speculum examination showed a blind vagina with no communication with the upper one-third. We created a neovagina after adhesiolysis. We hope to increase the awareness of the obstetricians around the globe about postpartum genital tract adhesion, which may even occur as a rare secondary complication of caesarean section. We also wish to bring to the light of obstetricians that numerous pelvic examinations or difficult vaginal delivery may lead to genital tract trauma, and thus, must be minimised in an attempt to prevent postpartum genital tract adhesions.

Background

Currently, acquired vaginal atresia is a very rare entity. In the past, acquired vaginal stenosis/atresia was a complication due to special cultural practices. In a Nigerian study, the incidence was 7–8.5/1000 and the more prevalent age was 20–30 years.¹ Chemical vaginitis due to cultural practices where insertion of caustic vaginal pessaries, use of local herb pessary or harmful foreign body insertion, female mutilating surgeries and female circumcision were the few causes of acquired gynatresia, mostly found in Nigeria.² Labia minora adhesions or adhesion of the vaginal canal in young reproductive age group women are known to be rare, yet, have been reported in a few cases postpartum. There are very limited case reports showing secondary vaginal atresia following vaginal delivery, but there have not been any reported cases of vaginal atresia at the level of upper one-third and lower two-thirds of the vagina following caesarean delivery.^{3 4} Here, we are presenting this case of secondary vaginal atresia following caesarean delivery which has not been reported in the literature previously. It is an uncommon complication of caeserean section managed surgically and postoperative follow-up showed good vaginal length.

Case presentation

A 21-year-oldP1L1 woman presented to the gynaecology outpatient department at All India Institute of Medical Sciences, Bhubaneswar with non-resumption of menstruation following caesarean section for the past 10 months. She also gave the history of cyclical pain lower abdomen for the past 5 months which had become severe in nature for the past 15 days. During the pregnancy, her antenatal period was uneventful, however, she had prolonged labour for around 18–20 hours, following which she went into obstructed labour for which emergency caesarean section was performed in the second stage of labour. Intraoperatively, her bladder was oedematous, her lower segment distended and amniotic fluid was thick meconium stained. A live baby was delivered by the modified Patwardhan technique. There was no postpartum haemorrhage. Postoperatively, Foley’s catheter was kept in situ for 7 days. She was discharged after 8 days of hospital stay with advice to review for a postnatal check-up after 6 weeks. However, she did not turn up for any follow-up postnatal visit. There is no history of sexual intercourse postdelivery. There is no history of postpartum fever. Her previous menstrual cycles were regular before this pregnancy. She had no history of diabetes, hypertension or thyroid disorder. She had no other surgical history. On general examination, she was conscious and oriented, moderately built and nourished. On per abdomen examination, on palpation, a cystic, tender pelvic mass was palpable just above the pubic symphysis, the lower margin of which could not be reached. On per speculum examination vagina was normal in the lower two-thirds which ended blindly with no communication with the upper one-third of the vagina or cervix. On per vaginal examination, the cervix was not felt and the vagina was blinded in the upper part. A cystic fluctuant mass of approximate size 8×4 cm was palpated in the midline on the bimanual examination which was tender. The size of the uterus could not be elicited separately. On per rectal examination, there was a cystic bulge palpable anteriorly. Ultrasonography showed that the uterus was anteverted, bulky, minimal collection in the endometrial cavity with a haematocolpos of size 8×5.2 cm (figure 1A). Under anaesthesia, on per speculum examination, vaginal stenosis was appreciated at the junction of upper one-third and lower two-thirds of the vagina (figure 2A). Under ultrasonographic guidance, an 18G spinal needle was introduced into the vaginal fibrous tissue to confirm haematocolpos and to find a safe plane for vaginoplasty (figure 2B). Under ultrasonographic guidance, a transverse incision was performed over the most prominent part of the blind vagina. The incision was extended and approximately 300 mL of collected altered blood was drained out. Dense vaginal adhesions were released gradually till the cervix could be visualised. Both lips of the cervix were visualised which was 3 cm above the site of vaginal atresia. Postdrainage ultrasonography image showed no collection (figure 1B).

Figure 1.

(A) USG image—haematocolpos and haematometra (blue arrow). (B) Postdrainage USG image—no collection (blue arrow), bladder (green arrow). USG, ultrasonography.

Figure 2.

(A) Vaginal stenosis at upper one-third and lower two-thirds of vagina. (B) Diagnosis of secondary vaginal atresia with haematocolpos by real time USG-guided aspiration. (C) Foley’s catheter in vagina to prevent readhesion after incision of fibrotic band. USG, ultrasonography

Number 22 Foley‘s catheter was inserted through the vagina and distended with 30 mL of normal saline and placed over the newly created raw area (figure 2C). Foley’s catheter was kept for 7 days. A vaginal mould was prepared and she was trained for self-dilation of the vagina with the mould regularly with a new lubricated condom put over the mould each time. The postoperative period was uneventful. She was allowed for intercourse after 6 weeks, which was not associated with dyspareunia. She got her periods after 20 days of the surgery and resumed her normal menses since then.

Investigations

Ultrasonography showed that the uterus was anteverted, bulky, minimal collection of blood in the endometrial cavity with a massive haematocolpos of size 8×5.2 cm (figure 1A).

After the procedure, the uterine cavity was empty and the collection in the cervical canal was cleared (figure 1B).

Differential diagnosis

• Vaginal adhesions.

• Vaginal atresia.

• Cervical stenosis.

• Cervical atresia.

• Asherman syndrome.

Treatment

Band of adhesion present between upper one-third and lower two-third of vagina was released. Approximately 300 mL of altered collected haematocolpos and haematometra were drained. Cervix did not have any macroscopic alterations. To maintain the patency, number 22 Foley’ss catheter was introduced and self-retained for 7 days.

After removal of Foley’ss catheter, to prevent readhesion, self-dilation of the vagina was done by a lubricated mould. Early intercourse was advised.

Outcome and follow-up

On day 7 postoperative period, per speculum examination showed healing areas of the vagina without adhesion formation (figure 3A). Further, she was asked to follow up on the 6th week postoperatively. On examination, vagina was healthy and the cervix showed no visible alteration (figure 3B). She resumed her period and had regular menstruation till 6 months of follow-up.

Figure 3.

(A) Day 7 postoperative showing raw areas of vagina without adhesion formation. (B) Six weeks postoperative—healthy vagina and normal looking cervix.

Discussion

Postcaesarean vaginal canal adhesions/stenosis are very rare and their attributable cause has not been appraised in literature properly. However, repeated pelvic digital examinations have been suggested by few authors as a possible cause. Past reports indicated that genital tract/vaginal canal trauma, such as instrumental (forceps/vacuum) delivery, large untreated vulvar oedema or inadvertent vaginal canal suturing to the anterior or posterior wall or the cervix is associated with postpartum adhesions/stenosis. Also, labial and vaginal lacerations are associated with postpartum adhesions/stenosis.^{3 5} Strangely, our case presented as atresia of the vaginal canal following caesarean section. Zahran et al had reported a case of pinhole vagina following vaginal delivery.⁶ The present case points a thought-provoking complication of caesarean delivery following a complication of obstructed labour.⁷ In the present case, the vaginal adhesion might have been due to fibrotic tissue, forming adhesion leading to acquired vaginal atresia. The patient had presented in the second stage of labour with obstruction and this excludes congenital transverse septum/adhesions of vagina. Subsequently, she underwent caesarean section and the baby was delivered by Patwardhan technique. In our case, two possibilities of formation of vaginal adhesions exists, first, obstructed labour leading to vaginal laceration, oedema and infection. During the healing process, fibrotic tissues formed adhesion in her vaginal canal. The second possibility is that of undiagnosed laparoelytrotomy (delivery of a baby through a vaginal incision in caesarean section) and accidental inclusion of posterior vaginal wall during the repair.⁸ Currently, as most lower segment caesarean sections are performed through Kerr’s incision, laparoelytrotomy may occur accidentally.^{9 10} The occurrence of these adhesions can be minimised by reducing the number of per vaginal examinations. Also, vaginal laceration and infection should be prevented by proper asepsis during the delivery process and preventing vaginal laceration by following proper techniques, both during vaginal delivery and during caesarean section. Also, proper anatomical repair if any laceration occurs, because during the healing process after this trauma, fibrotic tissues form causing adhesions in the vaginal canal.

Surgery is required in postpartum vaginal stenosis because of its dense nature. Simple incision of the fibrous bands of tissue is sufficient enough to restore the normal anatomy and repeated self dilation by a mould prevents restenosis and its complication. If there is extensive tissue damage then various age-old techniques described for vaginoplasty can be employed. Adhesiolysis followed by the use of vaginal moulds is the preferred method.¹¹

Learning points.

• We hope that present case will increase awareness about postpartum genital tract adhesions which can be prevented by putting the incision at a higher level of the lower uterine segment, in case of obstructed labour.

• Fully trained/experienced delivery assistance is very important for conducting delivery and supervised patient care by experts can prevent such complications.

• We recommend that obstetricians should evade numerous per vaginal examinations and trauma to the genital tract to prevent postpartum vaginal adhesions.

• Clinically blind vagina with a palpable cystic mass following a vaginal delivery or caesarean section should always raise doubt regarding secondary vaginal atresia.

• The thickness of vaginal adhesion and exact location of the haematocolpos can be assessed using a spinal needle and slow adhesiolysis under ultrasonography guidance can be undertaken for adhesiolysis of areas having a surgical alteration of vaginal canal anatomy.