Innovation
Author Information
Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Abstract
A transverse vaginal septum causes an obstruction to the outflow of menstrual blood and results in formation of hematocolpos, hematometra and hematosalpinx in that order. Excision of the septum relieves the obstruction. However if the newly created opening closes, the obstruction recurs. If the closure is partial, leaving behind a narrow channel, the collected menstrual blood may escape with difficulty and considerable pain, still producing hematocolpos and hematometra. Such a case with unique presentation and innovative management is presented.
Introduction
A transverse vaginal septum occurs in about 1:30000 to 1:80000 women. [1.2] It can be at different level in the vagina; about 45% percent being in the upper part, 35-40% in the middle part and the rest in the lower part.[3] If the septum has a hole, it does not cause any symptoms until sexual activity is started, and even that may not be experienced if the septum is in the upper third of the vagina. A complete septum produces cryptomenorrhea, cyclical lower abdominal and pelvic pain in premarital period, and dyspareunia if the septum is in the middle or lower third of the vagina. Complete excision of the vagina is usually adequate management. But if it is partially excised, and efforts are not made to keep the vagina patent postoperatively, the opening may close.[4] A case of this type with unusual features and innovative management is presented.
Case Report
A 16 year old unmarried girl presented with complaints of purulent discharge from an abdominal opening for 6 months and severe lower abdominal and pelvic pain for 3-4 days every month cyclically for 5 months. She had been diagnosed to have cryptomenorrhea due to a transverse vaginal septum in the past and had undergone surgical excision of the same at a healthcare facility elsewhere 7 months ago. That operation had been followed by an exploratory laparotomy for unknown indication. Operative findings were a ruptured hemorrhagic cyst in the left ovary, intense adhesions between the ovary and small intestine and 1 L of purulent fluid in the peritoneal cavity. Abdominal adhesions were separated at that time. Then the abdomen was closed after placing an intraperitoneal drain. The drain was removed on day 3 after the operation. She started discharging purulent fluid from drain site. A magnetic resonance imaging scan was performed on her, which showed a bicornuate uterus with stenosis of the distal cervical or vaginal canal, hematocolpos, and a fistulous tract opening on the anterior abdominal wall. She had menses every month subsequently. The flow was preceded by intense lower abdominal and pelvic pain for 3-4 days.
When she presented at our center, her general condition was good and vital parameters were in the normal range. Her general and systemic examination revealed no abnormality. Abdominal examination showed an infraumbilical midline vertical scar. The site of colostomy had healed except at one place where 5 mm x 5 mm part was open, discharging mucoid material. There was some fibrosis around that opening. The remaining abdomen was normal. Local examination showed normal external genitals. The vaginal depth was 5 mm. A 1 cm diameter opening was seen at the center of the pouch of vagina. Rectal examination showed scanty tissue between the anterior rectal wall and the posterior wall of the vagina. A mildly tender cystic lump measuring about 6-8 cm in diameter was felt high in the pelvic cavity. An MRI scan of the abdomen and pelvis was done (figure 1). It showed a bicornuate uterus, single vagina distended with blood, and a small hematosalpinx on each side. A sinogram was obtained, which showed a sinus tract leading from the anterior abdominal wall into the transverse colon (figure 2). A diagnosis of coloabdominal fistula was made. It was confirmed by performing a CT sinogram (figure 3). Gastrointestinal surgeon advised surgical treatment of the fistula after 6 months, giving the tissues to get consolidated.
Figure 1. MRI scan of the abdomen and pelvis. It shows right horn of the uterus (RH), left horn of the uterus (LH), left hematosalpinx (LHS) and urinary bladder (UB).
Figure 2. Sinogram showing cannula for injection (C), sinus tract (ST) and colon (CO).
Figure 3. CT sinogram showing sinus tract (ST) and colon (CO).
The patient had menses while in the ward. The flow was a drop at a time, accompanied by intense pain n the lower abdomen. Rectal examination showed the pelvic lump to have enlarged and become more tender. A fibrous tract was felt between the center of the top of the vaginal pouch and the pelvic lump. The length of the tract was about 4 cm. A diagnosis of extreme stenosis of the vagina was made. The patient and her parents were counseled about two treatment options – excision of the closed vaginal septum and skin grafting over the new vagina or dilatation of the stenotic vagina and a vaginoplasty at a later date when the patient was to get married. They opted for vaginal dilatation. The patients investigations for fitness for anesthesia showed normal findings. Dilatation of the stenosed vagina was initiated under general anesthesia. However the opening was too narrow to allow passage of even No. 3/6 Hegar’s dilator. The direction of the tract could also not be ascertained. So a finger was placed in the rectum and a thin probe was passed through the opening along the tract, remaining parallel to the anterior rectal wall so as to avoid perforating it. When the probe was passed successfully into the upper vagina distended with blood, a series of Hegar’s dilators were passed similarly. A dilator of size 5/8 could be passed, but not one larger than that. A decision was made to pass a No. 12 Foley’s catheter through the vagina. It could be passed easily. The balloon was inflated with 10 ml of normal saline. The catheter was replaced by another catheter of size 16 F a week later, and a third one of size 22 another week later. The collected menstrual blood drained over 4-5 days after the passage of the first catheter. After 3 weeks, the patient presented with foul discharge vaginally. Ascending infection was diagnosed and the catheter was removed. Vaginal irrigation was done twice a day with povidone iodine (5%) solution for one week. The pus discharging from the vaginal opening grew acinatobacter sensitive to ofloxacin. She was given ofloxacin for 1 week and the infection was controlled. The vaginal opening was wide enough to allow menstrual flow but did not permit passage of a little finger. The patient presented after a month with mentruation which was painless and the flow was normal. She was keen to go back to her native place so as to be able to resume school. So she was sent home with instructions to follow up if the menstrual flow was obstructed again, foul discharge occurred vaginally. She reported successful menstruation for 3 months subsequently.
Figure 4. A probe is passed into the lower end of the stenotic vagina, with an index finger in the rectum to guide it.
Figure 5. The stenotic vagina is being dilated with Hegar’s dilator.
Figure 6. A Foley’s catheter is being passed into the dilated vagina.
Discussion
Excision of a transverse vaginal septum is not an operation performed routinely by a gynecologist. It can result in an injury to the urinary bladder or the rectum if the operation is done without exercising due caution.[5] Fear of injuring the bladder and/or the rectum makes the gynecologist operate cautiously, so that the end result is often leaving a large part of the septum behind. This can result in closure of the opening partially or completely. If the septum is thick, its excision leaves behing a large raw area, which needs to be covered by partial thickness skin graft or amniotic membrane graft. If that is not done, the newly created opening can close again. A lot of fibrosis often develops around it, making future operations difficult. Reoperating in such cases can be difficult and more likely to cause the complications described above.[6,7] In this case the patient already had an enterocutaneous fistula as a complication of the abdominal operation. She had a partial closure of vagina in the area from which a vaginal septum had been excised. The length of the tract indicated that a septum 4 cm in length had been excised. It closed probably because no graft had been placed over it. There was a significant degree of fibrosis around it, so that dilatation was difficult. Placing self retaining catheters of progressively increasing sizes was an innovative technique which was noninvasive, painless and effective. It did not create a vaginal canal of normal dimensions, but it did relieve the obstruction to flow. Since the girl was just 16 and unlikely to get married for a number of years, a vaginoplasty at that stage would not have been useful anyway. The vagina would have closed as there would not be any means of keeping it open, other than wearing a mould at night. Doing that for years was not very practical. Ascending sepsis was an unavoidable complication of the procedure. But the resultant morbidity was much less than what would have perhaps occurred after a major operation for reexcision of the septum and placement of a graft.
Conclusion
Continuous placement of self retaining urinary catheters in stenotic vagina, increasing the size of the catheter every week is a useful and effective method of dilating vaginal stenosis after a failed excision of transverse vaginal septum.
Acknowledgement
I thank Dr Durga Valvi for taking intraoperative pictures.
Acknowledgement
I thank Dr Durga Valvi for taking intraoperative pictures.
References
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Parulekar SV. Balloon Catheter Dilatation Of Vaginal Stenosis Post Vaginal Septum Excision. JPGO 2017. Volume 4 No. 12. Available from: http://www.jpgo.org/2017/12/balloon-catheter-dilatation-of-vaginal.html