Discussion :
One of the main causes of haematocolpos is the transverse vaginal
septum, this transverse vaginal septum results either from incomplete
channelling of the vaginal plate or failure of the parameonephral ducts
to meet the urogenital sinus6. Vaginal septum was
first described in 1877 and since then other case series have been
published. However, they remain rare due to the low frequency of this
anomaly.
The diagnosis of transverse vaginal septum is made either pre-puberty or
post-puberty. In pre-pubertal patients, they present a hydrocolpos
caused by an obstruction in the drainage of genital secretions produced
by hypersecretion of the proximal reproductive glands which respond to
maternal hormonal stimulation. In post puberty, the clinical
presentation is variable, depending, above all, on whether or not there
is a perforation of the septum. If the septum is complete, as in our
case, clinically, patient present abdominal pain associated with primary
amenorrhoea with the presence of a haematocolpos, haematometry or
haematosalpinx depending on the location of the septum. If the septum is
incomplete, the diagnosis is more difficult, as it may be asymptomatic
with only dyspareunic or infertility symptoms7.
The transverse vaginal septum is not a common mullerian abnormality.
Similar to an imperforate hymen, it can present a diagnostic challenge,
as the symptoms are often not gynecological in nature, e.g. lower
abdominal pain, low back pain, chronic constipation8,
or urinary retention9. An obstructive genital anomaly
should be routinely sought in all young women with these symptoms
associated with primary amenorrhea. An imperforate hymen is easily
distinguished from a transverse vaginal septum on physical examination.
The bluish appearance with a bulge is often observed between the lips in
the case of an imperforated hymen. In addition, slight pressure applied
suprapubically causes visible distension of the imperforated hymen. On
the other hand, if a transverse septum is present, suprapubic pressure
does not cause a visible bulge in the perineum. The thickness and exact
location of a transverse vaginal septum is difficult to assess
clinically unless a patient is willing to undergo a careful vaginal
and/or rectoabdominal examination. Most young women before their first
sexual activities do not undergo such an examination without general
anaesthesia. Therefore, the thickness and location of the septum is most
often assessed by abdominal ultrasound, trans-perineal or trans-rectal
ultrasound or MRI before attempting management10.
Very little data is available in the literature on the surgical
management of this condition. In the experience of Dennie et
al.11, the septum should be removed when the girl
reaches the age of first menstruation, and surgery is easier if the
patient has a haematocolpos before drainage. Williams et
al.12 describe 46 patients with VSDs treated by 3
different routes: laparotomy abdomino-perineal vaginoplasty, simple
vaginal excision and laparoscopic resection of the vaginal wall. Another
surgical approach is the Grünberger method, which consists of a
cross-shaped incision in the caudal part of the septum and a cross
incision in the other part with transverse
closure13,14.
Van Bijsterveldt et al.15 proposed two new techniques
for the treatment of the vaginal wall: push and pull techniques. The
former requires a combined abdominal-vaginal approach, and is used in
patients with a higher risk of restenosis after surgery. The traction
technique is reserved for patients with a simple vaginal obstruction. A
modification of this technique was performed by Layman et
al.16 with traction through proximal distension of the
vagina using an Olbert balloon catheter to facilitate surgical
management and to limit postoperative narrowing of the vagina. Sardesai
et al.17 described a double cross-plasty/Z-plasty for
vaginal wall management after 20 years experience as the best technique
compared to other surgical methods.
Vaginal stenosis at the resection site remains the most common
complication18, postoperative vaginal dilation may
help to reduce scarring and stenosis at the surgical
site19, this postoperative dilation is essential to
the success of the procedure. Other less common complications are
described after surgery, such as dyspareunia, menstrual irregularities
and fertility problems.
Management of the vaginal septum with drainage of the haematocolpos at
an early age is necessary to preserve fertility and reduce the risk of
endometriosis. Therefore, these patients and their parents need to be
informed about these potential long-term complications and the
importance of regular follow-up19,20.