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.