Longitudinal Vaginal Septum

Longitudinal vaginal septum is a congenital sagittal partition dividing the vagina into two channels. It arises from failure of fusion of the Müllerian ducts or failure of resorption of the septum between them.

It is usually associated with a duplicated uterus (didelphys in about 75 percent, septate or bicornuate in others) and two cervices. The septum may be complete (extending from the cervix to the introitus) or partial. Prevalence is about 1 in 2,000 to 30,000 women.

The septum may be non-obstructing or obstructing. A unilateral septum or an imperforate hemivagina produces unilateral haematocolpos and is part of the OHVIRA syndrome (obstructed hemivagina and ipsilateral renal anomaly), also called Herlyn-Werner-Wunderlich syndrome. Ipsilateral renal agenesis occurs in 80 to 90 percent.

• Non-obstructive: often asymptomatic, discovered at first intercourse (dyspareunia, apareunia), at tampon insertion (tampon fails to control bleeding because one hemivagina is unused), at speculum examination, or at delivery (dystocia, obstruction of descent).
• Obstructive (OHVIRA): menstruation present but with progressive dysmenorrhoea and pelvic pain soon after menarche, a lateral paravaginal or pelvic mass, intermenstrual bleeding or purulent discharge (small communication), fever, and acute abdomen if pyocolpos or ruptured haematosalpinx.
• Examination: vaginal septum with two cervices; a bulging mass on one side of the vagina in OHVIRA.
• Complications: endometriosis, pelvic adhesions, infection, infertility, miscarriage and obstetric difficulties.

• Speculum and vaginal examination to define the septum and cervices.
• Pelvic ultrasound (preferably three dimensional) and MRI: duplicated uterus with haematocolpos on one side, assess the extent of the septum, uterus type and endometriosis; check ovaries.
• Renal ultrasound: ipsilateral renal agenesis or ectopic ureter is expected with obstructive septum.
• Hysteroscopy or laparoscopy if needed.

• Asymptomatic non-obstructive septum: no treatment unless it causes dyspareunia, difficulty with tampons, or is predicted to obstruct labour. Excision before pregnancy or at delivery.
• Resection of the septum is done by a vaginal approach under general or regional anaesthesia. Clamp and cut the septum along its base, close to the vaginal wall and avoiding the cervices. Excise the redundant tissue and oversew the mucosal edges with continuous 3-0 or 4-0 polyglactin.
• In a complete septum the dissection runs from the introitus to the cervical level. Take care to avoid injuring the bladder and rectum, which lie close to the septum.
• Obstructed hemivagina (OHVIRA): vaginal septum resection (marsupialisation) at the point of maximum bulge, with drainage of the haematocolpos and a wide opening to the hemivagina. This resolves pain, preserves the uterus and gives excellent fertility outcomes.
• In OHVIRA, do not remove the uterus or the obstructed side, and do not aspirate with a needle through the vaginal wall. Analgesia and temporary drainage may be needed before definitive surgery.
• Post-operative antibiotics if infection (co-amoxiclav 625 mg every 8 hours for 5 to 7 days). Recurrence of stricture is uncommon, but follow up at 3 to 6 weeks and 6 months is advised, with examination and ultrasound.
• Laparoscopy for endometriosis and adhesions.
• Pregnancy outcome is good after resection. A septum left in place and not obstructing can be divided at delivery.
• Counsel on risks of miscarriage, preterm birth and malpresentation with duplicated uterus. Mode of delivery is determined by uterine anatomy and position of the fetus.