Transverse Vaginal Septum

Transverse vaginal septum is a congenital horizontal membrane or wall that obstructs the vaginal canal, resulting from failure of fusion or canalisation between the Müllerian derived upper vagina and the urogenital sinus derived lower vagina. It occurs in about 1 in 30,000 to 80,000 women. Location: upper third of the vagina in 46 percent, middle third in 40 percent, lower third in 14 percent. Thickness varies from 1 mm to more than 2 cm.

Most septa are imperforate (causing haematocolpos) but some have a small central or eccentric perforation permitting menstrual egress and chronic hematocolpos. Associated anomalies include renal, skeletal and cardiac defects, and with hydrometrocolpos in the McKusick-Kaufman syndrome (with polydactyly and congenital heart disease) and Bardet-Biedl syndrome.

• Neonate: hydrometrocolpos with abdominal mass, urinary obstruction and respiratory compromise.
• Adolescent with an imperforate septum: primary amenorrhoea with normal development, cyclic pelvic pain, an abdominal mass, urinary symptoms, and a blind vaginal pouch without a bulging membrane at the introitus.
• Perforate septum: prolonged or intermittent spotting, foul discharge, dyspareunia, infertility, or recurrent infection (pyocolpos).
• Examination: normal external genitalia and hymen; vagina short and ending blindly in a firm septum; bulge palpable on rectal examination with a mass above.
• Complications: haematometra, haematosalpinx, retrograde menstruation, endometriosis, pelvic infection, and infertility.

• Ultrasound (transabdominal and transperineal) shows distended vagina, fluid with debris above the septum, and measures septum thickness; the septum position distinguishes it from imperforate hymen (membrane at the introitus, thin) and cervical agenesis.
• MRI of the pelvis defines septum thickness, level, uterine and cervical anatomy, endometriosis, and rules out vaginal agenesis and cervical dysgenesis.
• Renal ultrasound; consider spine and cardiac evaluation when syndromic features are present.
• Gentle examination under anaesthesia and vaginoscopy for confirmation; avoid needle aspiration.

• Surgical excision of the septum is definitive. Operate as soon as the diagnosis is made in symptomatic patients, ideally during menstruation, when the haematocolpos distends the vagina above the septum and acts as a guide.
• Technique: use a vaginal approach in the lithotomy position. Identify the septum by the bulge and by ultrasound or a probe from above through the cervix if possible.
• Make a cruciate or circular incision, drain the retained blood, then excise the septum. Anastomose the upper and lower vaginal mucosa with interrupted 3-0 or 4-0 polyglactin sutures.
• A thick septum (over 1 cm) may require a combined vaginal and abdominal approach. Alternatives are mobilisation of the vagina with a graft (split thickness skin or buccal), a Z-plasty, or a Foley catheter or mould held in the vagina for 1 to 2 weeks.
• Post-operative vaginal dilators or a vaginal mould for 3 to 6 months to prevent restenosis.
• Antibiotics: cefazolin 1 g single dose, then amoxicillin clavulanate 625 mg every 8 hours for 5 days if pyocolpos.
• Long term follow up: stenosis of the anastomosis is the most frequent complication (up to 20 to 30 percent and higher with thick or high septa), and may need dilatation or repeat resection.
• Endometriosis or adhesions found at laparoscopy are treated.
• Fertility: pregnancy rates after surgery are about 40 to 60 percent depending on septum height and endometriosis. A high septum has the worst outcome.
• Pregnancy needs delivery planning. Vaginal delivery is possible if the anastomosis is wide and elastic; caesarean for scarring.
• Counselling about recurrence is minimal, since the condition is not usually familial.