Vaginal septum is a congenital malformation in which the lumen of the vagina is divided into two parts by a longitudinal or transverse soft tissue formation. In case of violation of the outflow of bloody menstrual secretions, pathology is manifested by cyclically occurring cramping pains in the lower abdomen, oligomenorrhea or amenorrhea. Sometimes it is asymptomatic. For diagnosis, gynecological examination, ultrasound of the pelvic organs are used, which, if necessary, are supplemented with rectoabdominal palpation, MRI, probing of the vagina. Surgical correction involves excision, dissection of the septum, vaginoplasty.
Vaginal septum is a rare malformation, found in approximately one in 70 thousand women. If an abnormal formation prevents the natural release of menstrual blood, the pathology is usually diagnosed in adolescence after the onset of menarche. Extremely rarely, a continuous transverse vaginal septum, leading to the formation of a volumetric hydro-colpos, is determined in the fetus during transabdominal ultrasound in the third trimester of pregnancy or in a newborn girl. Elastic non-obstructive partitions dividing the vagina longitudinally are most often found at reproductive age during gynecological examination.
Doubling or transverse division of the vagina is a congenital defect associated with improper fusion of the Muller channels — paired embryonic formations from which the genitals are formed, or impaired sewerage of the vaginal plate. To date, the causes of the appearance of a septum in the vagina have not been definitively established. Specialists in the field of obstetrics and gynecology have proposed several theories of the development of pathology:
- Gene translocation. When the DNA portion activating the synthesis of the muller-inhibiting substance is moved to the X chromosome, the fusion of the paramesonephral channels is disrupted, which leads to the appearance of a longitudinally located fibrous vaginal septum. Such translocation may be the result of sporadic mutations or teratogenic effects during embryogenesis.
- Violation of the perforation of the genitourinary sinus. The early union of the Muller channels and the genitourinary sinus potentiates the pressure drop in the forming vagina. As a result, one of the key reasons causing the resorption of the septum between the paramesonephral ducts disappears. If the embryonic bookmarks merge incorrectly, a transverse vaginal septum may appear.
- Exposure from neighboring organs. The normal process of convergence and resorption of the walls of the Muller ducts, which come into contact with each other during organogenesis, is disrupted under the influence of malformations of adjacent organs. 60% of patients with a doubled vagina have various abnormalities of the urinary system, 35% have defects of the musculoskeletal system.
Often, a violation of the maturation of the genitals with the formation of a longitudinal or transverse septum in the vagina is provoked by the teratogenic effect on the embryo cells of chemical factors (medicines, industrial and household poisons) or biological agents (pathogens of some urogenital infections — herpes, mycoplasmosis, papillomatosis, ureaplasmosis). Such a malformation of the vagina is often combined with another congenital pathology — doubling of the uterus, atresia of the anus, coarctation of the aorta. A number of authors suggest the possibility of inheritance of pathology by autosomal dominant type.
The mechanism of formation of a doubled vagina or the formation of a transverse septum in it is based on intrauterine organogenesis disorder — partial fusion of paramesonephral ducts or incomplete germination of merged Muller passages into the urogenital sinus. The pathogenesis of disorders in the presence of a vaginal septum is due to a possible deterioration in the outflow of vaginal secretions and menstrual blood with their accumulation above the level of the obstacle (hematocolpos, hematometer, hematosalpinx, hematoperitoneum). The severity of the disorders directly depends on the degree of overlap of the lumen with fibrous formation.
Systematization of vaginal malformations, in which a soft-tissue septum is formed, plays an important role in choosing medical tactics, planning pregnancy, childbirth. The isolation of individual forms of pathology is based on the features of the organogenesis of abnormal formation, which determines the variant of its location in the lumen of the vagina. There are two main options for vaginal septum:
- Longitudinal. Doubling of the vagina is caused by incomplete fusion of paramesonephral embryonic passages. In 12% of cases, the longitudinal septum is symmetrical non—obstructive, in 88% – obstructive, disrupting the outflow of vaginal secretions. Fibrous formation can be located in any part of the vagina, be complete or partial.
- Transverse. The vagina is divided into two segments when the fusion of the Muller channels with the urogenital sinus is disrupted. There are solid (non-perforated) and perforated transverse partitions. In 46% of patients, the abnormal formation is located in the upper part of the vagina, in 40% — in the middle sections, in 14% — in the lower third.
Symptoms of vaginal septum
Clinical manifestations of pathology depend on the location of fibrous tissue and the degree of obturation of the lumen of the organ. Symptoms are almost completely absent in women with doubling of the vagina, both halves of which have an outlet in the vestibule. In such cases, the defect usually becomes an accidental finding during examination. In the presence of a perforated transverse septum or atresia of one of the parts of the doubled vagina, the patient during menstruation complains of poor menstrual discharge, heaviness and spastic pain in the lower abdomen, frequent urination, constipation. There may be vaginal discharge with an unpleasant odor in the intermenstrual period, dyspareunia and difficulties during sexual intercourse. Nonperforated vaginal septum is manifested by primary amenorrhea and cyclical pain in the lower abdomen caused by the accumulation of blood in the uterus and part of the vagina located above the site of atresia. Usually this variant of the disease is diagnosed in the absence of menstrual discharge before the age of 16.
Since vaginal secretions and menstrual blood accumulating in the vagina, uterus and appendages are a good breeding ground for the development of microorganisms, if there is a septum in the vagina, the risk of developing inflammatory processes (colpitis, cervicitis, endometritis, salpingitis, adnexitis), the formation of pyosalpinx, pyometra, piokolpos increases. The reverse casting of menstrual secretions into the uterus contributes to the occurrence of genital endometriosis. The penetration of blood from the uterus and fallopian tubes into the pelvic cavity leads to the formation of a hemaperitoneum, which can be complicated by pelvioperitonitis and the formation of adhesions in the pelvis. Vaginal septum can also cause sexual dysfunction and infertility. In childbirth, such patients are more likely to experience discoordination and weakness of labor, tissue ruptures, traumatic bleeding, soft tissue dystocia.
Patients with suspected vaginal septum are prescribed a comprehensive physical and instrumental examination that allows them to identify a malformation, determine the features of its location, assess the density of formation and the degree of change in the vaginal lumen. The most valuable for the correct diagnosis and the choice of further tactics are:
- Examination on a gynecological chair. Using mirrors, it is easy to detect a transverse or non-obstructive longitudinal septum in the lumen of the vagina. During bimanual palpation, in the case of complete atresia of the vagina, an enlarged, blood-stretched uterus is determined. If one of the lumen of the doubled vagina is atresized, a tight elastic formation is palpated through the wall of the open half. The method is supplemented with rectal examination.
- Transvaginal ultrasound. Sonography allows you to accurately assess the structure of the reproductive organs, to identify other anomalies with which doubling and atresia of the vagina are combined (doubled, bicornuate uterus, intrauterine septum). By changing the echogenic density of organs, it is possible to confirm the accumulation of fluid in the part of the doubled vagina, the area of the vagina above the transverse septum, uterus, fallopian tubes, pelvic cavity.
In doubtful cases and with an atypical structure of abnormal organs, colposcopy, probing of the vagina, MRI of the pelvic organs are performed. Since when the vagina is separated by a septum, malformations of the urinary system organs are often observed, patients are recommended to examine the condition of the bladder, ureters and kidneys. Differential diagnosis of vaginal septum is carried out with other abnormalities of the reproductive organs (hymen atresia, combined doubling of the vagina and uterus, complete aplasia of the vagina and cervix with a functioning uterus), various variants of delayed sexual development (gonadal dysgenesis, testicular feminization syndrome), uterine adenomyosis, functional dysmenorrhea, acute pelvic inflammatory diseases (appendicitis, adnexitis). If necessary, prescribe consultations of a urologist, nephrologist, surgeon.
Treatment of vaginal septum
Conservative therapy for this malformation is ineffective. With insufficient outflow of blood and vaginal secretions, significant violation of sexual and reproductive functions, pain syndrome, surgical correction of pathology is indicated. The choice of the time of the operation and the amount of intervention depend on the type of vaginal septum and the severity of clinical manifestations:
- Correction of the longitudinal partition. During the operation, a wedge-shaped resection of the abnormal formation is usually performed. Most obstetricians and gynecologists suggest performing an intervention before childbirth to exclude possible complications. The indication for a quick surgical operation is the overgrowth of half of the doubled vagina with the accumulation of blood in it. If the dense non-obstructive septum was not removed in advance in the prenatal period, delivery is preferably carried out by caesarean section.
- Correction of the transverse partition. The method is selected taking into account the thickness and location of the soft-tissue formation. Thin, low-lying partitions are dissected with suturing of the mucous membranes of the upper and lower parts of the vagina. In the presence of a thick, high-positioned septum, vaginoplasty by sliding flaps (Z-plastic) is the operation of choice. The intervention allows you to carefully empty the hematocolpos and form a full-fledged vagina. In the postoperative period, the patient is recommended to use a vaginal dilator.
Prognosis and prevention
Patients with partial non-obstructive longitudinal vaginal septum, as a rule, have no difficulty having sex, get pregnant and give birth to children in natural childbirth. In other cases, timely diagnosis and performing surgery in the right amount allows you to completely get rid of the pain syndrome during menstruation, restore sexual and reproductive functions. Since the pathology is congenital, its primary prevention is impossible. The objectives of secondary and tertiary prevention are to detect developmental abnormalities as early as possible in order to choose the optimal method and time of correction, to prevent possible inflammatory processes, complications of pregnancy and childbirth.