Virginity-sparing management of blind hemivagina in obstructed hemivagina and ipsilateral renal anomaly syndrome

The Opaque Language of Sexuality: Medical Students' and Providers' Beliefs About Virginity

Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers' and medical students' beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.

Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome: A Systematic Review about Diagnosis and Surgical Management

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare congenital defect of the Müllerian ducts characterized by uterus didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. The aim of this systematic review is to summarize the main symptoms and presentation of the OHVIRA syndrome, as well as the different types of management, fertility, and obstetrical outcomes. A comprehensive search was performed in PubMed, EMBASE, SCOPUS, and Web of Science databases since inception to May 1, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. After duplicate records removed, the search strategy retrieved 103 articles. The full texts of 73 articles further were assessed for eligibility, and 44 studies were finally included in the systematic review. The mainstay surgical treatment of OHVIRA syndrome is usually a minimally invasive vaginal approach to remove the septum. Ultrasound-guided hysteroscopic resection and laparoscopic resection of the septum have been described as alternatives. Considering the feasibility of minimally invasive approach for the management of the syndrome, laparotomy should be avoided as much as possible and considered only in selected cases.

Successful vaginoscopic excision of the vaginal septum in a virgin girl of obstructed hemivagina and ipsilateral renal anomaly: Case report and review of literature

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) is a rare malformation that not only causes severe menstrual cramps shortly after menarche but can also lead to endometriosis and infection in the future. We report a case of OHVIRA successfully managed by vaginoscopic excision of the vaginal septum. A 12-year-old virgin girl presented to our hospital with dysmenorrhea and lower abdominal pain. OHVIRA was diagnosed using magnetic resonance imaging. Vaginoscopic surgery was performed for drainage of hematocolpos and excision of the vaginal septum. Vaginoscopic excision of the vaginal septum was performed using a resectoscope, without a vaginal speculum. The procedure was completed safely without injuring the hymen. This is the first case report of successful excision of the vaginal septum by vaginoscopic surgery for OHVIRA in Japan. Vaginoscopic excision may be one of the effective options for the treatment of vaginal obstruction.

Preoperative MRI presentations of Herlyn-Werner-Wunderlich syndrome

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare complex female urogenital anomaly, with diverse anatomical presentations. Due to obstruction, most patients with HWW syndrome need to be addressed surgically. The treatment strategy should be tailored to the different anatomical variants of each patient. Therefore, a detailed and comprehensive preoperative evaluation is needed. In this review, we describe the embryology and clinical manifestations of HWW syndrome and discuss and illustrate its diverse preoperative magnetic resonance imaging presentations to guide clinical treatment.

Vaginoscopic Incision of Vaginal Septum With Preservation of the Hymen in a Child With Obstructed Hemi-Vagina Ipsilateral Renal Agenesis (OHVIRA) Syndrome

Obstructed hemi-vagina ipsilateral renal agenesis (OHVIRA) syndrome, also known as Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian duct anomalies that usually presents after menarche. Although there is increasing awareness about OHVIRA syndrome, high suspicion is needed for the diagnosis. Awareness of the syndrome is crucial for the management and to prevent serious complications. Surgical techniques and age at the surgery are still debatable but, minimally invasive vaginoscopic resection of the vaginal septum should be considered when feasible as it not only allows division of septum with preservation of hymen, but it provides excellent visualization, is less traumatic, and has promising postoperative outcomes. Hymenal integrity is of great concern in specific populations with cultural values. In this report, we present the case of a 24-month-old girl diagnosed with OHVIRA syndrome during a routine follow-up for renal agenesis and was managed with vaginoscopic incision of the vaginal septum using a pediatric cystoscope while maintaining the hymenal integrity.

Vaginoscopic Incision of Oblique Vaginal Septum in an Adolescent Girl with OHVIRA Syndrome: Simple Management of Complicated Anomaly

OHVIRA syndrome comprises uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. It usually presents with pain abdomen and pelvic or vaginal mass with normal menses. Early diagnosis is important to prevent complications in later life. The case of a 12-year-old girl who presented with pain abdomen and progressive dysmenorrhea for the last 6 months (since menarche) is discussed. She was managed successfully with vaginoscopic septal incision with simultaneous preservation of hymenal integrity.

Aqueous vaginal contrast and scheduled hematocolpos with magnetic resonance imaging to delineate complex müllerian anomalies

OBJECTIVE

To demonstrate the advantage of using aqueous vaginal contrast and scheduled hematocolpos with magnetic resonance imaging (MRI) to improve the delineation of gynecologic anatomy and to recommend that this modality be considered in patients with complex müllerian anomalies.

DESIGN

Video demonstration of MRI adjuncts to improve visualization of gynecologic anatomy.

SETTING

Academic Hospital.

PATIENT(S)

A patient with obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) who presented for definitive surgical management.

INTERVENTION(S)

OHVIRA is a unilateral obstructed müllerian anomaly that presents typically after menarche with progressively worsening dysmenorrhea caused by progressive distension of the obstructed hemivagina and uterine horn. The definitive treatment for this anomaly is resection of the unilateral obstruction. When the obstructed hemivagina is within close proximity to the patent hemivagina, vaginal septum resection should be performed to relieve the obstruction successfully. However, when the obstructed hemivagina and uterine horn are not adjacent to the patent hemivagina, a simple septum resection is not feasible and there is a high rate of restenosis if anastomosis is attempted. In this case, laparoscopic removal of the obstructed uterine horn, fallopian tube, cervix, and vagina should be considered as an alternative approach to resolving the obstruction. A surgical approach can be recommended only once the surgeon has a clear understanding of the patient's pelvic anatomy and the magnitude of the obstruction. In the presented case, a 17-year-old patient with OHVIRA presented for definitive surgical management. While on hormonal suppression, a pelvic MRI was performed that identified a uterus didelphys with a left hemiuterus and cervix communicating with a patent vagina. The right hemiuterus and cervix were measured 2.5 cm from the patent vagina. However, because of hormonal suppression, the vaginal cavity was decompressed, making it very difficult to discern the relationship between the two uteri and vaginas. To better determine whether vaginal septum resection to relieve the obstruction was feasible, norethindrone was discontinued to allow menstrual blood to fill the obstructed hemivagina followed by a subsequent pelvic MRI with aqueous vaginal contrast to fill the patent vagina with contrast gel to improve the visualization of the decompressed vaginal cavities.

MAIN OUTCOME MEASURE(S)

Advantage of aqueous vaginal contrast and scheduled hematocolpos with MRI to image pelvic anatomy in a patient with a complex müllerian anomaly to guide surgical decision-making.

RESULT(S)

The addition of vaginal aqueous contrast clearly delineated the course and caliber of the patent vagina and its relationship to the obstructed hemivagina, now filled with blood. The inferior margin was in closer proximity to the patent vagina, but with only a very narrow segment (<1 cm) adjacent to the patent vagina and the obstructed cervix was displaced superiorly, now measuring 3.5 cm above the patent vagina. Surgical management options were discussed with the patient, and given the superior location of the obstructed uterus and cervix with only a narrow border of the vagina in continuity with the patent vagina, the risk of postoperative stenosis after vaginal septum resection was determined to be too high. The decision was made to proceed with a laparoscopic resection of the obstructed right side, and the patient underwent laparoscopic resection of the right hemiuterus, fallopian tube, cervix, and vagina. Intraoperatively, a survey of the pelvis again confirmed that the two vaginas were too far to reconnect safely without a high risk of stenosis. The patient recovered without complications postoperatively and her menses resumed without any pain.

CONCLUSION(S)

We highlight the use of two techniques to optimize MRI imaging of pelvic anatomy in a patient with a complex müllerian anomaly. First, the use of aqueous vaginal contrast with MRI is advantageous to clearly delineate the course and caliber of the patent vagina in patients with complex gynecologic anatomy. Second, cessation of hormonal suppression to allow menstruation to cause hematocolpos helped delineate the relationship between the obstructed vagina and patent vagina. In the presented case, these MRI adjuncts provided necessary detail that could not be appreciated with standard MRI to confirm that vaginal septum resection to preserve the right uterus would be too high a risk for postoperative stenosis in this patient. Aqueous vaginal contrast and scheduled hematocolpos should be considered as adjuncts to MRI when standard imaging modalities are unable to clearly describe the relationship between pelvic structures in cases of complex müllerian anomalies to help guide treatment recommendations.

Clinical characteristics and management of patients with complete septate uterus, double cervix, obstructed hemivagina, and ipsilateral renal agenesis

AIM

To analyze the clinical characteristics and management of patients with complete septate uterus, double cervix, obstructed hemivagina, and ipsilateral renal agenesis.

METHODS

This retrospective study reviewed the medical records of 17 patients with complete septate uterus, double cervix, obstructed hemivagina, and ipsilateral renal agenesis admitted to the Third Xiangya Hospital of Central South University between June 2007 and December 2019.

RESULTS

The median age at surgery was 23 years. The most common presenting complaint was infertility. Seven (41.2%) patients were misdiagnosed previously. The obstruction was complete in five patients. All 17 patients underwent vaginoplasty, in which seven adolescent girls underwent vaginoscopic vaginal septum resections. Eight patients underwent hysteroscopic resections of the uterine septum for infertility or spontaneous miscarriage. Laparoscopy was performed in seven patients for specific indications, and only one patient was found to have pelvic endometriosis during the laparoscopy. During the follow-up, seven patients wished to conceive, and there were five living infants (four cesarean deliveries at term and one preterm vaginal delivery).

CONCLUSION

Complete septate uterus with double cervix, obstructed hemivagina, and ipsilateral renal agenesis is an variant of obstructed hemivagina and ipsilateral renal agenesis syndrome. Consequently, healthcare providers should be aware of this potential variant.

Long-Term Results of an Imperforate Hymen Procedure that Leaves the Hymen Intact

Purpose of the Study

The aim of this study was to show the clinical results of postoperative evaluation of cases of imperforate hymen that presented at our center during a 21-year period.

Methods

A Foley's catheter was inserted in 74 patients of imperforate hymen who reported to the Department of Obstetrics and Gynecology, Meram Faculty of Medicine, Necmettin Erbakan University, between January 1, 1996, and December 31, 2016 with history of pelvic pain. In each case, the hymen was opened via a circular incision from the central of the distended. A Foley's catheter was inserted, and estrogen cream was prescribed for application on the hymenal structure for 14 days. The catheter was removed after 14 days.

Results

The mean age of the patients at the time of this study was 28.3 ± 2.6 years, and the mean age at diagnosis was 13.2 ± 2.5 years. Twenty-nine (96.6%) patients had experienced vaginal bleeding during their first sexual intercourse experience, and one patient (3.4%) had not. Fourteen out of the 30 married women had become pregnant, of whom nine had delivered vaginally and five had delivered via a cesarean section. After undergoing renal ultrasound, none of the patients had any apparent anomalies. Only one patient had a uterine anomaly, which was a bicornuate uterus.

Conclusion

A circular incision with insertion of Foley's catheter prevents many social problems by preserving the hymen's architecture and allowing vaginal bleeding to occur during the first sexual intercourse experience.

Longitudinal vaginal septum: a proposed classification and surgical management

OBJECTIVE

To demonstrate various types of longitudinal vaginal septa (LVS), their classification, and the surgical management of typical and unique morphologic conditions of LVS.

DESIGN

Video presentation of clinical appearance and surgical techniques for treatment of LVS.

SETTING

University hospital and two private.

PATIENT(S)

Representative cases from 121 consecutive women treated from 2013 to 2018 with LVS as a part of complex uterovaginal malformations or in isolated forms with [1] typical morphologic configuration of LVS, [2] rarer variants, or [3] specific anatomic restrictions.

INTERVENTION(S)

Resection of LVS performed as a main surgical procedure in cases with didelphys and bicornuate uterus in symptomatic women and as a part of corrective surgery of complete septate uterus. The three main nonsuturing techniques used were speculoscopy and septum excision using three different electrosurgical modalities; speculoscopy with laparoscopic devices; and vaginoscopy with hysteroscopic instruments.

MAIN OUTCOME MEASURE(S)

Clinical appearance and suggested classification, feasibility of surgery, and perioperative and anatomic results in a short follow-up period (3 months).

RESULT(S)

We identified distinct types of longitudinal vaginal septa. Considering clinical appearance, we suggest classification of LVS based on four main features: [2] completeness of vaginal division: partial and complete type; [2] the symmetricity: symmetric and asymmetric position (with dominant left and right side); [3] association with the cervix: merged and isolated forms; and [4] concomitant vaginal openings: normal, and narrow openings: vaginal stenosis and hymen persistent (Fig. 1). Vaginoscopic techniques by hysteroscope were successful in atraumatic treatment of women with substantial anatomic restrictions, and all of the presented techniques can be effectively used for typical LVS. However, vessel-sealing systems allow for bloodless surgery in contrast with other methods. This study was based on previously acquired data during large prospective study approved by the local ethics committee, and written informed consent to participate in the prospective study and permit publishing anonymous data regarding the medical images, videos of procedures, and results was obtained from all patients.

CONCLUSION(S)

A new classification of longitudinal vaginal septum allows better characterization compared with the currently available classification systems. Different surgical modalities are discussed with their respective advantages and disadvantages. Vaginoscopic incision using resectoscope is a reasonable alternative for women with an intact hymen and vaginal stenosis. The impact of vaginal septum resection on obstetric, reproductive, and sexual outcomes should be assessed in randomized controlled trials and large well-designed studies.

Minimally Invasive Endoscopic Approach for Management of OHVIRA Syndrome

Background

Herlyn-Werner-Wunderlich syndrome is an uncommon entity characterized by uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis (also called OHVIRA syndrome). Due to rarity and varied presentations, often correct diagnosis is missed out during work up, leading to management problems. We describe our dependence on detailed preoperative work up and minimally invasive endoscopic approach in management of the eight patients of OHVIRA syndrome.

Methods

In this retrospective case series study, eight patients of OHVIRA syndrome were managed from January 2012 to March 2018 with the help of improved imaging facility and diagnostic work up. Precise diagnosis helped in adopting minimally invasive approach in management. Patients were reviewed, focusing on presentation, radiologic findings and surgical management.

Results

Median age at diagnosis was 19 years (range 13-41 years). Abdominal pain and dysmenorrhea were the main presenting complaint. All patients except one had associated ipsilateral renal agenesis. Surgical excision of the obstructed hemivaginal septum and hematometra drainage was the main treatment. In seven patients, vaginoscopic resection of vaginal septum was done with resectoscope except one 41-year-old patient, where resection of vaginal septum was performed laparoscopically along with hysterectomy.

Conclusion

Vaginoscopic resection of obstructed hemivaginal septum is an effective method. Management has shifted to minimally invasive approach due to improved imaging, precise preoperative diagnosis and proper understanding of the disease.

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy

OBJECTIVE

To present a case of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome complicated with pyometra and explain tips and tricks for laparoscopic hemihysterectomy.

DESIGN

A step-by-step explanation of the technique with the use of video (Canadian Task Force Classification III). Patient consent and Institutional Review Board approval were obtained.

SETTING

OHVIRA syndrome is characterized by the triad of uterovaginal duplication, obstructed hemivagina, and ipsilateral renal agenesis (1). Patients with OHVIRA syndrome usually present with dysmenorrhea and a vaginal or a pelvic mass. Renal, uterine, and vaginal pathologies can be diagnosed with the use of ultrasonography and magnetic resonance imaging (MRI) (2). In cases in which the diagnosis is not delayed, treatment consists of vaginal septostomy (3). Delayed diagnosis may lead to pelvic infections in patients with microperforations in the septum, which may lead to abscess formation, pelvic inflammatory disease, pyometra, and subsequent need for hemihysterectomy and adnexectomy (4).

PATIENT(S)

A 21-year-old G2 P2 patient who had a history of hospitalization with the diagnosis of tubo-ovarian abscess three times previously presented to the emergency department with pelvic pain, nausea, high fever, and malodorous vaginal discharge. On physical examination, a pelvic abscess draining to the left vaginal wall and a 10-12-cm left adnexal mass were noticed. A diagnosis of OHVIRA syndrome and pyometra was made after evaluation of ultrasonographic and MRI findings. Longitudinal vaginal septum excision and drainage of the abscess was performed. Ten cubic centimeters of purulent abscess material was drained by incising the left vaginal wall. However, the mass extending from the left vaginal wall to the left adnexal area could not be drained. On hysteroscopy, no cervix was visualized belonging to the obstructed hemivagina and the left uterine cavity could not be entered. On reexamination of the MR images, the presence of a transverse vaginal septum overlying the left hemivagina was detected, preventing access to the left hemiuterine cavity. The transverse vaginal septum could have been excised and the pyometra drained; however, owing to the presence of chronic pelvic pain and dyspareunia, and a history of three failed previous attempts at treatment, the decision to perform hemihysterectomy was made.

INTERVENTION(S)

A laparoscopic hemihysterectomy was performed in the patient, who was diagnosed as having OHVIRA syndrome complicated with pyometra. Patient consent and Institutional Review Board approval were obtained for this report.

MAIN OUTCOME MEASURE(S)

On laparoscopy, the left hemiuterus on the same side as the obstructed hemivagina appeared three to four times larger than the normal hemiuterus, in which two pregnancies had occurred, and dense adhesions were present between this hemiuterus and the bowel. The left hemiuterus was densely adherent to the pelvic side wall. Laparoscopic hemihysterectomy was performed. A monofilament barbed suture were used for the repair of the paracervical area and left hemivagina. A transverse septum and cervical atresia was noticed at the distal end of the left hemiuterus. The surgical challenges encountered during treatment of this case were the difficulty in recognizing anatomic structures owing to chronic inflammatory changes, dissecting dense adhesions without injuring neighboring pelvic organs, providing adequate hemostasis during dissection of fragile and hemorrhagic tissues, gaining optimal visualization of the surgical field owing to hampered hemostasis, obtaining adequate exposure of the surgical site owing to the inability to use a uterine manipulator, and the difficulty in dissecting the left hemiuterus without damaging the right hemiuterus for fertility preservation. The ultrasonic scalpel is an energy modality that is known to cause the least amount of collateral thermal tissue damage. In the present case, an ultrasonic scalpel was used to dissect dense adhesions between the left hemiuterus and the urinary bladder to minimize the risk of thermal injury to the urinary bladder. The ultrasonic scalpel was also used when dissecting the unhealthy hemiuterus from the healthy hemiuterus owing to its ergonomic tip and to avoid thermal damage to the cervix of the healthy hemiuterus. In areas of dense adhesions and distorted anatomy, the broad tips of bipolar forceps are also helpful for blunt dissection and the creation of tissue planes, and it is also used for effective concomitant hemostasis. A vessel sealer is the most appropriate energy modality for providing effective hemostasis during dissection of the uterine artery while causing minimal collateral tissue damage (5, 6). When deciding the kind of energy modality to be used during operative laparoscopy, the source that minimized thermal injury while providing optimal hemostasis was preferred. Furthermore, additional features such as rotation, dissection, grasping, and the ergonomics of the tip of the device were also considered when choosing the energy source to be used.

RESULT(S)

The patient was discharged 48 hours postoperatively with no complications. No symptoms of pelvic pain, dysmenorrhea, and dyspareunia were present at the end of the third month after surgery.

CONCLUSION(S)

Understanding the exact nature of the uterine anomaly before hemihysterectomy is of paramount importance for a successful surgery. Laparoscopy is a safe and effective treatment modality even in the presence of dense pelvic adhesions and distorted pelvic anatomy.

Virginity-sparing management of hematocolpos with imperforate hymen: case report and literature review

Imperforate hymen results from failure of the endoderm of the urogenital sinus to completely canalize and has an incidence of 0.01% to 0.05%. This sometimes presents as a pelvic mass that compresses the bladder causing acute urinary retention. A 13-year-old girl was referred to our department with a history of primary amenorrhea, cyclic lower abdominal pain, abdominal–pelvic mass, constipation and acute urinary retention. She had an ultrasonography misdiagnosis of a huge ovarian mass before referral to our unit. On examination, the vagina was bulging and compressing the rectum. Repeat abdominal ultrasonography confirmed the diagnosis of hematometrocolpos. She underwent X-shaped hymenotomy with a favorable outcome. Diagnosis of imperforate hymen requires high suspicion index. Virginity-sparing surgery constitutes a good treatment option for cultural and religious reasons.