Hysteroscopic resection of vaginal septum in an adolescent virgin with obstructed hemivagina

Successful management of Herlyn-Werner-Wunderlich syndrome in a 17-year-old virgin girl in the challenging socio-cultural-logistic setting of Syria: a case report

Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare developmental anomaly of the female reproductive system caused by a failure of fusion during Mullerian duct development. The triad of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis characterizes HWWS. The most common presenting symptoms are dysmenorrhoea, pelvic pain, primary infertility in later years, and an abdominal mass due to hematometrocolpos.

Case Presentation

A 17-year-old girl presented to the authors' department with recurrent low back pain, which was neither responsive to analgesics nor associated with urinary complaints, vomiting, or fever. Imaging techniques confirmed she had the triad of uterus didelphys, obstructed hemivagina, and right renal agenesis.

Clinical Discussion

The genital system is the same for males and females before 6 weeks of pregnancy. HWWS is a rare congenital disorder as a result of the failure of fusion during Mullerian duct development. It consists of a didelphic uterus, hemivaginal septum, and unilateral renal agenesis.

Conclusion

Shame and social stigma associated with virginity continue to endanger the lives of many girls in Syria. To complicate matters further, the low resources in Syria produced by war pose a difficult challenge in managing many gynecological conditions, including HWWS, like this case, in which endoscopic technologies were not available, necessitating open surgery while keeping in mind preserving hymen intactness. So, the authors indicate that preserving virginity could be conducted even though the approach is open surgery by very careful intervention and experienced surgeons.

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.

New Consideration of Herlyn-Werner-Wunderlich Syndrome Diagnosed by Ultrasound

OBJECTIVES

As a rare malformation of the female reproductive system, Herlyn-Werner-Wunderlich syndrome (HWWS) was categorized into 3 classifications. It was recommended recently that, on the basis of the past classification, cervicovaginal atresia without communicating uteri should be newly added as classification 4. The surgical intervention will differ by type. To better optimize patient counseling as well as the preoperative evaluation and planning, our objective was to describe the ultrasound characteristics of each type of HWWS, including the new type.

METHODS

From January 1995 to November 2015, 37 cases of HWWS in with complete ultrasound information confirmed by surgery in the Peking Union Medical College Hospital were reviewed. We analyzed their ultrasound features, including hematometra, hematocervix, hematocolpos, and an ovarian chocolate cyst.

RESULTS

All of the ultrasound images of the 37 patients showed uterus didelphys with ipsilateral renal agenesis. Compared with the other 3 types, classification 4 showed distinctive ultrasound characteristics. Most cases of classification 4 showed hematometra (5 of 7 [71.4%]) and an ipsilateral ovarian chocolate cyst (6 of 7 [85.7%]), which was significantly higher than in the other 3. A rudimentary uterine horn was also a distinctive characteristic in this type. Meanwhile none of the classification 4 cases showed hematocervix or hydrocolpos, which were common signs of the other 3.

CONCLUSIONS

According to this new classification criteria for HWWS, ultrasound characteristics of the new classification 4 differ from the others. As classification 4 was suggested to have a different surgical option, we should pay attention to its ultrasound characteristics, which might help in providing more information about the treatment and prognosis to the gynecologist.

Vaginoscopic Incision of Oblique Vaginal Septum in Adolescents with OHVIRA Syndrome

This study is to evaluate the efficacy and safety of vaginoscopic incision of oblique vaginal septum in adolescents with Obstructed hemi-vagina and ipsilateral renal agenesis (OHVIRA) syndrome. It is about Fourteen adolescents with OHVIRA syndrome managed by vaginoscopic incision of the oblique vaginal septum using a “No-touch” technique over an 8-year period. In all fourteen adolescents with OHVIRA the oblique vaginal septum was incised successfully without any intraoperative complications. Postoperative pain was unremarkable and each patient’s symptoms resolved postoperatively. The 3-month postoperative follow up office vaginoscopy revealed that the vaginal septum had not reformed nor was any vaginal stenosis noted. Vaginoscopic incision of the oblique vaginal septum using a “No-Touch” technique is a safe, minimally invasive, and effective approach for treating OHVIRA syndrome in adolescents with hematocolpos. This technique may be utilized to minimize disruption to the undeveloped vaginal wall and postoperative pain while providing excellent surgical visualization throughout the procedure.

Manual versus Pump Infusion of Distending Media for Hysteroscopic Procedures: A Randomized Controlled Trial

Fluid overload is a potential complication of hysteroscopic procedures with the possibility of dangerous electrolyte changes. This prospective randomized controlled trial aimed to compare perioperative outcomes and changes in electrolytes after hysteroscopic procedures between the manual infusion (MI) and the pump infusion (PI) methods for distending media infusion. One hundred consecutive women who had hysteroscopic procedures between December 2013 and February 2017 were recruited and randomly allocated to either the MI or PI group. The PI group was associated with an increased volume of infused fluid and collected fluid compared with the volumes of the MI group. Almost all serum electrolyte levels differed significantly between the baseline and postoperative values in both groups; however, no significant differences were noted between the groups. The change in potassium level was positively correlated with the volume of fluid deficit (Spearman's rho = 0.24, P = 0.03), whereas the change in calcium level was negatively correlated with the volume of fluid deficit (Spearman's rho = -0.26, P = 0.046). With no between-group differences in the changes in the other perioperative parameters and electrolytes, the MI method can be a good alternative for delivering distending media for hysteroscopic procedures.

Vaginohysteroscopy for the diagnosis and treatment of vaginal lesions

BACKGROUND

The vaginoscopic approach for hysteroscopy allows detailed endoscopic evaluation of the vaginal walls, fornices, and exocervix.

OBJECTIVES

To review the feasibility and efficacy of vaginohysteroscopy in the diagnosis and treatment of vaginal lesions.

SEARCH STRATEGY

A systematic review was performed of PubMed/Medline, Embase, Google Scholar, and the Cochrane Database to identify papers published in English. The search terms were "hysteroscopy," "vaginoscopy," "vagino-hysteroscopy," and "vaginal lesion." The last review was performed on January 31, 2015.

SELECTION CRITERIA

Studies in which the diagnosis and treatment of vaginal lesions used the vaginoscopic approach and hysteroscopic instrumentation were reviewed.

DATA COLLECTION AND ANALYSIS

Data were extracted from the identified studies and then analyzed.

MAIN RESULTS

Thirteen studies were reviewed. Eleven described one case; one reported observations from two patients, and one study reported a case series. All vaginohysteroscopies reported were performed successfully and without significant complications.

CONCLUSIONS

Vaginohysteroscopy is an easy way to gain access to the cervical canal and an important tool with which to diagnose and treat vaginal lesions.

Use of hysteroscope for vaginoscopy or hysteroscopy in adolescents for the diagnosis and therapeutic management of gynecologic disorders: a systematic review

STUDY OBJECTIVE

The purpose of this article is to review the published literature and perform a systematic review to evaluate the effectiveness and feasibility of the use of a hysteroscope for vaginoscopy or hysteroscopy in diagnosing and establishing therapeutic management of adolescent patients with gynecologic problems.

DESIGN

A systematic review.

SETTING

PubMed, Web of science, and Scopus searches were performed for the period up to September 2013 to identify all the eligible studies. Additional relevant articles were identified using citations within these publications.

PARTICIPANTS

Female adolescents aged 10 to 18 years.

RESULTS

A total of 19 studies were included in the systematic review. We identified 19 case reports that described the application of a hysteroscope as treatment modality for some gynecologic conditions or diseases in adolescents. No original study was found matching the age of this specific population.

CONCLUSIONS

A hysteroscope is a useful substitute for vaginoscopy or hysteroscopy for the exploration of the immature genital tract and may help in the diagnosis and treatment of gynecologic disorders in adolescent patients with an intact hymen, limited vaginal access, or a narrow vagina.

Clinical characteristics and treatment of Herlyn-Werner-Wunderlich syndrome

OBJECTIVE

To investigate the clinical characteristics and treatment of the Herlyn-Werner-Wunderlich syndrome (HWWS).

METHODS

Sixty-one patients diagnosed with HWWS were retrospectively analyzed. HWWS is categorized into three types in China.

RESULTS

Age at presentation of all the cases was after menarche. The most common clinical presentations were dysmenorrhea for type I and vaginal discharge for types II and III. Clinical presentations of types II and III may not occur until reproductive age. HWWS occurred on the right in 39/61. Excision of the obstructed vaginal septum was the treatment utilized in this cohort. After surgery, subsequent pregnancies were ipsilateral in 52.9 %.

CONCLUSIONS

Clinical presentation in untreated HWWS suggests the anatomic anomaly. Early recognition and treatment can reduce symptoms. Pregnancies occur in both the affected and unaffected uterus.

Extended resectoscopic versus sequential cold knife-resectoscopic excision of the unclassified complete uterocervicovaginal septum: a randomized trial

OBJECTIVE

To determine if resectoscopic sectioning of complete uterocervicovaginal septum is as effective as cold knife excision of the vaginal part followed by resectoscopic cutting of the cervicouterine part in symptomatic patients.

DESIGN

Randomized controlled clinical trial.

SETTING

University hospital.

PATIENT(S)

Thirty-two women with a diagnosis of complete uterocervicovaginal septum who had a history of pregnancy wastage or infertility. They were randomized into two groups: Group A underwent resectoscopic excision of the complete septum starting from the vaginal interoitus; group B underwent cold knife excision of the vaginal part followed by resectoscopic excision of the cervical and uterine parts.

INTERVENTION(S)

Hysteroscopic metroplasty alone or preceded by cold knife excision of the vaginal part.

MAIN OUTCOME MEASURE(S)

Operating time, perioperative bleeding, complications, reproductive outcome, and patient and husband satisfaction.

RESULT(S)

Patients in group A showed significantly less operative time and scar-related dyspareunia. There were no significant differences in the reproductive outcome in the two groups.

CONCLUSION(S)

Resection of the vaginal part of symptomatizing complete vaginocervicouterine septum using resectoscopic metroplasty makes the procedure faster with less possibility of scar-related dyspareunia than cold knife excision.

When virginity does matter: Rigid hysteroscopy for diagnostic and operative vaginoscopy—A series of 26 cases

Virginity in adult women, although a personal decision, is a limiting factor for gynecologists in diagnosis and treatment. This report presents 26 cases of virgin patients with various gynecologic problems: 11 with vaginal bleeding, 7 with heavy discharge and foul odor, 6 with protruding vaginal mass, and 2 with a sensation of vaginal pressure and pain. A rigid hysteroscopy setting was used for diagnostic and operative vaginoscopy. Eleven foreign bodies were removed, mostly clothing fibers and a piece of plastic. In 5 cases, cervical polyps and a subserous myoma were resected and cut into pieces for removal through the hymenal opening. In conclusion, the use of a rigid hysteroscope as a vaginoscope to replace the speculum in adult virgin patients is feasible and introduces an operative option as well.

Hysteroscopic resection of the vaginal septum in uterus didelphys with obstructed hemivagina: a case report

Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis is a rare congenital anomaly. Excision of the obstructed vaginal septum is the treatment of choice for symptom relief and the preservation of reproductive capability. A 14-yr-old girl complained of persistent vaginal spotting following each menstruation. Pelvic magnetic resonance imaging revealed a uterus didelphys with left hematocolpos and ipsilateral renal agenesis. Instead of conventional transvaginal excision of the vaginal septum, we used hysteroscopic excision under transabdominal ultrasonographic guidance to preserve the integrity of the hymen. The postoperative course was uneventful, and clinical symptoms were completely resolved after this intervention. Resectoscopic excision of the vaginal septum was found to be easy, safe, effective, and appropriate for young women as it preserved hymen integrity. We believe that this is the first Korean report on the use of a hysteroscopy for vaginal septum resection in a patient with uterus didelphys with obstructed hemivagina.

Septate uterus with double cervices, unilaterally obstructed vaginal septum, and ipsilateral renal agenesis: A rare combination of müllerian and wolffian anomalies complicated by severe endometriosis in an adolescent

We present a previously unreported combination of müllerian and wolffian anomalies of a septate uterus with double cervices, unilaterally obstructed vaginal septum, and ipsilateral renal agenesis; this constellation of findings may offer clues that could modify classic embryologic explanations. In spite of the young age of our patient (15-years old), a chief complaint of malodorous vaginal discharge, and absence of dysmenorrhea or any other symptoms of endometriosis, laparoscopic examination revealed severe endometriosis with dense adhesions, probably as a result of abundant menstrual regurgitation. Laparoscopic resection of endometriotic lesions, adhesiolysis, and vaginoscopic septotomy were successfully performed while preserving hymenal integrity.

Laparoscopic neo-os creation in an adolescent with uterus didelphys and obstructed hemivagina

Uterus didelphys is a rare congenital anomaly with a well-documented association with obstructed hemivagina and ipsilateral renal agenesis. Treatment of this anomaly includes drainage of hematocolopos and excision of the vaginal septum, which has traditionally used a scalpel or scissors, often with hymenotomy. Recently, a less invasive approach using hysteroscopic resection has been reported, allowing improved visualization with preservation of the hymenal ring. In this article, we present an alternative minimally invasive approach using a combination of laparoscopy and vaginoscopy in the case of a 10-year-old girl. This approach allows for treatment in cases wherein vaginoscopy provides inadequate visualization with the advantage of enabling full evaluation for associated complications affecting future fertility including endometriosis, pelvic infection, and pelvic adhesions.

Concomitant resection of congenital vaginal septum during the tension-free vaginal tape procedure

This case report illustrates how the tension-free vaginal tape (TVT) procedure can be successfully combined with another gynecological intervention. A 38-year-old patient had been diagnosed with didelphys uterus during cesarean section. She came to us for treatment of confirmed genuine stress incontinence. In conjunction with the TVT procedure, we resected the congenital vaginal septum. The patient has remained continent for over 1 year.

Resectoscopic treatment of complete longitudinal vaginal septum

Every gynecologist can easily recognize vaginal abnormalities and the subsequent disturbances of sexual function, such as dyspareunia and apareunia, arising from them. In the case of congenital vaginal septum, it is extremely important to completely assess the abnormality before planning for surgical treatment. Because normal vaginal development is subsequent to the canalization and fusion of the two Müllerian ducts once vacuolization has occurred, but not their union, a duplication of different degree will be the consequence. If the defect is complete, a didelphys uterus with a double vagina will result. The aim of our report is to describe the endoscopic technique used to treat three cases of complete longitudinal vaginal septum and to highlight the main differences between our technique and the standard surgical procedure.

Resectoscopic treatment of uterus didelphys with unilateral imperforate vagina complicated by hematocolpos and hematometra: case report

OBJECTIVE

To describe a technique for treating hematocolpos and hematometra in patients with uterus didelphys and unilateral imperforate vagina involving the use of resectoscopy under ultrasonographic control.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 13-year-old girl with uterus didelphys with unilateral hematometra, hematocolpos, and ipsilateral renal agenesis. The girl complained of severe abdominal pain, which appeared with each of her menses.

INTERVENTION(S)

The intervention was performed by a vaginoscopic approach to preserve the integrity of the hymen. The first incision on the vaginal wall was performed in correspondence with the hematocolpos under continuous ultrasonographic guidance with the use of a straight resectoscopic loop. Resection of the vaginal septum was continued with the use of an angled resectoscopic loop until almost complete excision of the septum was achieved.

MAIN OUTCOME MEASURE(S)

Clinical, echographic, and vaginoscopic findings before the operation and 2 and 6 months after the operation.

RESULT(S)

The surgical procedure was easy to perform. Almost complete excision of the septum was achieved with just a few passages of the resectoscope. Complete drainage of both the hematocolpos and the hematometra was confirmed by ultrasonography. The postoperative period was completely uneventful. Clinical and vaginoscopic evaluations 6 months after the operation confirmed the integrity of the hymen, the complete resolution of clinical symptoms, and the persistence of a large communication between the two vaginas.

CONCLUSION(S)

Resectoscopic excision under ultrasonographic guidance of the vaginal septum in a girl with uterus didelphys with unilateral hematometra and hematocolpos was effective and easy to perform, and it fully respected the integrity of the reproductive system.