Outflow Obstructions Treatment & Management
- Author: Latha Chandran, MBBS, MD, MPH; Chief Editor: Andrea L Zuckerman, MD more...
Once the diagnosis has been established, consultation with a pediatric gynecologist or urologist who is familiar with these conditions is recommended. In considering the appropriate management of the patient, the age of the patient as well as the psychological implications for the patient due to the condition must be taken into account.
An accurate assessment of the structural anatomy is imperative prior to surgical intervention.
Although repair is facilitated when estrogen stimulation is present, repair of an imperforate hymen can be performed in infancy, childhood, or adolescence. A Bovie with three fourths of its tip shielded can be used to excise the hymen close to the hymenal ring. After the fluid is drained, the hymenal area is opened further, and the vaginal mucosa is sutured to the hymenal ring to prevent recurrence. Segal et al described two cases in which microperforate hymen was treated with serial dilation instead of excision.
Puncture and drainage of a hematocolpos without a definitive surgical procedure is not recommended. The fluid is viscous and may not adequately drain, thereby increasing the risk of an ascending infection.
Surgery for a transverse vaginal septum depends on location, thickness, and need for vaginoplasty. Repair usually involves excision of the septum with end-to-end anastomosis of the vaginal walls. Image-guided balloon vaginoplasty, hysteroscopic resection, , and excision and insertion of a coated tracheobronchial stent to maintain patency until full epithelialization have all been described as techniques to manage vaginal septa.
In patients with müllerian agenesis, vaginal reconstruction is performed. However, repeat operations are often required, and complications (eg, stenosis and fistula formation) are not uncommon. Vaginal strictures may follow, necessitating repeated dilatation.
A follow-up examination 4-6 weeks after repair is recommended to ensure that scar tissue has not caused a recurrence of obstruction. A follow-up study among 42 women who have had laparoscopic exploration and resection of the vaginal septum found that the reproductive performance was comparable to that following the treatment of the associated uterine anomaly.
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