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Outflow Obstructions Treatment & Management

  • Author: Latha Chandran, MBBS, MD, MPH; Chief Editor: Andrea L Zuckerman, MD  more...
 
Updated: Aug 20, 2015
 

Approach Considerations

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.

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Surgical Care

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.[8]

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,[9] hysteroscopic resection,[10] , and excision and insertion of a coated tracheobronchial stent to maintain patency until full epithelialization[11] 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.[12] Vaginal strictures may follow, necessitating repeated dilatation.

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Long-Term Monitoring

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.[13]

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Contributor Information and Disclosures
Author

Latha Chandran, MBBS, MD, MPH Professor of Pediatrics, Vice Dean for Undergraduate Medical Education, Stony Brook University School of Medicine, New York

Latha Chandran, MBBS, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Andrea L Zuckerman, MD Associate Professor of Obstetrics/Gynecology, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center

Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Additional Contributors

Elizabeth Alderman, MD Director, Pediatric Residency Program, Director of Fellowship Training Program, Adolescent Medicine, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, Society for Adolescent Health and Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Joseph A Puccio, MD, FAAP Director, Division of Adolescent Medicine, Stony Brook University Hospital; Assistant Professor, Department of Pediatrics, Stony Brook University School of Medicine

Joseph A Puccio, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and Society for Adolescent Medicine

Disclosure: Nothing to disclose.

References
  1. Burel A, Mouchel T, Odent S, et al. Role of HOXA7 to HOXA13 and PBX1 genes in various forms of MRKH syndrome (congenital absence of uterus and vagina). J Negat Results Biomed. 2006. 5:4. [Medline].

  2. Oppelt P, von Have M, Paulsen M, et al. Female genital malformations and their associated abnormalities. Fertil Steril. 2007 Feb. 87(2):335-42. [Medline].

  3. Dietrich JE, Millar DM, Quint EH. Obstructive reproductive tract anomalies. J Pediatr Adolesc Gynecol. 2014 Dec. 27 (6):396-402. [Medline].

  4. Nielsen V, Vyrdal C. [Imperforate hymen can cause abdominal pain and primary amenorrhoea]. Ugeskr Laeger. 2013 May 20. 175(21):1500-1. [Medline].

  5. Rabani SM. A rare non urologic cause for urinary retention; report of 2 cases. Nephrourol Mon. 2013 Spring. 5(2):766-8. [Medline]. [Full Text].

  6. Deligeoroglou E, Iavazzo C, Sofoudis C, Kalampokas T, Creatsas G. Management of hematocolpos in adolescents with transverse vaginal septum. Arch Gynecol Obstet. 2012 Apr. 285(4):1083-7. [Medline].

  7. Nayci A, Avlan D, Oz U, et al. Does menstrual flow exclude hematometra? A rare case of uterine anomaly presenting with anorectal malformation. J Pediatr Surg. 2002 Apr. 37(4):666-7. [Medline].

  8. Segal TR, Fried WB, Krim EY, Parikh D, Rosenfeld DL. Treatment of microperforate hymen with serial dilation: a novel approach. J Pediatr Adolesc Gynecol. 2015 Apr. 28 (2):e21-2. [Medline].

  9. Kansagra AP, Miller CB, Roberts AC. A novel image-guided balloon vaginoplasty method to treat obstructive vaginal anomalies. J Vasc Interv Radiol. 2011 May. 22(5):691-4. [Medline].

  10. Cetinkaya SE, Kahraman K, Sonmezer M, Atabekoglu C. Hysteroscopic management of vaginal septum in a virginal patient with uterus didelphys and obstructed hemivagina. Fertility and Sterility. 2011/07. 96:e16-e18.

  11. Cooper AR, Merritt DF. Novel use of a tracheobronchial stent in a patient with uterine didelphys and obstructed hemivagina. Fertil Steril. 2010 Feb. 93(3):900-3. [Medline].

  12. Davies MC, Creighton SM, Woodhouse CR. The pitfalls of vaginal construction. BJU Int. 2005 Jun. 95(9):1293-8. [Medline].

  13. Haddad B, Barranger E, Paniel BJ. Blind hemivagina: long-term follow-up and reproductive performance in 42 cases. Hum Reprod. 1999 Aug. 14(8):1962-4. [Medline].

  14. Pletcher JR, Slap GB. Menstrual disorders. Amenorrhea. Pediatr Clin North Am. 1999 Jun. 46(3):505-18. [Medline].

  15. Altchek A, Deligdish L. Congenital absence of the uterus and the vagina. The Uterus: Pathology, Diagnosis and Management. 1991. 272-93.

  16. Edmonds DK. Congenital malformations of the genital tract. Obstet Gynecol Clin North Am. 2000 Mar. 27(1):49-62. [Medline].

  17. Emans SJ, Laufer MR, Goldstein DP. Structural abnormalities of the female reproductive tract. Pediatric and Adolescent Gynecology. 1998. 303-62.

  18. Spence J, Gervaize P, Jain S. Uterovaginal anomalies: diagnosis and current management in teens. Curr Womens Health Rep. 2003 Dec. 3(6):445-50. [Medline].

 
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