Hidden Spaces: Treatment of an Occult Utero-Vaginal Septum

Abstract

Study Objective To describe the unique presentation and surgical management of a complete utero-vaginal septum. Design Video case report. Setting Tertiary care academic medical center. Patients or Participants We present a 25-year-old G2P0020 who is referred for evaluation after imaging and clinical examination revealed conflicting information. She was initially seen by her local provider for menorrhagia. Locally, an ultrasound revealed a septate uterus and examination under anesthesia with hysteroscopy noted a single vagina and cervix with a unicornuate uterus. Due to incongruous findings, she was referred for evaluation. Interventions Magnetic resonance imaging (MRI), examination under anesthesia, vaginal surgery and operative hysteroscopy. Measurements and Main Results MRI identified a complete utero-vaginal septum with a single septate cervix. Vaginal gel was used to define vaginal anatomy and gel was noted to fill the right hemivagina, while none noted on the left. Examination under anesthesia revealed an imperforate hymen with a small opening on the left as the cause for confusion in the clinical presentation. A hymenectomy was performed followed by guided surgical management of a complete utero-vaginal septum, unicollis. Conclusion Presentation of mullerian anomalies are often complex and anatomic variations in commonly described anomalies make misdiagnoses common. Advanced imaging with use of MRI with vaginal gel or 3-dimensional ultrasonography and detailed examination are often helpful. Differentiating between unicollis and bicollis presentations in complete utero-vaginal septum cases is an important distinction during surgical management.