(82) Obstructed Hemi-Vagina: Variation and Management

Background: Obstructed hemivagina is a complex congenital uterovaginal anomaly.  It is typically associated with an ipsilateral renal anomaly. The incidence is unknown. Diagnosis can be delayed as there is less awareness of unliateral menstrual obstruction.
This study aims to describe presentations, anatomical variation, and surgical outcomes.

Methods: A retrospective case series of patients with obstructed hemivagina managed at a tertiary referral centre between 2015-2024. Data was collected on age, symptoms, radiological findings, surgical details and outcomes.

Results: 59 cases were identified. The median age at referral was 15years(11-31).
Median duration of follow up was 24 weeks (0-8 years), with one patient was lost to follow up following their surgery.

The majority of patients presented with pain and, or, dysmenorrhea (43/59), with 12/59 presenting with abnormal bleeding or discharge.

Median duration of symptoms prior to referral was 10months(1month to 5.5years).

Before referral 15/59 (25%) patients had previously had operative management with six patients having had multiple procedures. These included vaginal drainage of the obstructed hemivagina (6/15), laparoscopic drainage (4). Three patients had undergone laparotomies.

Uterine duplication was present in all with 55/59 (93%) being uterus didelphys and the rest septate uterus.
The obstructed hemivagina was right-sided in 36/59 and left-sided in 23/59. The septum was low in 33/59, mid in 10/59 and high in 17/59. Fallopian tubal distension affected 16/59 patients.

Renal anomalies were identified in 55/59 (93%), with 53/59 having ipsilateral renal agenesis.
Skeletal anomalies were recognised in 17/59, most commonly scoliosis (7/17) with one patient having previously had spinal surgery.

All procedures were performed vaginally with ultrasound guidance.

One procedure was converted to laparotomy to manage a bladder injury.
Two patients with high septums re-obstructed. Re-obstruction was managed by repeat vaginal septum resection in one patient and laparoscopic hemi-hysterectomy for the other.

Post-operative infection was managed with oral antibiotics in 9/59 patients.
Two patients’ had persistent pain which improved following laparoscopic salpingectomy.
Post-operative incontinence affected one patient. This resolved following uncomplicated robotic nephrectomy for a small dysplastic functioning kidney not identified pre-operatively on MRI renal.

Conclusions: Obstructed hemivaginas are rare and the unilateral menstrual obstruction can be more challenging to diagnose. Outcomes can be complicated by delayed diagnosis. Menstrual suppression with ongoing management in centres experienced with complex uterovaginal anomalies is recommended.