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MRI revealed low confluence of vagina to the urethra. It was like imperforate hymen with urogenital sinus. So the job was eacy. Blind vaginal pouch (2 mm thick) was cut transversely, POC's evacuated from vagina and also from uterus. Small UGS was present 5 mm in length communicating vagina to the urethra, which was excised and closed with 3-0 vicryl.. Vagina was marsupulated with blind vaginal pouch with 3-0 vicryl. Forcep is through the sinus.

Dear Niraj ,

You are lucky to manage this case. I got a case of 30 years old lady with fused labia and single opening resulting in menuria. I do not want to comment much but your case is already diagnosed and managed. In my case this was suspected, but I could not do much as my patient was not motivated to allow intervention.

I am sending a photographs and links of some article. Theses could be helpful.

Links are

http://www.ncbi.nlm.nih.gov/pubmed/14751378

http://www.ncbi.nlm.nih.gov/pubmed/24560718

http://www.ncbi.nlm.nih.gov/pubmed/21975178

In your case, is the uterus is bicornuate?

No single normal uterus

One should consider thart she may have had urethral coitus which can be prevented by an adequate surgical correction of the ug sinus

Uretral coitus is common in vaginal agenesis. It happened in the above case. rarely dilated urethra might be confused as vagia. Please see thephotograph below

Thank Niraj,

Your explanation is clear, but my worry is that by excising the sinus in a low confluence UGS you will temper  with the spincter  mechanism of the urethra and that might cause incontinence in the patient. I feel icising through the sinus tract and closing could have been better option. The choice of vicryl 3-0 is good enough. It will be interesting to hear the subsequent response of the patient to this surgery.

kindly keep us posted.

.

Urethral coitus was not happening here. It was not even admitting the tip of finger. She had blind vaginal pouch which was admitting my whole finger. Coitus was taking place in blind vaginal pouch. External urethral sphinctor is above the confluence of vagina. So there is no question of disturbing it, when the communicating tract was excised. Her catheter was removed 2 days back and she had no problem with voiding of urine. On local examination all tissues were looking healthy. No sign of infection. She is discharged now.

Dear Niraj,

Thanks for the prompt response.

You know the whole female urethra is approximately 4cm long. And the external sphinter - ie, rhabdosphincter muscles, has the most sphinteric action on the female urethra. This important muscle fibres occur at the urogenital triangle, located approximately 1.8cm distal to the bladder neck, and the effect extend about 1.5cm of the urethral length. see the image below.

So, that means less than a centimeter from the external urethral meatus (distal to the ext. sphincter) is where the sinus is located. That is why i, as a fistula surgeon, find it difficult to understand how a tissue there can be excised and the area stitched back without involving the external spincter.

I actually agree with Prabhat that you are lucky to sucessfully managed that patient without complication.

Kudos to you, and good luck

Ext urethral sphinctor in these cases is located above the tract joining vagina and urethra. Terminal portion of the urethra beyond these confluence can be used to reconstruct the terminal portion of the absent vagina. I think please go through the anatomy of UGS and surgeries to correct these. Photo I had drawn may give some insight into it.

 I have some confusions.

  Vaginal pouch was 6 cm long. Then fistula opening was above septum. This means during menstruation it destends vagina and menstrual flow happens through urethra. You described she had no complaints means dysmenorrhoea, dysperonea, menuria. Your first picture is just like an imperforated hymen except it is not bluish in color. 

  " MRI revealed low confluence of vagina to the urethra. It was like imperforate hymen with urogenital sinus. So the job was eacy. Blind vaginal pouch (2 mm thick) was cut transversely"  

 "She had blind vaginal pouch which was admitting my whole finger"

  The full description is confusing and conflicting.

You can see the photo. It was almost like imperforate hymen/ low transverse vaginal septum. The membrane (blind vaginal pouch), I was able to put my finger and after stretching it, it could accomodate entire length of my finger (which explains both husband and wife no difficulty during intercourse). You can compare it with some MRKH blind pouch, which can be stretched with finger. Anbd yes she was menstruating through the urethral opening.

Recently, I got a case of term pregnancy with absent vaginal introitus. I took her at OT where I found a pinhole with a thick membrane. I introduced a feeding tube no 6 and did CS. After taht I introduced my fingers into the vagina from above and felt the tube. Cruciate incision was given. It was a case of "Microperforate Hymen in a Full Term Primigravida in Active Labour". Your case is quite similar to mine.

http://www.jmsskims.org/Contents/152-24%20IMTIAZ%20SHAH%20MICROPERFORATE%20HYMEN.pdf