Management of Acute Obstructive Uterovaginal Anomalies _ ACOG.pdf

Management of Acute Obstructive Uterovaginal
Anomalies
Committee Opinion  | Number 779 | June 2019
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Number 779 (Reaffirmed 2025)
Committee on Adolescent Health Care
This Committee Opinion was developed by the American College of Obstetricians and
Gynecologists' Committee on Adolescent Health Care in collaboration with committee
members Anne-Marie E. Amies Oelschlager, MD, and Sloane W. Berger-Chen, MD.

ABSTRACT: Obstructive uterovaginal anomalies may present after puberty with amenorrhea,
dysmenorrhea, pelvic pain, recurrent vaginal discharge, or infertility. The evaluation of a
patient with a suspected obstructive reproductive anomaly should include a detailed medical
history, physical examination, and imaging. The genital examination is critical to differentiate
a patient with an imperforate hymen from a patient with labial adhesions, urogenital sinus,
transverse vaginal septum, or distal vaginal atresia. Pelvic ultrasonography is the initial
imaging method recommended for a patient with cyclic pain and amenorrhea or a patient
with persistent dysmenorrhea. It is important to note that diagnosis of a uterine or vaginal
anomaly by imaging before puberty can be challenging and misleading because of the small
size of the prepubertal uterus and the lack of endometrial stimulation and menstrual
distention of the vagina. Consultation with a radiologist experienced with imaging of
uterovaginal anomalies may be helpful to determine the most accurate diagnosis. In general,
obstructive vaginal and uterine anomalies are not surgical emergencies, and the complexities
of these conditions are best managed by gynecologic care providers familiar with the surgical
management of these conditions. Given the high risk of stenosis and complications
associated with transverse vaginal septum, distal vaginal atresia, and cervical atresia, referral
to a center with expertise in the management of these anomalies is paramount. The best
long-term outcome is achieved with a complete evaluation, clear understanding of the
anomaly, mobilization of appropriate surgical resources, sufficient preoperative counseling,
and planned surgical intervention.
Recommendations and Conclusions
The American College of Obstetricians and Gynecologists makes the following
recommendations and conclusions:
In general, obstructive vaginal and uterine anomalies are not surgical emergencies, and
the complexities of these conditions are best managed by gynecologic care providers
familiar with the surgical management of these conditions.
•
Obstructive uterovaginal anomalies may present after puberty with amenorrhea,
dysmenorrhea, pelvic pain, recurrent vaginal discharge, or infertility.
•

Background
Obstetrician–gynecologists should be familiar with uterovaginal anomalies, which may have
an incidence as high as 7% in females . Obstructive uterovaginal anomalies may present
after puberty with amenorrhea, dysmenorrhea, pelvic pain, recurrent vaginal discharge, or
infertility. The evaluation of a patient with a suspected obstructive reproductive anomaly
should include a detailed medical history, physical examination, and imaging. Accurate
diagnosis is critical to manage the obstruction properly. The best long-term outcome is
achieved with a complete evaluation, clear understanding of the anomaly, mobilization of
appropriate surgical resources, sufficient preoperative counseling, and planned surgical
intervention.
Müllerian obstructions are more common in patients with renal, vertebral, anorectal,
cardiac, tracheoesophageal, and limb anomalies. Females at high risk of obstruction
should be monitored closely for early signs and symptoms of obstruction during pubertal
development and initial menses.
•
If the diagnosis is not certain or there is a concern for a distal vaginal atresia, transverse
vaginal septum, cervical atresia, or an obstructed uterine horn, magnetic resonance
imaging (MRI) is recommended.
•
Simple incision and drainage of hematocolpos should not be performed because it is
associated with a high rate of ascending infection and sepsis and may complicate
definitive surgery.
•
Given that adolescents may not be sufficiently mature or prepared to adhere to a
postoperative dilation schedule, obstetrician–gynecologists and other gynecologic care
providers should consider menstrual suppression and delay of surgical intervention until
the patient is prepared to perform postoperative vaginal dilation.
•
The best long-term outcome is achieved with a complete evaluation, clear understanding
of the anomaly, mobilization of appropriate surgical resources, sufficient preoperative
counseling, and planned surgical intervention.
•
1

Embryology
During embryogenesis, the müllerian ducts fuse and develop into the fallopian tubes, uterus,
cervix, and upper vagina. Distally, the urogenital sinus separates into the urethra and distal
vaginal. Any portion of the development or canalization process may be incomplete, which
results in müllerian anomalies. Obstetrician–gynecologists should be aware of obstructive
conditions that result from a failure of the müllerian ducts to fuse. Incomplete vertical fusion
of the caudal müllerian duct with the sinovaginal bulbs leads to cervical atresia, transverse
vaginal septa, or distal vaginal atresia. Incomplete resorption of uterine or vaginal septa leads
to rudimentary and obstructed uterine horns or obstructive hemivagina and ipsilateral renal
anomaly (also referred to as OHVIRA or Herlyn-Werner-Wunderlich syndrome). Patients with a
history of a solitary or multicystic dysplastic kidney have a risk of an obstructed uterine horn
or an ipsilateral obstructing vaginal septum with a patent contralateral vagina . Most
patients with obstructive hemivagina and ipsilateral renal anomaly have a didelphic,
bicornuate, or septate uterus. Obstructive uterine horns may be found in a hernia, laterally in
the pelvis, or connected to a patent uterus. A rudimentary horn is most commonly
encountered when there is vaginal agenesis or in the presence of a renal anomaly ,
. Müllerian obstructions are more common in patients with renal, vertebral,
anorectal, cardiac, tracheoesophageal, and limb anomalies. Females at high risk of
obstruction should be monitored closely for early signs and symptoms of obstruction during
pubertal development and initial menses . See for the most commonly used
classification system for uterine anomalies.
2
Figure 1
Figure 2
3 Figure 3

Symptoms
The most common symptom associated with obstruction is pain. In a patient who presents
with pain, the presence of menstruation does not rule out obstruction. Pain may occur in a
cyclic manner or may be continuous. However, in patients who are amenorrheic, a pattern
may be more challenging to identify. Other associated symptoms include urinary frequency,
dysuria, hematuria, and urinary retention. Case series report urinary retention in up to 46% of
patients with hematometrocolpos caused by an imperforate hymen . Because of the
rectal pressure associated with low vaginal obstructions, patients may report feeling the need
to defecate but may be unable to do so. Patients who have a transverse vaginal septum with
spontaneous perforation may report sudden onset of heavy menstrual bleeding. If there has
been a chronic microperforation with ascending infection, symptoms may include chronic
ongoing vaginal discharge or pelvic inflammatory disease. Patients with longitudinal vaginal
or hymenal septa may report difficulty placing or removing tampons. Patients also may report
bleeding through tampons and dyspareunia. Additional risks include septal tearing with
coitus and obstructed labor.
Physical Examination
4

Examination should begin with an evaluation of sexual maturity (Tanner staging) to assess
the degree of pubertal development. An abdominal examination may reveal tenderness or an
abdominal mass due to an enlarged obstructed uterus. The genital examination is critical to
differentiate a patient with an imperforate hymen from a patient with labial adhesions,
urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Downward labial
traction can open and separate the labia majora and minora sufficiently to visualize the distal
introitus. An imperforate hymen with hematocolpos (blood in the vagina) will reveal a dark-
colored or bluish-tinged bulge without hymenal fringe identified . Distal vaginal
atresia will appear as pink mucosa without discoloration . If the patient can tolerate
a digital examination, a shortened vagina on examination without a palpable cervix may be
consistent with a transverse septum, cervical atresia, or vaginal agenesis. There may or may
not be a bulging proximal vagina if there has been a spontaneous perforation. For the patient
with obstructive hemivagina and ipsilateral renal anomaly, there may be a bulge along the
patent vaginal wall that deviates the patent vagina away from the obstructed side .
Frequently, the cervix on the patent vaginal side is pulled medially toward the septum and
may be difficult to palpate. Often, a patient cannot tolerate a speculum examination. If the
patient can tolerate a speculum examination, using a smaller, shortened, Huffman speculum
or a nasal speculum may allow visualization of a vaginal septal microperforation, which may
appear as a small dot or opening with either dark blood or purulent discharge noticeable
. For adolescents, a digital rectal examination is often less painful than a vaginal
examination and may be particularly helpful to confirm the presence of the cervix or assess
the distance from the hematocolpos to the perineum with vaginal or hymenal obstructions.
Figure 4
Figure 5
Figure 6
Figure 7

Pelvic ultrasonography is the initial imaging method recommended for a patient with cyclic
pain and amenorrhea or a patient with persistent dysmenorrhea . A preimaging
discussion with a radiologist is helpful. In adolescents, transabdominal pelvic
ultrasonography is recommended before proceeding with transvaginal ultrasonography,
particularly for those who have not used tampons or had sexual intercourse. Often
hematocolpos may be identified posterior to the bladder. Obstructed uterine horns may be
difficult to identify by pelvic ultrasonography because they may be located laterally and much
higher in the pelvis . If the diagnosis is not certain or there is a concern for a distal vaginal
atresia, transverse vaginal septum, cervical atresia, or an obstructed uterine horn, MRI is
recommended. Magnetic resonance imaging is especially useful to identify the presence and
location of the uterine corpus, endometrial cavity, cervix, and proximal vagina . The use of
vaginal gel or a vitamin E capsule placed in the distal vagina may assist in determining the
distance between the distal and proximal vagina, which will help with surgical planning for a
transverse vaginal septum resection.
Figure 8
5
6

It is important to note that diagnosis of a uterine or vaginal anomaly by imaging before
puberty can be challenging and misleading because of the small size of the prepubertal
uterus, the lack of endometrial stimulation, and the lack of menstrual distention of the vagina
. Consultation with a radiologist experienced with imaging of uterovaginal anomalies may
be helpful to determine the most accurate diagnosis.
In patients with identified müllerian anomalies, renal imaging should be obtained . If
the urinary bladder and ureters cannot be distinguished clearly from hydrocolpos, a magnetic
resonance urogram or ureteral stenting can be considered .
General Principles of Treatment
In general, obstructive vaginal and uterine anomalies are not surgical emergencies, and the
complexities of these conditions are best managed by gynecologic care providers familiar
with the surgical management of these conditions. Given the high risk of stenosis and
complications with transverse vaginal septum, distal vaginal atresia, and cervical atresia,
referral to a center with expertise in management of these anomalies is paramount. In fact,
hematocolpos creates vaginal distention, increasing the size of the proximal vaginal tissue
that can be mobilized to bridge the distance between the proximal and distal vagina.
Therefore, delaying surgical intervention may allow further distention of the distal vagina or
thinning of the septum, which may decrease the risk of stenosis.
There are multiple strategies to allow time for referral to an experienced gynecologic surgeon
for definitive surgery. Simple incision and drainage of hematocolpos should not be performed
because it is associated with a high rate of ascending infection and sepsis and may
complicate definitive surgery. Indications to expedite surgery include urinary retention, severe
pain, and ascending infection. If a patient presents with acute urinary retention, an indwelling
urinary catheter may be placed. Stool softeners and pain medication also should be
prescribed. If a patient presents with acute pyometrocolpos, broad spectrum antibiotics
should be initiated and surgical management should be expedited.
7
8 9
10
11

Oral medroxyprogesterone acetate, 20 mg by mouth three times per day, may be given to
suppress menses acutely . Continuation of complete menstrual suppression can improve
patient pain and provide time for referral to a surgeon with expertise. Relief of pain will not be
immediate but will improve with time, typically in 7–14 days. Options for menstrual
suppression include continuous combination oral contraceptive pills, progestin-only pills or
injections, or gonadotropin-releasing hormone agonists . Given that
adolescents may not be sufficiently mature or prepared to adhere to a postoperative dilation
schedule, obstetrician–gynecologists and other gynecologic care providers should consider
menstrual suppression and delay of surgical intervention until the patient is prepared to
perform postoperative vaginal dilation. Menstrual suppression allows time for an adolescent
to mature, understand the diagnosis and dilation process, and actively participate in shared
decision making.
Patient and Family Counseling
Many patients and families will have limited understanding of the anomalies of the
reproductive tract and will benefit from education regarding embryology and the physiology
of menstruation. Patients should be informed that the best long-term outcome is achieved
when a complete evaluation to accurately diagnose the obstructive anomaly has been
performed, and the patient has been completely evaluated, has been counseled by a surgeon
with expertise in managing acute obstruction, and is mentally ready. For procedures that may
require vaginal dilation, patients should be educated about the process of dilation and be
mature enough and prepared to dilate postoperatively . Patients with distal vaginal
atresia or transverse vaginal septum can be encouraged to dilate preoperatively to thin the
distance between the proximal and distal vagina to decrease the need for graft . Patients
with these anomalies should be counseled that postoperative dilation may be necessary to
prevent stenosis and reoperation.
12
Table 1 1
1 13
14

Surgical Management
After a comprehensive evaluation and stabilization, surgical management of the obstruction
may be appropriate. Surgical management is dependent on the type of obstructive vaginal or
uterine anomaly. If the obstetrician–gynecologist does not have experience with distal
vaginal atresia, high or thick transverse vaginal septa, and cervical atresia, referral to a
specialty care center or to a surgeon with expertise in these conditions is warranted. Given
the high risk of infection with an obstruction, the use of prophylactic antibiotics is
recommended .
Imperforate Hymen
Before puberty, the imperforate hymen without hematocolpos appears similar to distal
vaginal atresia; therefore, surgical intervention should be delayed until the obstetrician–
gynecologist can confirm that a uterus and vagina are present during thelarche. See ACOG
Committee Opinion No. 780, Diagnosis and Management of Hymenal Variants, for more
information .
Distal Vaginal Atresia
Distal vaginal atresia is notable for the presence of the upper vagina, cervix, and uterus
without evidence of hymenal tissue at the introitus and is associated with anorectal and
urologic anomalies. The first-line approach for management of distal vaginal atresia involves
a pull-through vaginoplasty. A pull-through vaginoplasty involves making an introital incision
and dissecting between the urethra, bladder, and rectum until the proximal obstructed vagina
is reached. The proximal vagina is then mobilized and anastomosed to the introitus. If the
proximal vagina is 3 cm or greater from the introitus, the risk of stenosis is high, and an
interposition graft may be necessary . For high atresia, a combined abdominal and
vaginal approach using laparoscopy or laparotomy may be considered .
Transverse Vaginal Septum
15
16
17
18

The locations of transverse vaginal septa include the upper one third of the vagina (46%),
middle one third of the vagina (40%), and lower one third of the vagina (14%) . Associated
anomalies include imperforate anus, bicornuate uterus, coarctation of the aorta, atrial septal
defect, and malformations of the lumbar spine. As in patients with a distal vaginal atresia, the
risk of vaginal stenosis is high; therefore, surgical intervention is best performed when the
patient is committed to postoperative dilation.
Surgical management includes completely excising the intervening septal tissue. Because
the risk of stenosis and injury to the bladder and rectum is high, the surgeon should proceed
with caution. Surgeons who are inexperienced with the procedure should consider referring
patients to a center with surgeons experienced in excising the septal tissue. The proximal
vagina may be mobilized with care to avoid the bladder, rectum, and anastomosed to the
distal vagina. A Z-plasty technique may increase the length of the vaginal flaps and decrease
the risk of narrowing the vagina . For long transverse septa, an interposition graft also
may be considered. Postoperative stenting may be required for longer vaginal septa and with
interposition grafting .
Obstructed Hemivagina and Ipsilateral Renal Anomaly
During renal imaging before puberty, patients with obstructive hemivagina and ipsilateral
renal anomaly present with a lateral bulging cystic mass at the introitus or an incidental
hydrocolpos posterior to the bladder . Patients who present postmenarche often
report severe dysmenorrhea. A vaginoscopy may be performed to assess for a microscopic
perforation between the two vaginal canals. Care should be taken to resect as much of the
septal tissue as possible with extreme care to avoid both of the cervices, bladder, and
rectum. Often the obstructed cervix is dilated and may be pulled toward the medial septal
tissue . It is important to note that there may be an ectopic ureter in the obstructed
vagina, and if patients have urinary drainage after excision of the septum, the dysplastic
kidney may need to be excised . This condition usually is associated with uterine
didelphys, a bicornuate bicollis uterus, or a complete septate uterus.
Longitudinal Vaginal Septum
19
20
21
Figure 6
2 22
23

Longitudinal vaginal septum is commonly associated with uterine didelphys, bicornuate
uterus, or complete septate uterus. The excision should be performed with extreme care to
avoid the bowel, bladder, and urethra, which can be tented toward the septum. Additionally,
care should be taken to avoid injuring the cervix or cervices. The vaginal septum typically is
clamped and transected, and the mucosa is approximated between the two sides after the
septal tissue has been excised.
Cervical Atresia
Surgical management of cervical atresia is controversial because of the high risk of
complications, stenosis, and ascending infection associated with reconstructing the cervix
and vaginal anastomoses. Although there have been reports of menstrual suppression with
pregnancies achieved by in vitro fertilization, as well as pregnancies after interposition graft
anastomoses, there also have been reports of deaths associated with sepsis and very high
rates of reoperation . Given the challenging nature of this diagnosis and high risk of
complications associated with surgical intervention, patients with suspected cervical atresia
should be referred to an experienced surgeon for definitive diagnosis, counseling, and
management. If a patient undergoes a hysterectomy for cervical atresia, vaginal elongation
for vaginal sexual activity typically can be accomplished by vaginal dilation alone without
further surgical treatment. Dilator therapy should be deferred until the patient is ready .
Rudimentary Horn
A rudimentary horn may be identified at the time of diagnosis of a prepubertal herniorrhaphy,
but typically it is resected after puberty . Because it is difficult to assess for the presence
of a cervix and small upper vagina before puberty, incidentally identified prepubertal horns
should not be resected unless there is no potential for fertility. If MRI indicates no
endometrium in a uterine horn, resection typically is not necessary, and observation is
reasonable. If there is an active endometrium, laparoscopic resection of the uterine remnants
to decrease pain, retrograde menstruation, and endometriosis is warranted . Menstrual
suppression can be considered to decrease pain if a patient prefers to defer operative
intervention. Given the high rate of urologic anomalies associated with uterine anomalies,
avoiding aberrant ureters during surgery is important .
Postoperative Care
24
25
26
25
Figure 6 27 28

Patients at high risk of vaginal stenosis, including those who have had pull-through
vaginoplasty, resection of a thick transverse vaginal septum, or those with a vaginal graft,
typically will require postoperative hospitalization on bedrest with an indwelling vaginal stent.
A vaginal stent may be fashioned from foam, silicone, or packed gauze covered with a sterile
condom or glove. It may be left in place from 3 to 7 days depending on the extent of grafting.
While the stent is in place, an indwelling urinary catheter, progestin hormonal suppression,
antibiotics, and deep vein thrombosis prophylaxis should be prescribed. Once the stent has
been removed, the patient may be discharged with close postoperative follow-up for
monitoring of healing and dilation, ideally every 1–2 weeks until the patient is comfortable
with the dilation process and pain is improved. Dilator therapy should not be initiated until the
graft or suture line has healed enough to permit dilation. Gynecologists should continue to
monitor patients closely to address patient concerns and encourage adherence with dilation
.
Long-Term Follow-up
All patients with a history of obstruction or müllerian anomalies are at high risk of ongoing
endometriosis. Although the initial treatment of the obstruction may alleviate pain, patients
should be monitored closely and counseled about menstrual suppression options for
ongoing dysmenorrhea . All patients with a history of an obstructing septum or distal
atresia have a risk of stenosis and may require ongoing dilation or additional surgical
intervention . Although fertility may not be affected after early intervention for obstructing
vaginal lesions, because endometriosis is associated with infertility and uterine anomalies
are associated with adverse obstetric outcomes, patients should receive long-term follow-up
care to address any reproductive issues proactively .
For More Information
The American College of Obstetricians and Gynecologists has identified additional resources
on topics related to this document that may be helpful for ob-gyns, other health care
providers, and patients. You may view these resources at www.acog.org/More-
Info/UterovaginalAnomalies.
29
30
29
31

These resources are for information only and are not meant to be comprehensive. Referral to
these resources does not imply the American College of Obstetricians and Gynecologists'
endorsement of the organization, the organization's website, or the content of the resource.
The resources may change without notice.
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Management of acute obstructive uterovaginal anomalies. ACOG Committee Opinion No.
779. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e363–
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direct, special, indirect, or consequential damages, incurred in connection with this
publication or reliance on the information presented.
All ACOG committee members and authors have submitted a conflict of interest disclosure
statement related to this published product. Any potential conflicts have been considered and
managed in accordance with ACOG's Conflict of Interest Disclosure Policy. The ACOG
policies can be found on acog.org. For products jointly developed with other organizations,
conflict of interest disclosures by representatives of the other organizations are addressed by
those organizations. The American College of Obstetricians and Gynecologists has neither
solicited nor accepted any commercial involvement in the development of the content of this
published product.
Topics Genital diseases Gynecologic surgical procedures Urogenital diseases
Uterine diseases Vaginal diseases

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