VOL. 46, No. 2 Marc!, 1954 113
Aplasia and Atresia of the Vagina
Two Case Reports
N. R. DAVIDSON, M.D. and A. J. HACKETT, M.D.
Deparinieni of Gynecology. Flint Goodridge Hospital. New Orleans,, La.
D URING the embryological development of also be a feeling of heaviness and pres-ure agaiinst
the organism, malformations may occur as the surrounding organs.
the result of arrested growth or as the result of In incomplete atresia the developed barrier
excessive growth of cells. The development of the which is usually located at the site of the lower
vagina has a commnon origin with the development third of the vagina may have but a small opening,
of the uterus from the mesial fusion of the enough to allow menstrual blood to trickle through.
Miullerian ducts. Frequently there is malformation In spite of this however, there is always some
of the uterus in conjunction with malformation drainage of serosanguinous discharge as was in
of the vagina. In complete absence of the vagina, Case Numb.er 2. In complete atresia when sym-
there may be absence of uterus, ovaries, tubes, toms arise surgical intervention is necessary. In
kidney and ureter and/or deformity of the remain- incomplete atresia surgery can be postponed until
ing kidney and ureter as in this case. Most embry- marriage is imminent, but it may have to be done
ologists agree that if only that portion of the earlier for the alleviation of sex complexes.
Millerian ducts which goes to form the vagina is at Careful perusal of literature pertaining to
fault, then the abdominal genital appendages will gynecology reveals infrequent occurrences of em-
be of normal development. If the uterus and tubes bryological defects of the vagina, hence the report
are present and the v,agina absent, when puberty of these two cases:
is reached and men-truation has begun, there will Case No. !.-M. A., an 18 year old girl was admitted
be no exit. If this continues there will be complete to the hospital October 2, 1944, with a history of absence
retention of blood and the developing hematometra of the vaginal (Aplasia). The patient stated that one
year ago she suffered with pains in the right middle
and hematosalpinx and will lead to the first clue quadrant. She consulted a local surgeon who performed
of aplasia. Adequate conservative measures should an appendectomy. Later she was told that she had no
b.cemployed for eliminating the anomaly. An arti- vagina of which she was wholly unaware. She admitted
ficial vagina should be made and adequate drain- that she likes to play baseball as well as playing with
age from the uterus established. If the vagina and dolls. She has never been intimate with the opposite sex
and prefers the company of girls. She denies any venereal
uterus are absent and only ovaries are present as disease. Family history was non-contributory. There was
in this case, then surgery may be withheld until a mid-line scar, the result of an appendectomy. Labora-
the patient is desirous of entering into wedlock or tory findings were as follows: Urine was acid, SpG:
to remove a developed psychosis, feeling that she 1031 Albumen Neg, Sugar Neg, Microscopic 10-20
is different from other girls. W.B.C. urates and Epithelian cells. P.Sp-1st Specimen
47 per cent-2nd Specimen 7 per cent R.B.C. 4,880,000
In atresia of the vagina the condition may be W.B.C. urates and Epithelian cells. P.S.P-1st Specimen
complete or incomplete. Curtis states that partial Neg.
diaphragm-like membranes may result, due to Physical Examination revealed an apparently well-
incomplete canalization of cells of one segment, nourished, well-developed female lying in bed in no
or there may be long solid areas without the forma- apparent discomfort. EENT revealed no diseased pathol-
tion of a lumen as the result of atresia of the lower ogy. Heart was within normal limits and lung fields were
clear. Breasts were of regular dimensions. There were
part of one of Muller's ducts: however since there no masses nor secretions. The abdomen was symmetrical
is much discrepancy concerning the development showing operative scar with keloid formation especially
of the vagina, other theories should not be over- in the right lower quadrant. Abdominal palpation re-
looked. If complete atresia is present there will be vealed a moderate size immovable mass in the middle-
damming-up of menstrual blood creating hematocol- right quadrant laterally and somewhat below the trans-
verse axis of the umbilicus. Her health has always been
pos and resulting in marked distention of the good. Admits having had measles. Her special senses
barrier toward the external genitalia. There will EENT were acute. All symptoms indicative of cardio-
114 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1954
respira.tory pathology were nil. Gastrointestinal tract many years-after which she moved to another state
except for appendicitis, revealed no abnormal pathology. and there she got married.
Genitourinary tract D/N 4-5. Denies all urinary pa- Case No. 2.-P. N., a 20 year old married young
0-1 woman complaining of intermittent cramp-like pains in
thology but does admit that she has never menstruated. the lower abdomen of 18 months duration was admitted
Liver and spleen not enlarged No shifting dullness nor to the hospital December 9, 1953. Prior to coming to
ascities. External genitalia showed presence of well-devel- this department she had had an appendectomy in April
oped labia majora. Labia minora poorly developed. 1953 with some relief from the lower abdominal pains
Urinary meatus somewhat overly dilated. No discharges. of which she complained. The menarche was at 12, inter-
Vaginal examination revealed the semblance of the ex- val 28 days duration 5 days-regular.
ternal portion of a vagina which presents dimpling at Cramp-like pains at onset and at post menstrual periods.
the site of the external orifice about 1/2 of an inch in She stated that her present condition (atresia of the
depth. Extremities were negative. Reflexes physiological. vagina) did have some pain and disturbing element in
Urological Examination: There is a palpable mass her married life. The laboratory findings were as follows:
moderately tender in the right lower quadrant. No kid- RBC 4,400,000 WBC 7,650 Hb Estimation 84 per cent
neys palpable in costovertebral angles and no tenderness. -Neutrophiles 76-Small monos 24. Type 0 Rh. posi-
Absence of vagina noted. Braaseh cystoscope passed with tive. The urine was essentially negative.
ease. The bladder mucosa showed no abnormality. After Physical examination revealed no diseased pathology.
diligent search, no left ureteral orifice was visible. The Vaginal examination revealed a vagina with depth of
right ureteral orifice protruded into the bladder lumen about 2 cm. completely obliterated at this point by a
resembling a small nipple and urine spurted at regular septum and consisting of only a small opening at its
intervals. It was catheterized with ease. The urine from upper third, which could only admit a small probe. Bi-
right kidney was clear and negative for pus cells or manual examination was impossible. Rectal examination
organisms. Bladder urine showed a few W.B.C. and a however revealed the presence of a cervix and uterus.
few gram negative bacilli. Retrograde pyelograms showed The urological survey revealed urethra of normal size,
a right kidney situated in the pelvis and rotated so that bladder mucosa normal, the ureteral orifices were patent
the calyces pointed toward the mid-line. Impression and urine was negative. Retrograde pyelogram showed
congenital absence of left kidney. 2) Ectopic right kid- the presence of both kidneys and ureters with some
ney, 3) mild chronic cystitis. Right kidney function fairly ptosis of the right kidney and tortuosity of the right
good. X-ray report-Right kidney pelvis is situated ureter.
laterally and is apparently rotated. It extends from the Operation December 10, 1953. The patient was placed
level of the transverse process of the 3rd lumbar vertebra in lithotomy position under general anesthesia. The
to the upper margin of the sacrum. The minor calyces shortened vagina and external genetalia were cleansed
are well defined and there is no evidence of dilatation of with tincture of green soap and tincture merthiolate. The
the pelvis. The ureter is somewhat tortuous and dilated. small opening in the septum was eventually dilated and a
The left ureter and left pelvis are not visualized. serosanguinous fluid flowed freely, the result of remains
The operation was performed December 28, 1944. The of menstrual blood being accumulated behind the septum.
patient was placed in the lithotomy position under general The site of the opening was grasped with tenaculum
anesthesia. The external vagina and rectum were cleansed and an incision made below it, but this dissection failed
with tincture green soap and tincture merthiolate. A logi- to penetrate the septum into the inner portion of the
tudinal incision of about 11/2 inches was made, following vagina, so the upper portion was opened above the small
which a transvere incision of about 2 inches was made opening; after it was proved that there were no other
between the levator ani muscles at the base of the vagina. attachments to the septum it was opened transversely on
By blunt dissection the loose connective tissue between both sides of the false opening to reach the lateral walls
the bladder and the rectum was separated up to a point of the vagina on both sides. The vagina behind the sep-
where the finger felt a small ridge-like juncture at which tum was normal except it was more tube-like in its
point the dissection was stopped-A depth of about four development, however the new introitus was wide enough
to five inches was obtained in this case. Then the open- to admit two fingers freely. After inspection of the
ing was stretched laterally with fingers from both hands vagina and cervix, the edges of the upper portion of the
to obtain maximum width. Following this a plastic septum were sutured to the raw surface under the
vaginal plug was placed into the cavity and held in bladder where dissection had begun before getting into
place by a T-binder. After the patient returned to her the septum and the posterior flap was likewise sutured to
room she was given lmg stilbestrol enseals three times the mucocutaneous junction where an attempt was made
a day (as in these patients the presence of estrogen is un- to dissect into the septum. Chromic 00 was used for the
certain). Epithelization which started at the site of the suturing.
incision and which grew inward around the vaginal plug Following the operation hysterosalpingography was
was complete in about 60 days. The vaginal plug which done with medopaque-H a newer aqueous media and
remained in position for the above duration was removed there was visualization of both tubes and ueterus. The
every other day, and the vaginal canal irrigated with patient was discharged from the hospital December 16,
normal saline. Contact was kept with this patient for 1953. Recovery was uneventful.