Concomitant Imperforate Hymen and Transverse Vaginal Septum Complicated with Pyocolpos and Abdominovaginal Fistula

A 13-year-old patient with a complaint of worsening lower abdominal pain during the past 4 months was admitted to the emergency department. An abdominopelvic ultrasound scan revealed a distended uterocervical cavity suggestive of hematometrocolpos. Imperforate hymen was observed on examination of the external genitalia. MRI scan revealed an air-fluid level representing pyometrocolpos within a distended vagina. Posterior vaginal extraperitoneal leakage as the sign of a fistula between the vagina and the rectovaginal space was detected. Although laparoscopic approach was planned, malodorous pus expelled after the insertion of the Veress needle, it was decided to proceed to laparotomy. Pus with peritoneal microabscess formations was observed at laparotomy. The imperforate hymen and TVS were excised vaginally. A more complex anomaly should be suspected in cases with hematometra and concomitant imperforated hymen without any bulging and thorough evaluation using radiological imaging techniques should be performed before surgical approach. 1. Introduction The prevalence of Mullerian duct anomalies, although rare, ranges from 0.001% to 10% in general population and 8–10% in women with an adverse reproductive history [1]. Among these anomalies, imperforate hymen is the most common anomaly with an incidence of 1/1,000 to 1/10,000 [2]. Transverse vaginal septum (TVS) with a prevalence of 1 in 30,000 to 1 in 80,000 women is more rare than imperforate hymen [3]. Both obstructive vaginal malformations may be asymptomatic in childhood or become symptomatic due to mucocolpos with the stimulation of maternal estradiol. Most of the cases become symptomatic after menarche with a complaint of hematometrocolpos. Concomitant imperforate hymen and TVS with unicornuate uterus [4] and concomitant imperforate hymen with a uterocervicovaginal septum [5] were presented previously. Congenital vesicovaginal [6] and iatrogenic or congenital urethrovaginal fistula formations [7, 8] due to obstructive vaginal lesions have been described, but the current case is the first to have abdominovaginal fistula related to both imperforate hymen and TVS. 2. Case Report A 13-year-old premenarchal girl was admitted to the emergency department with a complaint of worsening lower abdominal pain during the past 4 months. Secondary sexual characteristics had developed normally; she had Tanner stage IV breasts and normal pubic and axillary hair development compatible with her age. The absence of a hymeneal opening without any bulging was observed on examination of the external genitalia. The abdomen