EP25.20: Clinical dilemma solved by transperineal ultrasound

A 39-year-old lady menopausal since 5 years, consulted for inability to have vaginal intercourse and infertility. She attended menarche at 11 yr and had regular cycles for 2 yr when she developed abdominal pain with vaginal discharge. A laparotomy for removal of left ovarian pathology was then performed. She continued to have regular menses until 5 years ago. Her first marriage lasted for few months and was non-consummated. On examination she is of normal stature with normal secondary sexual characteristics. Abdomen shows a Pfannenstiel's scar. Vulva normal and introitus showed vaginal dimple. On digital rectal examination uterus could not be felt. According to her history of secondary amenorrhea premature ovarian insufficiency was suspected but examination ruled out possibility of normal menses and suggested MRKH syndrome/ transverse vaginal septum/vaginal atresia. This caused clinical dilemma due to non-corresponding history and examination. Transperineal ultrasound (TPUS) showed a hypoplastic uterus and a 5cm long vagina with lumen and a transverse vaginal septum. Transabdominal ultrasound confirmed the findings and also showed adhesions between uterus, bladder and bowel. MRI showed 6cm long vagina with collapsed vaginal walls and narrow lower vagina suggestive of transverse vaginal septum/atresia of lower vagina, uterus and both ovaries hypoplastic. Final diagnosis is premature ovarian insufficiency with transverse vaginal septum with frozen pelvis. This case emphasises importance and feasibility of TPUS for complete and low cost evaluation of vagina. TVS route under evaluates vaginal lesions by rendering it out of the field. MRI provides excellent soft-tissue detail and diagnose most vaginal diseases and associated genitourinary abnormalities. A focused approach towards understanding and correctly recognising different vaginal entities is needed. TPUS is best for evaluation of the vagina given its feasibility, easy availability and low cost. AI-based machines can guide to perform TPUS.