Excision of Transverse Vaginal Septum

INTRODUCTION: Vaginal septae are classified into two main types: transverse and longitudinal. A transverse vaginal septum is a horizontal wall of tissue that can partially or completely block the vaginal canal, while a longitudinal vaginal septum is a vertical partition that divides the vaginal canal into two separate channels. Most commonly, these anomalies arise from improper fusion or resorption of the müllerian ducts and may present with symptoms like dyspareunia, obstructed menstruation, or difficulties in childbirth, depending on the type and severity. Less commonly, a secondary septum can be a surgical sequela or from chronic vulvar disorders. We present a case of an adult patient with a secondary transverse vaginal septum. OBJECTIVE: This video provides an example of a surgical approach to the excision of a thin transverse vaginal septum. METHODS: A 49-year-old patient presented to our clinic complaining of a 6-month history of “vaginal stenosis” and difficulty with penetration during intercourse. She reported no difficulty with gynecologic exams or intercourse prior to this time period. She had previously had vaginal deliveries, and she continued to have normal monthly menstrual cycles. Notably, she had no history of congenital malformations, trauma, or injury in the vagina, no connective tissue disorders, or other known risk factors for development of a vaginal septum. On exam, she was found to have a transverse vaginal septum with a small pinpoint opening at the right, superior aspect of the septum. Her cervix was not able to be visualized and her vaginal canal was noted to be 3 cm in length. A transvaginal ultrasound was obtained to aid in surgical planning. A sonohysterography catheter was placed through the opening in the septum, and saline was used to distend the portion of the vagina proximal to the septum. Ultrasound confirmed the septum was thin and the cervix was noted in its normal location proximal to the septum. There were no other masses or other abnormalities noted. After informed consent, the patient elected for surgical excision of the septum. A hemostat was used to carefully dilate the pinpoint opening. The tip of the hemostat was then inserted through the opening and used to apply forward traction to the septum. A transverse incision was made with cautery, allowing visualization beyond the septum and safe excision of the remainder of the accessory tissue. This normalized the caliber of the vagina, and a vaginal length of 9 cm was noted. The area of septum excision remained hemostatic without additional sutures. RESULTS: The patient was discharged home the same day with vaginal estrogen cream and lidocaine gel prescriptions. She was educated on the use of vaginal dilators and was instructed to use dilators twice daily. She was seen at 1 and 5 weeks postoperatively and recovered well without complications. Pap smear was obtained at her postoperative follow-up visit with normal results. CONCLUSIONS: We describe a safe and effective strategy for the surgical excision of a thin transverse vaginal septum. Our patient maintained a normal vaginal caliber and access to cervical cancer screening with continuation of a vaginal dilation protocol.