Human Reproduction vol.14 no.8 pp.

19621964, 1999

Blind hemivagina: long-term follow-up and reproductive

performance in 42 cases

B.Haddad1, E.Barranger and B.J.Paniel

Materials and methods

Service de Gynecologie-Obstetrique, CHI Creteil, 40 avenue de

Verdun, 94010 Creteil, France

We carried out a retrospective study of patients with a blind hemivagina

who were treated in our centre between 1970 and July 1997. A total
of 42 patients (mean age: 18 years, range: 1130) were reviewed.
four women had five pregnancies before referral, two of whom
(didelphic and complete septate uterus) had three pregnancies. These
latter pregnancies took place in the ipsilateral uterus and were
delivered before 37 weeks by Caesarean section; a communication
between blind and normal vagina was found in these two patients.
Two other patients (didelphic and complete septate uterus) had two
pregnancies which occurred in the normal cavity and were terminated
early. These five pretreatment pregnancies were not included in
the results.
Symptoms at time of referral are outlined in Table I. Right blind
hemivagina was found in 52% of patients. All patients underwent
ultrasound examination of the kidneys or intravenous pyelography:
an ipsilateral renal agenesis was found in all cases except for one
patient who had normal kidneys and a didelphic uterus.
Pelvic ultrasonography and, where possible, hysterosalpingography
were performed in 74 and 19% of the cases, respectively. All patients
except one underwent laparoscopy prior to the surgical procedure, in
order to clarify the uterine malformation (as a function of American
Fertility Society Classification, 1988) and to explore the upper genital
tract. The exception underwent resection of vaginal septum in 1970
without prior laparoscopy; 18 years later this patient underwent
laparoscopy for Fallopian tube ligation. Although this permitted
exploration of the genital tract, the results were excuded from this
study. Didelphic and complete septate uterus were found in 78 and
22% of cases, respectively. Associated complications of the upper
genital tract were found in 39% of cases (Table II). Endometriosis,
when present, was stage I, II, III in 11, one and three cases,
respectively (revised American Fertility Society Classification).
Surgical treatment consisted of vaginal septum excision in 37
patients (88%). Vaginal septum excision was performed in one
procedure for 34 patients. Two interventions were needed for three
patients (one with a pyocolpos and two with a haematocolpos which
reached the hymeneal ring): a limited resectionmarsupialization
(nearly 3 cm diameter) and drainage of the blind hemivagina was
followed 1 month later by the resection of the septum. Associated
complications of the upper genital tract were treated after resection
of the septum (Table III).
Hemihysterectomy and ipsilateral hemicolpectomy were performed
in five patients (12%) with severe adnexal complications including
adhesions between Fallopian tubes and ovaries and Fallopian tube
lacerations. Two of these patients also had an associated oophorectomy. Two severe complications arose in these patients. In one case
blood transfusion was needed after the surgical intervention and in
the second the presence of a pelvic haematoma required a second
intervention 14 days later. All patients received broad-spectrum
antibiotics (Ampicillin) during surgical treatments.
Patients were examined 3 months later. Morphological results were
obtained from medical records. To assess long-term reproductive
performance the patients were asked by phone to complete a question-

1To

whom correspondence should be addressed, c/o Baha M.Sibai,

MD, Division of MaternalFetal Medicine, University of
Tennessee, 853 Jefferson Avenue, Memphis, TN 38163, USA

Our purpose was to analyse the reproductive performance

of women with obstructed hemivagina after surgical treatment. After laparoscopic exploration of 42 cases (mean
age: 18 years), didelphic and complete septate uterus were
found in 78 and 22% of cases respectively. Resection
of vaginal septum and hemihysterectomy with ipsilateral
hemicolpectomy were performed in 88% and 12% of the
cases, respectively, between 1970 and 1997. Long-term
results were assessed by a questionnaire and obtained for
38 patients (mean years after treatment and range: 6.5; 1
23). Dysmenorrhoea and abdominal pain were resolved in
87% and 100% of the cases, respectively. Nine patients
experienced 20 pregnancies (13 living children, four early
spontaneous abortions, two early terminations and one
ectopic pregnancy). Nine offspring (69% of live births)
were delivered after 37 weeks. Four patients had four
pregnancies ipsilateral to blind hemivagina after vaginal
septum resection (two living children, one early spontaneous
abortion and one ectopic pregnancy). These results suggest
that laparoscopic exploration and resection of vaginal
septum are the appropriate treatments for obstructed
hemivagina. Subsequent reproductive performance was
comparable to that reported following treatment of the
associated uterine malformation.
Key words: blind hemivagina/pregnancy outcome/renal agenesis/
uterine malformation

Introduction
Blind hemivagina is a rare malformation which involves
Mullerian and Wolffian ducts. Although the condition was first
recognized in 1922 (Purslow, 1922) and is represented by the
presence of a didelphic uterus and ipsilateral renal agenesis,
the pathogenesis remains unclear and its aetiology is still
unknown. Most reports concerned small series, the maximum
being a series of 36 patients (Candiani et al., 1997). Conservative surgical treatment (excision of the obstructing septum
followed by a marsupialization of the blind hemivagina)
is generally regarded as appropriate. However, long-term
functional results and reproductive performance after surgical
treatment have not been well established. We therefore studied
a series of 42 cases in order to evaluate these parameters.
1962

European Society of Human Reproduction and Embryology

Blind hemivagina and long-term follow-up

Table I. Patient characteristics (n 5 42)

n (%)
Dysmenorrhoea
Haematic vaginal discharge
Abdominal pain
Purulent discharge
Dyspareunia
Paravaginal mass
Septum communication
Pelvic mass

35
17
5
2
2
35
15
7

(83)
(40)
(12)
(5)
(5)
(83)
(36)
(17)

Table II. Upper genital tract complications (n 5 41)

n (%)
None
Haematometra
Haematosalpinx
Pyosalpinx
Inflammation of Fallopian tubes
Pelvic adhesions
Endometriosis

25
15
9
1
2
4
15

(61)
(37)
(22)
(10)
(37)

Table III. Associated surgery performed for upper genital tract

complications in women undergoing resection of the septum (n 5 37)
n (%)
None
Adhesiolysis
Coagulation of endometriotic nodes
Salpingectomy
Paratubal cyst removal
Cystectomy of ovarian endometrioma and ovariolysis

26
4
4
2
1
2

(70)
(11)
(11)
(5)
(3)
(5)

Table IV. Reproductive performance of women with blind hemivagina after

surgical procedure (n 5 9)
Didelphic
(n 5 7)
Pregnancies
17
Live birth
12
Delivery ,37 weeks
4
Caesarean section
1
Vaginal
3
Delivery 37 weeks
8
Caesarean section
3
Vaginal
5
Early spontaneous abortion
3
Ectopic pregnancies
1
Early termination
1
Pregnancies ipsilateral to blind 3
hemivagina

Complete septate
(n 5 2)

Total
n (%)

3
1
0
0
0
1
0
1
1
0
1
1

20
13 (65)
4 (20)
1
3
9 (45)
3
6
4 (20)
1
2 (10)
4 (20)

naire; this occurred an average of 6.5 years after surgical procedure

(range: 123 years). The questionnaire concerned dysmenorrhoea,
vaginal discharge, dyspareunia and pregnancies, including their number and results (live birth, early termination, early spontaneous
abortion and ectopic pregnancy), gestational age at delivery, mode of
delivery and whether the pregnancy was ipsi- or contralateral to the
obstructed hemivagina.

Results
Surgical treatment assessed after 3 months appeared to be
satisfactory in 39 cases (93%). In three cases (7%), a minor
and ipsilateral stricture was observed at the lateral side of the
vagina, near the fornix, twice after hemihysterectomy and
ipsilateral hemicolpectomy and once after conservative treatment. Further surgery was not required.
Thirty-eight patients (90%) answered the questionnaire.
Dysmenorrhoea and abdominal pain were resolved in 87%
(27/31) and 100% of cases, respectively. Vaginal discharge
was noted in 16% of cases. Dyspareunia was resolved in both
patients (Table I), and no new cases were noted after surgery.
With regard to reproductive performance, eight patients had
not attempted intercourse, 19 did not wish to become pregnant,
two had been trying for 6 and 12 months respectively to
achieve pregnancy. Nine women who had undergone vaginal
septum excision experienced 20 pregnancies after surgical
procedure and the results are outlined in Table IV. Four women
had 4 ipsilateral pregnancies after resection of vaginal septum.
Two of them (with a didelphic and complete septate uterus)
had vaginal deliveries after 37 weeks and two others (with
didelphic uterus) had an early spontaneous abortion and an
ectopic pregnancy. The five patients who underwent hemihysterectomy and ipsilateral hemicolpectomy did not achieve
pregnancy.
Discussion
Uterine malformation, when associated with obstructed hemivagina and ipsilateral renal agenesis, has been generally
described as a double, mainly didelphus, uterus (Rock and
Jones, 1980; Morgan et al., 1987; Stassart et al., 1992; Candiani
et al., 1997). However, the external shape of uterus was
frequently unknown since diagnosis was generally achieved
by hysterosalpingography. Rare cases of septate uterus have
been reported (Vinstein and Franken, 1972; Robert and Le
Charpentier, 1974; Yoder and Pfister, 1976; Rock and Jones,
1980; Chelli et al., 1994). In our study, laparoscopic exploration
showed a complete septate uterus in nine cases (22%).
Ipsilateral renal agenesis is prevalent since the development
of the urinary system parallels that of the genital tract (Muller
et al., 1967; Acien, 1992). However, the presence of normal
kidneys has been reported (Johnson and Hillman, 1986) and
we found a case of a normal urinary tract in our series. It has
been reported that the right one is predominantly involved,
occurring in 66% of cases (Rock and Jones, 1980; Morgan
et al., 1987). However, our results did not confirm this, right
and left sides being equally involved.
Clinical management of blind hemivagina must include
renal imaging by ultrasonography or intravenous pyelography,
both to confirm the absence of a normal kidney in the affected
side and to detect abnormalities in the contralateral urinary
tract (Stassart et al., 1992). Our series included a case of
contralateral vesico-ureteral reflux with a normal kidney which
necessitated surgical treatment. Assessment of uterine malformation by hysterosalpingography may not be beneficial
(Acien, 1997), though it may permit a communicating uterus
to be diagnosed especially in patients with haematic vaginal
1963

B.Haddad, E.Barranger and B.J.Paniel

discharge. Abdominal and endovaginal ultrasonography (Nasri

et al., 1990) and more recently three-dimensional ultrasound
(Jurkovic et al., 1995; Raga et al., 1996) may contribute to
the analysis of the external uterine shape. Magnetic resonance
imaging may also be helpful to detect uterine anomalies (Mintz
et al., 1987; Pellerito et al., 1992; Sardanelli et al., 1995).
However, these two latter techniques are expensive and do
not change radically the management of this malformation.
Laparoscopic exploration has the ability to assess the type of
uterine malformation and reveal other complications in the
upper genital tract which may require appropriate surgery.
Early correct diagnosis will allow the appropriate surgical
treatment to be performed in a single procedure, including
laparoscopic exploration and resection of the vaginal septum.
Incision of the septum followed by resection 23 months later
(Morgan et al., 1987) should be avoided as incision alone may
lead to the development of haematocolpos or pyocolpos after
a spontaneous closure. However, to avoid resection of normal
vaginal tissue, particularly when the obstructed hemivagina
reaches the hymeneal ring, a limited resectionmarsupialization
(3 cm diameter) may be performed during an initial surgical
procedure, allowing the remaining vaginal septum to be
removed 1 month later. This was performed three times in this
study, twice for haematocolpos and once for pyoclopos. In the
second case of pycolpos, resection of vaginal septum was
performed in one surgical procedure and was not affected by
infected menstrual retention (Candiani et al., 1997).
The obstetric outcome in our series was similar to other
studies (Acien, 1993; Raga, 1997). Pregnancies occurred
mainly in the contralateral cavity (80%), although four patients
had pregnancies in the affected side after surgical procedure.
These latter findings confirm that, once the obstruction has
been relieved, both the dilated uterus and its corresponding
tube recover their normal function.
In conclusion, our results confirm that diagnosis of blind
hemivagina should be made as early as possible to avoid
genital complications which may necessitate aggressive surgical treatment. Resection of the vaginal septum preceded by
laparoscopic exploration of the upper genital tract allows
uterine anatomy and function to recover. Obstetric outcome
after surgical treatment depends on the type of uterine malformation present.

References
Acien, P. (1992) Embryological observations on the female genital tract. Hum.
Reprod., 7, 437445.
Acien, P. (1993) Reproductive performance of women with uterine malformations. Hum. Reprod., 8, 122126.
Acien, P. (1997) Incidence of Mullerian defects in fertile and infertile women.
Hum. Reprod., 12, 13721376.
American Fertility Society (1988) The American Fertility Society
classifications of adnexal adhesions, distal tubal occlusion secondary to
tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine
adhesions. Fertil. Steril., 49, 944955.
Candiani, G.B., Fedele, L. and Candiani, M. (1997) Double uterus, blind
hemivagina, and ipsilateral renal agenesis: 36 cases and long-term followup. Obstet. Gynecol., 90, 2632.
Chelli, H., Lebbi, I., Ayed, M. et al. (1994) Luterus cloisonne total avec
hemi-vagin borgne et rein dysplasique homolateral. J. Gynecol. Obstet.
Biol. Reprod., 23, 681684.

1964

Johnson, J. and Hillman, B. (1986) Uterine duplication, unilateral imperforate

vagina, and normal kidneys. Am. J. Roentgenol., 147, 11971198.
Jurkovic, D., Geipel, A., Gruboek, K. et al. (1995). Three-dimensional
ultrasound for the assessment of uterine anatomy and detection of congenital
anomalies: a comparison with hysterosalpingography and two-dimensional
sonography. Ultrasound Obstet. Gynecol., 5, 233237.
Mintz, M.C., Thickman, D.I., Gussman, D. et al. (1987) MR evaluation of
uterine anomalies. Am. J. Roentgenol., 148, 287290.
Morgan, M.A., Thurnau, G.R. and Smith, M.L. (1987) Uterus didelphys with
hematocolpos, ipsilateral renal agenesis and menses. A case report and
literature review. J. Reprod. Med., 32, 4758.
Muller, P., Musset, R., Netter, A. et al. (1967) Etat du haut appareil urinaire
chez les porteuses de malformations uterines. Etude de 132 observations.
II. Essai dinterpretation. La Presse Medicale, 75, 13311336.
Nasri, M.N., Setchell, M.E. and Chard, T. (1990) Transvaginal ultrasound for
diagnosis of uterine malformations. Br. J. Obstet. Gynecol., 97, 10431045.
Pellerito, J.S., McCarthy, S.M., Doyle, M.B. et al. (1992) Diagnostic of uterine
anomalies: Relative accuracy of MR imaging, endovaginal sonography, and
hysterosalpingography. Radiology, 183, 795800.
Purslow, C.E. (1922) A case of unilateral haematocolpos, haematometria and
haematosalpinx. J. Obstet. Gynaecol. Br. Emp., 29, 643.
Raga, F., Bonilla-Musoles, F., Banes, J. et al. (1996) Congenital Mullerian
anomalies: diagnostic accuracy of three-dimensional ultrasound. Fertil.
Steril., 65, 523528.
Raga, F., Bauset, C., Remohi, J. et al. (1997) Reproductive impact of congenital
Mullerian anomalies. Hum. Reprod., 12, 22772281.
Robert, H.G. and Le Charpentier, D. (1974) Les bifidites uterovaginales
asymetriques avec ou sans retention menstruelle unilaterale. Apropos de 19
observations. J. Gynecol. Obstet. Biol. Reprod., 3, 12351254.
Rock, J.A. and Jones, H.W.J. (1980) The double uterus associated with an
obstructed hemivagina and ipsilateral renal agenesis. Am. J. Obstet. Gynecol.,
138, 339342.
Sardanelli, F., Renzetti, P., Oddone, M. et al. (1995) Uterus didelphys with
blind hemivagina and ipsilateral renal agensis: MR findings before and
after vaginal septum resection. Eur. J. Radiol., 19, 164170.
Stassart, J.P., Nagel, T.C., Prem, K.A. et al. (1992) Uterus didelphys, obstructed
hemivagina and ipsilareral renal agenesis: the university of Minnesota
experience. Fertil. Steril., 57, 756761.
Vinstein, A.L. and Franken, E.A. Jr (1972) Unilateral hematocolpos associated
with agenesis of th and kidney. Radiology, 102, 625627.
Yoder, I.C. and Pfister, R.C. (1976) Unilateral hematocolpos and ipsilateral
renal agenesis: report of two cases and review of the literature. Am. J.
Roentgenol., 127, 303308.
Received on December 30, 1998; accepted on April 9, 1999