Difficult Management of a Rare Case of Distal Vaginal Atresia in an Adolescent

A transverse vaginal septum is a rare congenital anomaly that can present with primary amenorrhea and cyclic pelvic pain due to obstructive Müllerian malformation. We report the case of a 16-year-old adolescent who presented with primary amenorrhea and eight months of progressive cyclic lower abdominal pain. Physical examination revealed normal secondary sexual characteristics. Hormonal evaluation confirmed normal hypothalamic-pituitary-ovarian axis function. Pelvic MRI demonstrated hematometra and hematocolpos with a thin, regular vaginal septum and an associated distal vaginal agenesis component. Initial surgical correction was performed via vaginal approach, involving circumferential incision of the obstructive septum, controlled drainage of retained menstrual blood, complete excision of septal tissue, and end-to-end mucosal anastomosis. Despite initial resolution of symptoms and establishment of normal menstrual flow, the patient experienced recurrent obstruction at two months postoperatively, requiring vaginal dilation. At four months, she developed pelvic sepsis from infected hematocolpos, necessitating surgical revision with fibrotic tissue excision and attempted vaginal mold placement, which was poorly tolerated and removed after four days. This case highlights the challenging nature of complete transverse vaginal septum management, particularly when associated with distal vaginal agenesis. Despite appropriate initial surgical correction, a significant risk of stenosis, recurrent obstruction, and infectious complications exists, necessitating close postoperative surveillance and readiness for multiple interventions to achieve satisfactory long-term outcomes.