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Atresia of Lower Genital Tract and Its Various Problems ATRESIA OF LOWER GENITAL TRACT AND ITS VARIOUS PROBLEMS . by KALYANI MuKHERJEE,* M.O. (Cal.) and S. K. BANERJEE,** M.O. (Cal.), M.R.C.O.G., Ph.D. (Lond.) Introduction first group the cervix is present but Atresia of the lower genital tract has not been canalised and in the either complete or partial, may b~ second group the cervix is not formed due to congenital or acquired condi­ at all. In some of the latter cases tions. The causes of the latter are there may be a few strands of com­ many, for example severe vaginal in­ munication between the uterus and fection, after-effects of the repair of vagina. The acquired causes are intractable vesico-vaginal fistula and cervical infection, such as tuberculosis following Wertheim's hysterectomy. or after cauterization. The conge­ Congenital absence is a develop­ nital varieties may be associated with mental defect. Counseller (1949) a non-functioning or a functioning stated that the incidence of atresia of uterus; the latter is the real problem the vagina was one in four thousand as it will produce cryptomenorrhoea of gynaecological admissions. The with its complications if left un- ~ .....- congenital variety may be of many treated. · types depending' on the nature of de­ The cases of congenital atresia of velopmental anomaly. Absence of the cervix without atresia of the vagina may rarely be associated with vagina and with a functioning uterus absence of the whole or part of Mul­ were reviewed by Sherwood and lerian system. However, complete Speed (1941). They found only 6 absence of the Miillerian system ac­ case-records of this variety to which cording to Ward McQuaid and they added a case of their own. Lennon (1950) is very rare; they re­ Anomalies of the urinary tract are ported 3 cases of their own. We had commonly associated with those of the 6 in our series. genital tract. Such associations have Atresia of the cervix alone again been reported by many authors, may be due to congenital or acquired Thompson and Pace (1937), Schrei­ causes. The congenital variety is ber and Smith ( 1946), Counseller very rare and may be further sub­ ( 1949) and others. divided into two main groups. In the It will not be out of place to dis­ cuss the problem of female pseudo­ *Registrar. hermaphrodites who may rarely need **Eden Hospital, Calcutta. an artificial construction of the vagina Received for publication on 10-4-1969. from the psychosexual point of view. .~ ----1-..) ATRESIA OF LOWER GENITAL TRACT AND lTS VARIOUS PROBLEMS 721 There may be rare cases where a male trocar down through the noncanalis­ will want an artificial vagina to be ed cervix into the vagina. But he did constructed. We had one such case not furnish any follow-up report. in this series. Bernard and Kernauner repqrted a case where they did a hysterectomy Evolution of Treatment for such a condition. Duyzings re­ The problem of atresia of the lower ported a case in which they incised genital tract created interest from the the cervix and placed in a drain. year 1827 when the great French sur­ Fortes, in 1938, performed the first geon, Dupuytren, reported his opera­ successful operation where he could tive technique in such a case. establish a canal between the uterus . and vagina, by-passing the cervix . The dexterity and ingenuity of Engelhains ( 1939) reported a case many general, gynaecological and where he excised the solid cervix and plastic surgeons have been exercised anastomosed the endometrium with in devising different methods of treat­ the vagina. Sherwood and Speed ment. They vary from the simple (1941-42) modified Engelhains' tech­ non-operative pressure technique of nique by using a stem pessary for Frank and Geist (1927) to different several weeks to maintain an open methods of skin grafting• (Mcindoe channel and reported a successful and Banister, 1938, 50, 57; Counsel­ follow-up. Maliphant (1948) used ler, 1944, 48, 57), and others, and the indwelling catheter to maintain various types of intestinal transplan­ the patency of the cervical canal tation as done by Baldwin (small created within the solid block of _ intestinal in 1904), Shirodkar (pel­ tissue. vic colon transplantation) and the Russian technique (Allexandrov). In the above cases there was atresia Amongst these various methods the of the cervix but the uterus and the one that has stood the test of time vagina were well developed. The is the Mcindoe operation. Recently, problem of atresia of the cervix with there have been few modifications of a well developed uterus will be more this operation. These modifications complicc.ted when there is partial or mainly involve the change in the pat­ complete absence of the vagina. tern and consistency of the mould. This paper is an endeavour to dis­ All these methods can be success­ cuss all the problems that may be con­ fully applied in cases of non-forma­ nected with atresia of the vagina and / tion of the vagina with absence of the cervix, with main emphasis on the uterus. congenital variety. A new abdo­ A short resume of the history of minoperinial approach to tackle the management of nonformation of the problem where the whole of the lower cervical canal with or without vaginal vagina is absent, with or without atresia and a developed uterus is atresia of the cervix, with a function­ given. This type of case was first re­ ing uterus., will be discussed here. A ported by Ludwig, in the year 1900, new modification of the mould for this who did a hysterotomy and forced a purpose will also be discussed. 722 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA Development o'f vagina munication between uterus and the The development of the vagina ac­ vagina. cording to Koff ( 1933) occurs from two sources. The upper 4j 5th of the CLinical problems . vagina develops from the caudal por­ The mode of presentation of cases tion of the Mullerian duct and the with lower genital tract anomalies lower 1/ 5th from the sinovaginal will primarily depend on the types of bulb. They together form the primi­ the maldevelopment and secondly on tive vaginal plate. The part that de­ the presence or absence of a fuJ1.ction­ velops from the Mullerian duct cana­ ing uterus. So, a case may be pre­ lises from above downwards and that sented to a gynaecologist with one or which develops from the sinovaginal more of the.following complaints: bulb canalises from below upwards. (a) Delayed puberty. Failure of canalisation of these two (b) Recurrent attacks of pain. parts may result in the formation of (c) Swelling of abdomen. various developmental anomalies of (d) Urinary retention or difficulty the vagina. The cervix develops in defaecation. from the lower portion of the fused Mullerian tubes, just proximal to the It we now correlate the clinical fea­ primitive vaginal plate. The isola­ tures with the anatomical defects it tion of the cervix from the rest of the will be evident that anatomical type vagina occurs after the canalisation 'A' will come to the gynaecologist as of the upper part of the vagina. a case of delayed menarche only. The presence of a functioning Anatomical types (See Figs. 1 and 2) ~ uterus is the cause of recurrent (A) Absence of vagina with non­ attacks of pain. The nature or seve­ functioning uterus. rity of the pain can again be correlat­ (i) Absence of vagina with absence ed with the development of uterus, of the uterus. , atresia of the cervix and site of non­ (ii) Absence of vagina with rudi­ development of the vagina. mentary uterus. A case where there is cervical (iii) Absence of vagina with deve­ atresia or non-development of the lopmental anomaly of the uterus. upper part of the vagina with a func­ (B) Absence of vagina (partial or tioning uterus will cqmplain of pain complete) with well developed uterus earlier than a case where only the.... and cervix: lower part of vagina is absent. Re­ (i) Lower vagina developed but tention of urine is due to distension upper part undeveloped. of the vagina which presses on or dis­ ( ii) Only lower part of vagina not places the urethra. Retention of developed. urine is possible if there is adequate (C) Only cervical atresia: vaginal development with only non­ ( i) Cervix present in the vagina canalisation of the lower part. but not canalised. (ii) Cervix not formed at all but Investig,ations there may be few strands of com- (1) General examination with A Study of Postmenopausal Endometrium-Bhatnagctr and Mctllik pp. 710-719 Fig. 1 Fig. 2 Atrophic endometrium x 80. Showing secretory as well as proliferative glands in the same field x 80. / Fig. 3 Fig. 4 Atypical proliferative glands with mitosis x 280. Section showing endometriosis interna x 80. ) i Atresia of Lower Genital .Tract and its various problems-Mukhe1·jee & Banerjee pp. 720-730 . Fig. 5 Fig. 6 Case 1-Posterior approach-distended upper Case 1-Posterior approach-Hegar dilator d vagina is shown by a probe. passed through the incision. Fig. 7 Fig. 8 Case 1-Posterior approach-artery forceps is Case 1-Posterior approach-dilatol? is· seen passed through vaginal wound and dissection is coming out f~dm abdominal wound 'through the being carried out per vagina under the guidance created vaginal space. of the forceps. Fig. 9 Fig. 10 Case 1-Posterior approach-the hollow mould Case 1-Posterior approach-skin was sutured covered with skin graft is seen inside the space. over the hollow mould through which the tube _ from the uterine cavity is seen coming out. ii Effect of :JH 3~~ on Endometrium and Cervical mucus-Achari pp.
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