This information leaflet is about obstructed hemi-vaginas.
This leaflet will describe what this means, how it can affect you and what are the treatment options.
Right obstructed hemi-vagina with uterine didelphys
What is an obstructed hemi-vagina?
Hemi-vagina is when someone’s vagina has a septum (an extra piece of vaginal tissue) that separates the right side and left side of the vagina.
The lower end of the septum merges with the vaginal wall on one side and obstructs this side of the vagina, which is why this condition is called an obstructed hemi (half) vagina.
Having this type of vaginal septum means that period blood and discharge will be trapped in this side of the vagina.
An obstructed hemi-vagina causes increasing lower tummy pains from the trapped period blood.
Sometimes the obstruction can also cause difficulties with weeing or can lead to constipation.
If periods have been obstructed for a long time, it can increase the risk of a condition called endometriosis (when cells like the lining of the womb (endometrium) are found elsewhere). Endometriosis can make periods more painful, cause internal scarring and can lead to fertility problems later in life, even after an operation to relieve the obstruction.
The level that the septum divides the vagina can vary. Some are high (nearer the womb) and some are low (nearer the vulva). How high the septum is can affect the options for management.
Occasionally the septum can have a small opening which means period blood can flow out from this hemi-vagina. There may initially be no symptoms although sometimes periods can last longer.
Left partially obstructed hemi-vagina with uterine didelphys
The vagina develops before birth during the early stages of pregnancy.
The vagina and womb (uterus) are made by a pair of tubes (Mullerian ducts) which fuse together.
An obstructed hemi-vagina is formed when the lower sections of these tubes don't follow typical development. Usually this is also associated with a difference in how the womb and kidneys form.
Generally, someone with an obstructed hemi-vagina will either have a double womb (uterine didelphys: two smaller left and right sided wombs) or a single womb with a dividing septum (band of tissue dividing left and right sides of the womb). Your doctor will explain this and how a womb this shape might affect you.
Right obstructed hemi-vagina with uterine didelphys
Right obstructed hemi-vagina with septate uterus
People with an obstructed hemi-vagina typically will have kidneys that have developed differently and often they will only have one kidney.
(This condition is therefore often referred to as OHVIRA: Obstructed Hemi-Vagina Ipsilateral Renal Absence [same-side kidney absent]).
Your doctor will arrange a kidney ultrasound to look for this if you haven’t already had one.
Most people born with a single, healthy kidney will not be affected but it’s important to be aware to stay healthy and protect that kidney.
Your doctor will arrange for an MRI scan to better assess the septum obstructing the hemi-vagina and whether there is a ureter (water pipe from the kidney down to the bladder), which could affect or be affected by surgical management of the obstructed hemi-vagina.
Left obstructed hemi-vagina with ipsilateral renal agenesis (OHVIRA) and uterine didelphys
Whilst we get the reports of your scans you will be prescribed hormone medicines to stop your periods. This will help with the pain and discomfort from obstructed periods.
Typically, our team will recommend surgery to remove the vaginal septum.
If you didn’t have surgery, we would recommend continuing on hormonal medications long-term to prevent further build up of obstructed period blood.
The surgery is carried out in the operating theatre with you asleep (under a general anaesthetic). As you will be asleep with an anaesthetic you will not feel pain. Often an injection into the septum is given after you are asleep to help reduce bleeding and pain after the surgery.
The majority of obstructed hemi-vagina operations are performed vaginally. This involves placing your legs in special stirrups to allow access to the vagina. The team may use an ultrasound scan in theatre to help guide the procedure.
Occasionally a small ultrasound scan probe is used in the rectum (back passage) to help guide the surgery.
A small tube (urinary catheter) will be passed into your bladder. This will allow for your urine to be drained into a collection bag during the surgery.
The septum is removed so the hemi-vagina is no longer obstructed.
The surgical team may also use some dissolvable stitches to help healing and any bleeding. These dissolve and so do not need to be removed.
At the end of the operation the surgical team may insert a vaginal mould. A mould isn’t needed for everyone, and this depends on the septum and operation.
The vaginal mould is a small balloon filled with water. It holds the vagina open to help prevent the edges of where the septum has been removed healing together. We use temporary stitches to help close the labia and keep the balloon in place in the vagina. The balloon remains in the vagina for three to five days during which time you will stay in hospital. It is then deflated by draining out the water and is gently removed from the vagina.
The operation typically takes one to two hours. You will wake up in recovery and after a while be transferred back to the ward.
You will have a fine tube in your arm (drip or iv) until you are drinking.
The surgical team will see you afterwards on the ward to let you know how the operation has gone.
If no mould was inserted, then we would aim to get you home the as the surgery. You would be able to go home provided there were no concerns during the surgery, you are feeling well, able to pass urine and are eating and drinking.
If the surgical team have needed to place a mould in the vagina at the end of the surgery, then you will wake up with this and a tube (catheter) in your bladder to drain away urine. The urinary catheter is important, as it is difficult to pass urine (wee) with the vaginal balloon in place. The catheter will be taken out when the mould is removed.
You will have some discomfort from the vaginal mould. You will be able to discuss the best options for pain relief with the anaesthetist before your operation.
The surgical and nursing team will help support you with getting out of bed and gently moving around with a vaginal mould.
We will aim to get you home either the same day as the surgery or the same or next day we remove the vaginal mould.
You may be given a daily injection to thin your blood during your stay in hospital following your operation. This is to reduce the risk of blood clots forming in the legs and the lungs.
You are likely to have some light vaginal bleeding and discharge for the first couple of weeks after the surgery. It’s common for there to be thick and dark red/ brown discharge for the first few days. If you notice fresh bleeding or smelly discharge then please contact the teams’ Clinical Nurse Specialist or your GP. These may be signs of an early infection that can be treated with antibiotic tablets.
If you feel unwell with heavy bleeding, fever, chills, increasing pain or diarrhoea or vomiting you should attend your local A&E for potential admission and antibiotics through a drip (your local team can contact the UCLH team for advice).
The surgical team will advice you on when to stop your hormonal medications.
Typically, vaginal dilation isn’t needed after surgery to remove an obstructing hemi-vagina septum. The team will have discussed this with you in clinic beforehand if it’s likely you may need to use dilators. Vaginal dilators can help reduce the potential of vaginal narrowing or re-obstruction.
You will have seen the team’s nurse specialist in clinic to understand this and what it will involve. If vaginal dilation after surgery is recommended the nurse specialist will see you after your surgery – when the vaginal mould has been removed – and will help you get started using the vaginal dilators. They will help you plan a maintenance dilation schedule.
Your team will discuss this with you after the procedure, depending on the operation you had and how you are feeling.
Generally, we recommend two weeks off school, college or work. To help with healing we recommend showers rather than baths for the first few weeks after the operation. Most people can use tampons with their second period after the procedure.
A follow up appointment will be arranged for around six to eight weeks after the operation. We will check on how you are feeling after the surgery and advice about vaginal sex.
All operations and anaesthetics carry small risks that your doctor will discuss with you when you sign the consent form.
Risks of this procedure include injury to the neighbouring body parts, such as the urethra (tube that urine leaves the bladder through), bladder and bowel. These are serious but uncommon risks with this operation.
If this happened and was recognised, then it would be repaired during the operation. It is possible that damage to the urethra, bladder, or bowel may cause long-term incontinence (leakage of urine or stools). We may need to perform key-hole surgery with a camera inserted into the bladder (cystoscopy), tummy(laparoscopy) or an open operation (laparotomy) to check or repair an injury.
There is a risk of developing blood clots in the veins of the leg (deep vein thrombosis: DVT) which can travel to the lungs (pulmonary embolism). To reduce this risk you will have some special socks to wear and you may also need injections to keep your blood thin whilst you are in hospital.
There is a small risk of bleeding from where the vaginal septum is removed but this is uncommon to be heavy and require blood transfusion.
Sometimes infection can affect where the vaginal septum has been removed. Infection can cause scarring which can cause narrowing of the vagina.
Occasionally infection may travel up into the womb, fallopian tube and abdomen. This can cause sepsis and the infection could cause damage to fallopian tubes, which could affect future fertility. If you feel unwell with fever, chills, increasing pain or diarrhoea or vomiting you should attend your local A&E. You may need to be admitted for antibiotics through a drip (your local team can contact the UCLH team for advice).
Sometimes the vagina can heal narrowed or reclose where the septum was removed. To help reduce the risk re-obstructing (heals closed where septum removed) or narrowing (stenosis) the team may recommend vaginal dilation to help reduce this risk. If the vagina re-obstructs or is narrowed then further surgery will be carefully considered with you.
The surgical team will discuss how your vaginal and uterine differences can affect your future fertility and management of any future pregnancies (including whether future vaginal birth would be suitable for you).
Your doctor will consider the benefits and risks of having this surgery with you and your alternative options.
Our team’s psychologists can help you decide if this operation is the right choice for you. They can also help you consider when would be the right time for you to have this operation.
In clinic your doctor will explain why they have recommended this surgery. They will talk through the procedure what to expect on the day and recovery from the operation as well as go through the surgical risks. You will have the opportunity to meet the team’s psychologist who can help you with the decision process and your feelings about the procedure.
You will need to sign a consent form for the surgery. If you have previously had vaginal sex, swabs will also be taken from the vagina at your clinic appointment.
A short while before the operation you will need to come to hospital for a pre-operative assessment to have some blood tests and other routine investigations.
On the day of the operation, you will be seen by the surgical and anaesthetic teams on the ward before the operation. You will have the opportunity to ask any questions you may have since your last clinic appointment.