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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 84-86

Gynatresia with cryptomenorrhea following cesarean section after failed vacuum extraction: Case report in a 26-year-old woman


1 Department of Obstetrics and Gynaecology, Barau Dikko Teaching Hospital, College of Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Obstetrics and Gynaecology, Dr Gwamna Awan General Hospital, Kaduna, Nigeria

Date of Submission05-Apr-2021
Date of Decision12-Oct-2021
Date of Acceptance30-Nov-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Dr. Joel A Adze
Department of Obstetrics and Gynaecology, Barau Dikko Teaching Hospital, College of Medicine, Kaduna State University (KASU), Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_15_21

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  Abstract 

Acquired Gynaetresia is underreported in developing countries and is usually due to harmful cultural practices. It may result from obstructed labor or labor trauma. This is a rare case report of a 26-year-old P1 + 0 who presented with no penetration during coitus and history of amenorrhea about 1 year and 7 months after cesarean delivery. Failed attempts at vacuum extraction were made before surgery. She was investigated and a diagnosis of Gynaetresia with cryptomenorrhea was confirmed. She had vaginoplasty and menstrual and sexual functions were established. Postpartum genital examination should be ensured, no matter the mode of delivery to ensure Gynaetresia is diagnosed early and managed promptly.

Keywords: Cryptomenorrhea, gynatresia, vacuum extraction, vaginoplasty


How to cite this article:
Adze JA, Bature SB, Durosinlorun AM, Caleb M, Taingson MC, Moroof SO. Gynatresia with cryptomenorrhea following cesarean section after failed vacuum extraction: Case report in a 26-year-old woman. Niger J Basic Clin Sci 2022;19:84-6

How to cite this URL:
Adze JA, Bature SB, Durosinlorun AM, Caleb M, Taingson MC, Moroof SO. Gynatresia with cryptomenorrhea following cesarean section after failed vacuum extraction: Case report in a 26-year-old woman. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Aug 14];19:84-6. Available from: https://www.njbcs.net/text.asp?2022/19/1/84/350710


  Introduction Top


Gynatresia is underreported in the developing world.[1] There is a reported prevalence of 7/1,000 in Nigeria.[2]

In developing countries, it is usually due to some cultural practices such as vaginal insertion of local herbs for the treatment of infertility, amenorrhea, procurement of abortion, uterine fibroids, uterovaginal prolapse, and genital mutilation.[3],[4] It may also result from obstructed labor and labor trauma.[5],[6] Other reported causes in Nigeria include vaginitis from herbal pessaries, female genital mutilation, and from repair of broken down perineal lacerations.[3],[7],[8] In Arabian countries, it is usually due to insertion of rock salt during the puerperium in the vagina to tighten it to enhance sexual pleasure.[1]

Vaginal occlusion after cesarean section is rare and reportable. It is a sexual calamity that may lead to social, psychological, physical, and even financial challenges in the pursuit of treatment that may never completely restore anatomical, sexual, and reproductive functions.

The objective of this case report is to highlight the significance of postnatal pelvic examination irrespective of mode of delivery.


  Case Report Top


A 26-year-old woman, Para1 + 0, 1 alive, last childbirth 1 year 7 months, who presented with a history of amenorrhea since childbirth. She had presented in labor in another hospital at term and assessed and labor allowed to progress to full cervical dilatation, but could not deliver after several bearing down efforts. There were many failed attempts at vaginal delivery by vacuum extraction. Subsequently, she consented to, and she was delivered by cesarean section. She delivered a live male baby who only cried after prolonged attempts at resuscitation. Postoperative recovery and puerperium were said to have been normal with no fever or foul-smelling lochia. She did not remember any pelvic examination done on her during hospital admission and during the puerperium. She exclusively breastfed her baby for 6 months and had noristerate injectable contraceptive, which she discontinued 10 months prior to presentation. She became concerned about her amenorrhea and her doctor reassured her that it was probably due to the injectable contraceptive. She later represented to the hospital and was prescribed several medications to initiate menstruation but to no avail. Thereafter, she started having cyclical abdominal pains and progressive distension. She also complained of no vaginal penetration during sexual intercourse and severe superficial dyspareunia.

Physical examination revealed an anxious-looking young woman with a depressed affect. She was not febrile and not pale. Her vital signs were normal.

An abdominal examination revealed a Pfannenstiel surgical incision and suprapubic fullness. The uterus was 22 weeks in size and tender. There was no rebound tenderness.

A pelvic examination revealed a normal vulva and the lower third of the vaginal canal was only about 0.5 cm patent, admitting only a tip of the finger [Figure 1].
Figure 1: Marked gynatresia

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Investigations revealed a packed cell volume (PCV) of 35%, and all other blood and urine investigations were normal. An ultrasound showed an enlarged uterus measuring 96 mm × 91 mm × 86 mm containing hypoechoic fluid extending to the upper third of the vagina and the cervix was not visualized.

A diagnosis of acquired Gynaetresia with cryptomenorrhea was made. She had a vaginoplasty under spinal anesthesia. Intraoperative findings were a uterus of about 22 weeks in size, 0.5 cm of the lower third of the vagina was patent, whereas the remaining part up to the middle third of the vaginal walls was strongly adherent to each other. The upper one-third was ballooned out and contained menstrual fluid extending through the cervix to the uterine cavity. The lips of the cervix were hypertrophied. Menstrual fluid, about 1.5 L was drained. The surgical procedure involved the patient being placed in a lithotomy position, and the vulva and perineum were cleaned and draped. A pelvic examination was done with the findings as already noted. The urinary bladder was drained with a metal catheter. The labia were parted exposing the vagina. A needle from a 10 mL syringe was passed through the blind end of the vagina and menstruum aspirated. This spot was stabbed with a size 15 surgical blade and blunt and sharp dissection was made opening the vaginal cavity until the upper third of the vagina was reached and cervical lips identified. Menstruum was drained under gravity till there was little draining. Bleeding vessels on the raw areas of the vagina were ligated and hemostasis secured [Figure 2].
Figure 2: After vaginoplasty

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A mold made of three pieces of gauze tied together and covered with Vaseline gauze was used to pack the vagina and left in situ. This also allowed some menstruum to sip through postoperatively. This was changed every 3 days and was finally removed after 2 weeks, and the patency of the vagina was confirmed. Postoperative recovery was good and she was discharged home after 5 days with the vaginal mold.

She was seen 3 weeks after surgery and she said she had seen her menses 9 days earlier that lasted for 5 days with a normal flow. A vaginal examination showed a patent vagina admitting two fingers though with a little constriction at the mid vagina and roomy at the upper third.


  Discussion Top


Acquired Gynaetresia can result from badly managed vaginal delivery causing vaginal injuries and later scarring.[9] For this patient, though vaginal delivery was abandoned, the failed several attempts at vacuum extraction could have caused unrecognized trauma to the vagina and eventual healing with scarring. Because of the abdominal delivery, most likely attention was not paid to pelvic examination to detect any infection and abnormality to the lochia including healing from any possible trauma during the attempts at vacuum extraction.

Prolonged amenorrhea became a source of concern to the patient. She had done exclusive breastfeeding and subsequently took parenteral noristerat that could both cause amenorrhea. This explains the late diagnosis since she complained earlier and was reassured that it was not a source of concern. Noristerat injection for contraception caused amenorrhea in 55.9% in a case study in Nigeria.[10]

The monthly cyclical lower abdominal pains were expected since she was menstruating only that there was mechanical blockage resulting in cryptomenorrhea and the resultant enlarged uterus.

She expectedly presented with a lack of penetration at sexual intercourse. Procreation is a central issue in marriage in Nigeria.[10] This loss of sexual function can lead to long-lasting psychological effects.[1] It is no surprise that she was anxious and looked depressed.

A vaginal mold was maintained for about 2 weeks. This allowed for continuous drainage of the menstruum and maintained the vaginal space. An important step in vaginoplasty is to maintain the vaginal space during the contraction period of wound healing using molds and stents.[9]

Menstrual function was established about 3 weeks after the surgery. At her subsequent clinic visits, she was not depressed as previously observed. She was encouraged to, and she started early sexual intercourse as a form of dilatation. She will be followed up for other reproductive functions.


  Conclusion Top


Acquired Gynaetresia has social and reproductive implications and should be a differential diagnosis in any case of secondary amenorrhea in a woman within the reproductive age. In this case, it resulted from poorly managed attempts at vaginal delivery and eventual cesarean section. Postnatal genital examination should be conducted in all patients no matter the mode of delivery to detect possible cases of acquired Gynaetresia.

Declaration of patient consent

We certify that appropriate consent forms were filled. She consented that her clinical information including images can be used in a journal. She understood that efforts will be made to conceal her identity and her name or initials will not be published, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kunwar S, Khan T, Gupta H. Acquired Gynaetresia. BMJ Case Rep 2014;2014:bcr2014203529.  Back to cited text no. 1
    
2.
Arowojolu A, Okunlola M, Adekunle A, Ilesanmi A. Three decades of acquired gynaetresia in Ibadan: Clinical presentation and management. J Obstet Gynaecol J Inst Obstet Gynaecol 2001;21:375-8.  Back to cited text no. 2
    
3.
Ugburo AO, Fadeyibi IO, Oluwole AA, Mofikoya BO, Gbadegesin A, Adegbola O. The epidemiology and management of gynatresia in Lagos, Southwest Nigeria. Int J Gynecol Obstet 2012;118:231-5.  Back to cited text no. 3
    
4.
Kaur G, Sinha M, Gupta R. Postpartum vaginal stenosis due to chemical vaginitis. J Clin Diagn Res 2016;10:QD03-4.  Back to cited text no. 4
    
5.
Hassan M, Nasir S. Co morbidities associated with vesico vaginal fistula in patients managed in Maryam Abacha Fistula Hospital Sokoto, Northwestern Nigeria. Trop J Obstet Gynaecol 2019;36:44-8.  Back to cited text no. 5
  [Full text]  
6.
Ozumba BC. Acquired gynetresia in Eastern Nigeria. Int J Gynecol Obstet 1992;37:105-9.  Back to cited text no. 6
    
7.
Umar AG, Ahmed Y, Garba JA, Adoke AU, Saidu AD, Hassan M. Successful pregnancy following acquired gynatresia. Ann Afr Med 2019;18:108-10.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Rathod S, Samal SK. Secondary vaginal atresia treated with vaginoplasty using amnion graft: A case report. J Clin Diagn Res 2014;8:OD05-6.  Back to cited text no. 8
    
9.
Sotunsa JO, Inofomoh A, Akinseku AK, Ani FI, Olatunji AO. Bleeding patterns and weight gain in users of injectable progestogen-only contraceptives: A retrospective study. Babcock Univ Med J 2015;1:27-34.  Back to cited text no. 9
    
10.
Okunlola MA, Adekunle AO, Arowojolu AO. Management outcome in patients with acquired gynaetresia in Ibadan. Trop J Obstet Gynaecol 2001;18. DOI: 10.4314/tjog.v18i1.14442.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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