MRI-based Stratification and Surgical Management of Hydrocolpos in Children and Adolescents

Abstract

Introduction In this report we present a new anatomical stratification for vaginal obstruction (hydrocolpos) based on MRI findings while referring the level of obstruction to a fixed bony landmark (the pubic symphysis). This new approach can overcome the limitations of current classifications, which are prone to approximation errors during measurement and fail to account for variations in body mass across different age groups.

Methods Data of cases diagnosed with vaginal obstruction were retrospectively analyzed. Cases of cloaca with vaginal obstruction were excluded. MRI confirmed the diagnosis and enabled classification of the level of vaginal obstruction relative to the pubic symphysis in the mid-sagittal plane as low, intermediate, or high—opposite the lower, mid, or upper end of the pubic symphysis, respectively.

Results A total of 13 girls presented with vaginal obstruction during the period 2010 through 2024. Their age ranged between 1 month and 14 years (mean: 54 months; median: 18 months). Three cases presented in the neonatal period with antenatal diagnosis of hydrocolpos, while six cases were referred later during infancy/childhood from other centers. Another group of adolescent girls (four cases) presented with a clinical picture of cryptomenorrhea. The cause of vaginal obstruction was imperforate hymen in one, vaginal atresia in six, persistent urogenital sinus (five cases), and one case of obstructed hemi-vagina. In this series, six cases (46%) had features related to genetic syndromes (Bardet Biedl/ McKusick-Kaufman spectrum). Chronic parenchymatous renal disease was present in three cases among other syndromic features of Bardet Biedl syndrome, in addition to another case with obstructed left hemi-vagina that had absent left kidney (Herlyn-Werner-Wunderlich syndrome). Surgical techniques included simple excision of distal obstructing membrane (four cases), abdominal assisted vaginoplasty (two cases), vaginal pull-through (four cases), simple introitoplasty (one case), urogenital sinus mobilization (one case), and division of longitudinal vaginal septum for a case of obstructed hemi-vagina. Vaginal stenosis or retraction occurred in three cases with intermediate to high-level obstruction—two following abdominal assisted vaginoplasty and one after vaginal pull-through.

Conclusion MRI-based stratification of vaginal obstruction using the pubic symphysis as a reference provides a practical and reproducible approach for surgical planning.

Type of Study and Level of Evidence This is a case series (level IV evidence).

Keywords

urogenital sinus - vaginal atresia - genetic syndromes - MRI - classification - Mullerian anomalies

Publication History

Received: 10 April 2025

Accepted: 11 August 2025

Accepted Manuscript online:
12 August 2025

Article published online:
25 August 2025

• References

• 1 Stallion A. Vaginal obstruction. Semin Pediatr Surg 2000; 9 (03) 128-134
• 2 Ruggeri G, Gargano T, Antonellini C. et al. Vaginal malformations: a proposed classification based on embryological, anatomical and clinical criteria and their surgical management (an analysis of 167 cases). Pediatr Surg Int 2012; 28 (08) 797-803
• 3 Wood RJ, Reck-Burneo CA, Levitt MA. Cloacal malformations: technical aspects of the reconstruction and factors which predict surgical complexity. Front Pediatr 2019; 7: 240
• 4 Abdelmalak Abokandil M, Waheeb S, Eltagy G, Khairi A, Farghaly Y, Aly S. Correlation between common channel length and urethral length in cloacal malformations. Eur J Pediatr Surg 2022; 32 (04) 310-315
• 5 AbouZeid AA, Mohammad SA. The cloacal anomalies: anatomical insights through a complex spectrum. J Pediatr Surg 2019; 54 (10) 2004-2011
• 6 AbouZeid AA, Mohammad SA. Transformation of the female genitalia in congenital adrenal hyperplasia: MRI study. J Pediatr Surg 2020; 55 (05) 977-984
• 7 Spencer R, Levy DM. Hydrometrocolpos: report of three cases and review of the literature. Ann Surg 1962; 155 (04) 558-571
• 8 Nguyen L, Youssef S, Guttman FM, Ahlgren LS, Schlechter R. Hydrometrocolpos in neonate due to distal vaginal atresia. J Pediatr Surg 1984; 19 (05) 510-514
• 9 Zhang M, Meng L, Du Y. et al. Modified balloon vaginoplasty for high position vaginal atresia. Pediatr Surg Int 2022; 38 (04) 631-635
• 10 Mansouri R, Dietrich JE. Postoperative course and complications after pull-through vaginoplasty for distal vaginal atresia. J Pediatr Adolesc Gynecol 2015; 28 (06) 433-436
• 11 Rink RC, Adams MC, Misseri R. A new classification for genital ambiguity and urogenital sinus anomalies. BJU Int 2005; 95 (04) 638-642
• 12 Ramenofsky ML, Raffensperger JG. An abdomino-perineal-vaginal pull-through for definitive treatment of hydrometrocolpos. J Pediatr Surg 1971; 6 (03) 381-387
• 13 Elsherbeny M, Abdelhay S, Mousa M. Neonatal single-stage surgical management of complicated distal vaginal atresia: revisiting an appropriate and feasible technique. J Pediatr Adolesc Gynecol 2024; 37 (01) 63-66
• 14 Aboalazayem A, Fares AE, Ahmed SAH. et al. Preoperative evaluation of the persistent urogenital sinus in cases with congenital adrenal hyperplasia. Egypt Pediatr Assoc Gaz 2024; 72: 24
• 15 Rink RC, Metcalfe PD, Kaefer MA, Casale AJ, Meldrum KK, Cain MP. Partial urogenital mobilization: a limited proximal dissection. J Pediatr Urol 2006; 2 (04) 351-356
• 16 Karaca L, Pirimoglu B, Bayraktutan U, Ogul H, Oral A, Kantarci M. Herlyn-Werner-Wunderlich syndrome: a very rare urogenital anomaly in a teenage girl. J Emerg Med 2015; 48 (03) e73-e75
• 17 Newman CL, Forbes-Amrhein MM, Brown BP, Kaefer M, Marine MB. Prenatal hydrocolpos: imaging findings and differential diagnosis. Pediatr Radiol 2024; 54 (10) 1618-1630
• 18 Arora E, Fuks A, Meyer J, Chervenak J. Prenatal diagnosis of Bardet Biedl syndrome: a case report. Radiol Case Rep 2022; 18 (01) 326-330
• 19 Pinter A, Alchihabi N. High vaginal atresia: surgical considerations. Pediatr Surg Int 1992; 7: 449-453