Vulval Inspection and Diagnosis

Hysteroscopy and Other Diagnostic Techniques

• Hysteroscopy is a diagnostic technique used to visualize the uterus and diagnose abnormalities.
• Vaginoscopy is another diagnostic technique used to examine the vagina.
• Laparoscopy is a surgical diagnostic technique used to visualize the uterus and surrounding organs.
• Laboratory investigations, including hormonal assays, testosterone levels, and chromosomal studies, are also used to diagnose abnormalities.

Treatment of Structural Abnormalities

• Treatment depends on the type and extent of the structural abnormalities.
• Bicornuate uterus: Strassman's metroplasty can be recommended, either open surgery or laparoscopically, with a 90% rate of full pregnancy.
• Septate uterus: Hysteroscopic metroplasty is the chosen treatment.
• Uterus didelphys: Strassman metroplasty procedure unifies the two uterine cavities and leaves the cervix intact.
• Obstructed duplicate uterus: Full excision of the vaginal septum and hemi-hysterectomy are required.
• Transverse vaginal septum/imperforate hymen: Operative vaginoplasty procedure creates a cavity and lines it with a split-thickness skin graft.

Reproductive Outcomes

• Patients with structural abnormalities may experience reproductive difficulties, including infertility and recurrent miscarriage.
• Reproductive techniques such as ART/IVF/surrogacy may be possible.

Fusion Anomalies

• Bicornuate uterus: A heart-shaped appearance with separate cornual parts, but no clinical signs or symptoms.
• Septate or Subseptate uterus: Presence of a septum extending down the uterine cavity, leading to clinical problems such as recurrent miscarriage and malpresentation.
• Uterus didelphys: Complete duplication of the uterus and cervix, often associated with a septate vagina.
• Rudimentary horn: Rupture can occur with profound bleeding, dysmenorrhoea, and pelvic pain; surgical removal is indicated.

Investigations and Diagnosis

• Pelvic ultrasound, pelvic magnetic resonance imaging (MRI), and hysterosalpingography are used to diagnose structural abnormalities.
• Vulval inspection may reveal imperforate membrane or vaginal septum.
• Imaging: ultrasound or MRI.

Treatment of Vaginal Abnormalities

• Transverse vaginal septum/imperforate hymen: Simple excision of the membrane and release of retained blood, or resection of the absent segment and reconstruction of the vagina.
• Longitudinal vaginal septum: Surgical excision of the septum.