CASE 16894 Published on 17.07.2020

Neovaginal obstruction secondary to introitus stenosis.

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Loreto Ana de Llano Ibisate1, Guillermo Unzué Garcia-Falces1, Paúl López Sala1, Nerea Alberdi Aldasoro1, Tamara Laxe Vidal1, Iván Vicaría1, Héctor Lajusticia1

1 Department of Radiology, Complejo Hospitalario de Navarra, Spain. Calle Irunlarrea,e. 31008. Pamplona. Spain.

Patient

38 years, male

Categories
Area of Interest Abdomen ; Imaging Technique CT
Clinical History

A 38-year-old patient with sex reassignment surgery (Vaginal Reconstruction with Sigmoid Colon), came to the Emergency room for abdominal pain located in the hypogastrium. She referred vaginal introitus stenosis for years as a complication of surgery, being impossible to perform a gynaecological examination or have sexual relations.

Imaging Findings

Ultrasound (US) images showed a cystic pouch-like structure posterior to the bladder and anterior to the rectum, containing heterogeneous fluid, a thin and regular wall without Doppler vascularization or septa (Fig.1). There was a small amount of free fluid in the rectovaginal space. In order to make an accurate diagnosis, it was decided to perform a computed tomography (CT).

Contrast-enhanced CT images confirmed a tubular blind-ended big structure located in the rectovesical space, with no evidence of communication with adjacent structures. It showed a thin wall with moderate enhancement and intermediate-density content inside, which resembled an intestinal loop (Fig. 2).

Considering the history of sigmoid colon vaginoplasty, the suspected diagnosis was dilation of the neovagina with mucinous secretion accumulation inside.

Discussion

There is an increase in vaginal reconstructions within the transgender community. 

Inversion vaginoplasty with penile-scrotal flaps is the preferred and most commonly practised procedure. However, not all patients have sufficient tissue to achieve satisfactory depth, so the sigmoid colon can be used to create the neovagina [1].

The introitus contracture in rectosigmoid vaginoplasty is more uncommon than in other surgical techniques, although it can also happen.

Neovaginal mucosa (sigmoid colon) produces its own secretions, hence excessive mucosal secretion through the vagina is the most common complication. [1,2]

If vaginoplasty is complicated with vaginal introitus stenosis, secretions from the mucosa of the sigmoid colon accumulate inside causing dilation of the neovagina.

It presents as abdominal pain located in hypogastrium, so it is important to carry out imaging tests to rule out other pathologies that can cause the pain.

The US can be used to rule out other causes of hypogastric pain and to make a diagnostic approach. The CT gives a more accurate diagnosis of the pathology.

The neovagina has characteristics that resemble an intestinal loop, it is seen as a tubular blind-ended dilated structure with mucinous content located in the rectovesical space.

The diagnosis was confirmed because the patient suddenly began to drain a large amount of smelly green fluid from the vagina. It was analyzed and corresponded to intestinal secretion.

A regimen of dilation is advisable for the first 6–12 months after surgery to prevent introital stenosis. 

In cases of vaginal introitus contracture, it is necessary to correct the condition by excision, Z-plasty, and a local flap when expanders fail. 

Never forget to study the personal history of each patient, especially surgical ones.

In patients with a history of vaginoplasty and hypogastric pain, consider the possibility of obstruction of the neovagina.

In US and CT, the neovagina is seen as a tubular blind-ended dilated structure located in the rectovesical space with mucinous content.

 

'Written informed patient consent for publication has been obtained.'

Differential Diagnosis List
Neovaginal obstruction secondary to introitus stenosis after sigmoid vaginoplasty
Lymphangioma
Lymphocele
Haematoma
Abscess
Rectal duplication cyst
Final Diagnosis
Neovaginal obstruction secondary to introitus stenosis after sigmoid vaginoplasty
Case information
URL: https://www.eurorad.org/case/16894
ISSN: 1563-4086
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