102 J Gandhara Med Dent Sci
October - December 2025
CASEREPORT
:
:
PARTIAL CERVICO-VAGINAL APLASIA WITH FUNCTIONAL ENDOMETRIUM: A CASE
REPORT ON A SIMPLE RECANALIZATION TECHNIQUE FOR OUTFLOW RECONSTRUCTION IN
LOW-RESOURCE SETTINGS
Naheed Parveen1, Sadia Shoukat2, Erum Samreen Siddiqui3, Sakeena Ahmed4, Nadia Shoukat5
How to cite this article
Parveen N, Shoukat S, Siddiqui ES,
Ahmed S, Shoukat N. Partial Cervico-
Vaginal Aplasia with Functional
Endometrium: A Case Report on A
Simple Recanalization Technique For
Outflow Reconstruction in Low-
Resource Settings. J Gandhara Med
Dent Sci. 2025;12(4):102-105. https://doi.
Date of Submission: 29-09-2025
Date Revised: 01-09-2025
Date Acceptance: 03-09-2025
1Professor, Chairperson and Head of
Department Obstetrics and Gynecology,
Liaquat University of Medical and
Health Sciences
3Associate Professor and Consultant
Gynecology and Obstetrics, Liaquat
University of Medical and Health
4Assistant Professor and Consultant
Gynecology and Obstetrics, Liaquat
University of Medical and Health
5Post Graduate Resident, Department of
Peadiatric Surgery, Liaquat University
of Medical and Health Sciences
Correspondence
2Sadia Shoukat, Assistant Professor
and Consultant Gynecology and
Obstetrics, Liaquat University of
Medical and Health Sciences
+92-334-2041601
nadiashoukat2010@hotmail.com
ABSTRACT
A 13- year- old girl presented with cyclical pelvic pain and primary
amenorrhea, revealing a rare complex cervicovaginal hypoplasia with
hematometra. Diagnosis was confirmed through clinical examination,
ultrasound, and MRI, emphasizing the importance of rectal examination
when vaginal inspection was inconclusive. Surgical management involved a
novel, cost-effective Foley catheter technique that combined an abdomino-
vaginal pull-through with two-phase stenting (using a gauze mold and a
balloon catheter) to establish neocervicovaginal patency. Initial drainage of
500 mL hematometra was achieved, but adhesions required reintervention
with balloon stenting and psychiatric support for compliance. This case
highlights three key innovations:1 a modified approach for low-resource
settings, a structured adhesion prevention protocol, and integrated
psychosocial care-addressing gaps in adolescent gynecological
management.2,3 The technique has a minimally invasive nature, and dynamic
stenting outperformed traditional methods (e.g., McIndoe vaginoplasty),
aligning with ACOG’s multidisciplinary care guidelines. Challenges included
the risk of restenosis, requiring vigilant follow-up. This case and approach
offer a practical, holistic solution for complex Müllerian anomalies,
emphasizing diagnostic precision, surgical adaptability, and psychosocial
support in pubertal patients. Written informed consent was obtained from the
patient for publication of this case report and accompanying images.
KEYWORDS: Pelvic Pain, Cervicovaginal Hypoplasia, Müllerian Ducts
Sciences
Sciences
org/10.37760/jgmds.12-4.750
INTRODUCTION
The presence of a patent vaginal and cervical canal is
necessary for menstrual blood to exit the uterus.
Aberrant development of the Müllerian ducts and
urogenital sinus during embryogenesis can lead to
congenital reproductive tract anomalies, occurring in
approximately 7% of females.1 Among these, a rare
variant involves segmental malformation of the
Müllerian system, characterized by cervical agenesis
with preserved uterine function, with an estimated
incidence of 1:80,000-100,000 live births. Clinically, it
often occurs alongside partial or complete vaginal
aplasia, which happens in 1 in 4000 births.2,12 These
structural abnormalities may involve any level from the
hymen to the uterus, potentially causing outflow
obstruction. The retention of menstrual blood often
results in hematocolpos or hematometrocolpos, usually
presenting with cyclical pelvic pain despite primary
amenorrhea. Patients often experience progressive,
severe abdominal pain that requires urgent evaluation.
Accurate diagnosis depends on a patient's history, a
thorough physical examination including perineal
inspection and rectal assessment, and careful
interpretation of ultrasound and MRI results.3,4 These
steps are crucial for distinguishing between various
obstructive causes and determining the appropriate
surgical treatment. Our case is unique because it
involves a rare variant of Müllerian anomaly
management. We illustrate how a modified Foley
catheter approach can address both anatomical
obstruction and adhesion issues. It highlights the
103J Gandhara Med Dent Sci
October - December 2025
importance of clinical examination skills, accurate
imaging interpretation, and integrated psychiatric care
to tackle challenges related to postoperative self-
dilatation compliance in adolescents, a topic rarely
documented in adolescent gynecology.
CASE PRESENTATION
A thirteen-year-old unmarried girl, accompanied by her
mother, arrived at the Gynecology and Obstetrics
outpatient department of a tertiary care public facility.
She reported severe lower abdominal pain lasting one
week, which did not improve despite analgesics
prescribed by her primary care physician. Notably, she
also noted experiencing cyclical pelvic pain over the
past five months without the onset of menstruation.On
examination, her secondary sexual characteristics
matched Tanner stage 3. Abdominal palpation showed a
soft-to-firm, globular uterine mass measuring 16–18
weeks, with mild tenderness. External genitalia
inspection revealed a blind-ending vagina with a
pinkish membrane and a shallow hymenal dimple,
without bulging. Her rectal exam demonstrated a tense,
globular mass anteriorly in the upper rectum, suggestive
of a distended mass at the uterocervical region
consistent with hematometra and ruling out
haematocolpos. The hormonal profile confirmed normal
endocrine function. Ultrasound of the abdomen showed
an anteverted, enlarged uterus (7.3 × 12 cm) with a
cystic, echogenic endometrial cavity indicating
hematometra. Both ovaries appeared normal (right: 3 ×
1.9 cm; left: 3.2 × 1.5 cm), and renal ultrasound
revealed no abnormalities. Pelvic MRI confirmed
hematometra, showing T1/T2 hyperintense collections
in the uterine and upper cervical regions, with a narrow
lower segment ending in focal stenosis or aplasia
(Figure 1). A non-contrast CT revealed a distended
uterus (5.6 × 13 cm) with hypo-dense fluid (40–50 HU)
in the endometrium, leading to myometrial thinning and
bladder compression. During initial vaginal surgical
exploration under anesthesia, the narrow vagina was
dilated and canalized using Hegar dilators #6 and #7,
following removal of a thin septum and para-vaginal
tissue with fine dissection. The upper part of the vagina
was completely blind, with no cervical opening
detected. Subsequently, an abdominal approach was
performed. The uterus was found to be enlarged, and a
transverse incision was made in the lower uterus. No
properly formed cervix or cervical os was identified;
only a peritoneal layer was palpable. A combined
approach was then undertaken. The uterus was
distended (16-week size) with normal adnexa. A 2 cm
semi-lunar incision was made at the distal uterine
segment, and a 24-gauge Foley catheter was threaded
via the pull-through technique to establish uterovaginal
continuity. About 500 mL of old, chocolate-colored
blood was drained. The catheter was left in place for 28
days to stent the neocervical opening, and a gauze-
wrapped syringe mold served as a vaginal dilator. At
one month, vaginal patency allowed for 3-4 cm digital
insertion. However, the patient returned at three months
with recurrent pain due to vaginal adhesions despite a
patent cervical os. Adhesiolysis and Hegar dilation
were performed under sedation, and a 5 cc balloon-
tipped Foley catheter was placed vaginally for two
weeks to prevent re-adhesion (Figure 2), along with
short-term antibiotics to prevent pelvic infection.
Initially, it was challenging to encourage the adolescent
girl to perform self-manual dilatation, but psychiatric
and parental counseling emphasized diligent use of
vaginal dilators, resulting in satisfactory patency on
follow-up. The patient still requires long-term
monitoring to evaluate outcomes.
Figure 1: T2-weighted MRI shows hematometra (Arrow A) with
myometrial thinning and hematocervix terminating in focal
stenosis/narrowing/hypoplasia at the lower end (Arrow B),
diagnostic of outflow obstruction.
Figure 2: Foley Catheter Acting as a Stent to
Maintain Patency and Prevent Adhesion Recurrence
Partial Cervico-Vaginal Aplasia with Functional
104 J Gandhara Med Dent Sci
October - December 2025
DISCUSSION
The ESHRE/ESGE classification system categorizes
cervical aplasia into four distinct subtypes: (1) cervical
external os obstruction, (2) cervical agenesis, (3)
cervical atresia, and (4) cervical cord or fragment. Both
the American Fertility Society (1988) and
ESHRE/ESGE classification systems further classify
congenital vaginal atresia as either complete or partial.
Additionally, the Embryological-Clinical Classification
System delineates these anomalies into complete and
segmental types based on developmental patterns.5,6,7
Our patient's presentation-featuring functional
endometrium with cervical hypoplasia and absent os,
proximal vaginal aplasia, and distal vaginal hypoplasia-
represents a complex variant within this spectrum.
These malformations typically require surgical
intervention to establish uterovaginal continuity,
thereby facilitating hematometra drainage and
preventing endometriosis secondary to retrograde
menstruation.8 This case of primary amenorrhea caused
by a complex Müllerian anomaly offers important
clinical lessons. The rectal examination proved valuable
when vaginal inspection was inconclusive, effectively
distinguishing between hematometra and hematocolpos
and demonstrating that basic clinical skills remain
essential despite the availability of advanced imaging
technologies. Our management strategy introduces an
innovative Foley catheter technique with three distinct
advantages: its minimally invasive approach reduces
surgical risks, the use of inexpensive and widely
available equipment makes it practical for resource-
limited settings, and dynamic stenting maintains
patency more effectively than static dilators. This
approach represents a significant improvement over
traditional methods, such as McIndoe vaginoplasty or
laparoscopic-assisted canalization, providing a balanced
solution between complex reconstruction and
conservative treatment, while specifically targeting the
challenges of cervical os obstruction. The 24-gauge
Foley catheter served dual purposes—initially creating
cervicovaginal continuity through pull-through traction
and later preventing restenosis via balloon stenting-
showcasing its versatility, especially in low-resource
environments where conventional approaches may be
unsuitable.9,10 To our knowledge, only a single reported
case has been found in the literature where a Foley
catheter was used for recanalization, confirming its
viability as a practical solution for outflow tract
reconstruction in cervical atresia.11 This technique
emphasizes cost-effectiveness and technical
reproducibility, especially valuable in resource-limited
settings.11 Our case study is also consistent with ACOG
guidelines, which recommend a multidisciplinary
approach to care and nonsurgical neovaginal creation
through progressive perineal dilation with dilators, as
we initially did.12 This patient requires long-term
follow-up given the ongoing clinical debate regarding
optimal management. While some gynecologists prefer
conservative outflow tract restoration to relieve pain
and maintain menstrual drainage, others advocate
hysterectomy as a definitive treatment to prevent future
serious complications-including cervicovaginal
restenosis, chronic pelvic inflammation, sepsis, and
secondary endometriosis resulting from obstructed
menstrual flow due to restenosis-a rationale favored by
many practitioners. However, current evidence remains
limited regarding surgical efficacy, sustained cervical
patency, and prevention of stenosis. Additional case
reports are critically needed to evaluate long-term
anatomical outcomes (cervicovaginal patency) as well
as functional results (sexual and reproductive health) in
these complex cases.13,14
CONCLUSIONS
This case provides valuable clinical perspectives for
addressing complex Müllerian anomalies in pediatric
and adolescent gynecology practice. Future long-term
studies are needed to assess anatomical and functional
outcomes, the therapeutic potential of this simple,
readily available Foley technique, and to identify any
associated complications, thereby optimizing
management strategies for these challenging cases.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
REFERENCES
1. Breech LL, Laufer MR. Müllerian anomalies. Obstet Gynecol
Clin North Am. 2009 Mar;36(1):47-68.
https://doi.org/10.1016/j.ogc.2009.02.002 PMID: 19344852
3. Dwivedi D, Jain M, Jain S, Jain S. A rare case report on
complete cervical agenesis with vaginal atresia and suspended
didelphys uterus with hematometra and left haematosalpinx. Int
J Reprod Contracept Obstet Gynecol. 2020 Mar 1;9(3):1274-7.
https://doi.org/10.18203/2320-1770.ijrcog20200914
3. ACOG Committee on Adolescent Health Care. ACOG
Committee Opinion No. 349, November 2006: Menstruation in
girls and adolescents: using the menstrual cycle as a vital sign.
Obstet Gynecol. 2006 Nov;108(5):1323-8.
https://doi.org/10.1097/00006250-200611000-00059
PMID: 17077267
4. Skinner B, Quint EH. Obstructive reproductive tract anomalies:
a review of surgical management. J Minim Invasive Gynecol.
2017 Sep;24(6):901-8.
https://doi.org/10.1016/j.jmig.2017.04.020 PMID: 28495609
5. American Fertility Society. The AFS classification of adnexal
adhesion, distal tubal occlusion, tubal occlusion secondary to
tubal ligation, tubal pregnancies, müllerian anomalies and
intrauterine adhesions. Fertil Steril. 1988;49(6):944-55.
https://doi.org/10.1016/S0015-0282(16)59942-7. PMID:
3371491
Partial Cervico-Vaginal Aplasia with Functional
105J Gandhara Med Dent Sci
October - December 2025
LICENSE: JGMDS publishes its articles under a Creative Commons Attribution Non-Commercial Share-Alike license (CC-BY-NC-SA 4.0).
COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.
It includes scholarlynetworks such as Research Gate, Google Scholar, LinkedIn, Academia.edu, Twitter, and other academic or professional networking sites.
6. Grimbizis GF, Gordts S, Di Spiezio Sardo A, Brucker S, De
Angelis C, Gergolet M, Li TC, Tanos V, Brölmann H, Gianaroli
L, Campo R. The ESHRE/ESGE consensus on the classification
of female genital tract congenital anomalies. Hum Reprod. 2013
Aug;28(8):2032-44. https://doi.org/10.1093/humrep/det098.
PMID: 23827969
7. Acién P, Acién MI. The history of female genital tract
malformation classifications and proposal of an updated system.
Hum Reprod Update. 2011 Sep;17(5):693-705.
https://doi.org/10.1093/humupd/dmr021. PMID: 21622946
8. Pfeifer SM, Attaran M, Goldstein J, Lindheim SR, Petrozza JC,
Rackow BW, Siegelman E, Troiano R, Winter T, Zuckerman A,
Ramaiah SD. ASRM müllerian anomalies classification 2021.
Fertil Steril. 2021 Nov;116(5):1238-52.
https://doi.org/10.1016/j.fertnstert.2021.09.025PMID:34736715
9. Richards A, Phy JL, Huang J. Primary cervico-uterine
anastomosis in a patient with agenesis of the uterine isthmus.
Fertil Steril. 2017 Sep;108(3):e388.
https://doi.org/10.1016/j.fertnstert.2017.07.1137
10. Robson S, Oliver GD. Management of vaginal agenesis: review
of 10 years practice at a tertiary referral centre. Aust N Z J
Obstet Gynaecol. 2000 Nov;40(4):430-3.
https://doi.org/10.1111/j.1479-828X.2000.tb01175.x. PMID:
11194424
11. Bakhtiar UJ. Surgical Approach to a Case of Complete Cervical
Atresia and Partial Vaginal Agenesis. EC Gynaecology.
2019;8:624-7.
12. Gargollo PC, Cannon GM, Diamond DA, Thomas P, Burke V,
Laufer MR. Should progressive perineal dilation be considered
first line therapy for vaginal agenesis? J Urol. 2009 Oct;182(4
Suppl):1882-91. https://doi.org/10.1016/j.juro.2009.03.071
PMID: 19683753
13. Xie Z, Zhang X, Liu J, Zhang N, Xiao H, Liu Y, Li L, Liu X.
Clinical characteristics of congenital cervical atresia based on
anatomy and ultrasound: a retrospective study of 32 cases. Eur J
Med Res. 2014 Dec 1;19(1):51. https://doi.org/10.1186/s40001-
014-0051-2. PMID: 25496304
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
14. Faraj C, Essetti S, Bahlouli N, Chait F, Allali N, Chat L, El
Haddad S. Congenital cervico-vaginal aplasia with a functional
uterus: A case report and review of literature. SAGE Open Med
Case Rep. 2024 Jun;12:2050313X241260217.
https://doi.org/10.1177/2050313X241260217. PMID: 38883800
Naheed Parveen - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Sadia Shoukat - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Erum Samreen Siddiqui - Concept & Design; Data
Acquisition; Data Analysis/Interpretation; Drafting
Manuscript; Critical Revision; Supervision; Final Approval
Sakeena Ahmed – Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Nadia Shoukat - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Partial Cervico-Vaginal Aplasia with Functional