From
StayCurrentMD
Case Presentations Part I: Cloaca and Complex ARMs 2015
With Dr. Lesley Breech · hosted by Dr. Em Gootee
Part of
Cloaca 33 items
Chapter 1 of 9 · Case-Based Learning
Newborn hydrocolpos
Case 1 Presentation: Newborn with Hydrocolpos
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Hydrocolpos occurs in approximately 28% of female patients with cloaca, with the majority having bilateral hemivaginas
More than half of patients with hydrocolpos did not receive timely diagnosis and treatment, leading to complications including infection, sepsis, recurrent UTIs, and hydrocolpos rupture
69.4% of patients with hydrocolpos had common channel length greater than 3 centimeters
In patients with duplicated uteri and vaginas, the cervices are typically located at the same level on either side of the vaginal septum
Intermittent catheterization might work especially in short common channel cases or where the catheter preferentially goes to the vagina
Whatever drainage method is used for hydrocolpos, follow-up ultrasound is essential to confirm there is no reaccumulation and that the hydrocolpos is indeed drained
The advantage of open vaginostomy over tube placement is the ability to divide the vaginal septum and ensure both hemivaginas drain, avoiding the need for a second tube
Common channel length approximately 3 centimeters is the cutoff for confidently approaching from posterior sagittal versus needing to discuss possible abdominal approach
Common channel length alone is insufficient for surgical planning - urethral length, rectal takeoff location, and other anatomic factors must also be considered
Sufficient female hypospadias must be accepted to allow the patient or doctor to identify the meatus for catheterization if needed
There is no explanation for why patients develop hydrocolpos under tension, as no obstruction or atresia is found at surgery - it remains a mystery
The rectal fistula in cloaca is usually located in the posterior aspect of the vaginal septum, sometimes as a tiny orifice that must be intentionally sought
In patients with congenital adrenal hyperplasia and urogenital sinus, the majority have urethral length of approximately 1.5 to 2 centimeters
Endoscopic assessment of bladder neck competency is unreliable due to hydrostatic pressure effects during the examination
Long common channel length is definitively important for prognosis, and when vaginas attach to the bladder neck or trigone, separation may result in loss of bladder neck function
Attempting total urogenital mobilization on very long common channels (5+ cm) risks devascularizing the urethra by separating structures, which will cause bladder neck closure
When common channel is very long (5+ cm) preoperatively, it is better to go directly to abdominal approach without attempting total urogenital mobilization to preserve the common channel for future intermittent catheterization
Cases with extremely long common channels where vaginas enter at bladder neck and rectum at trigone are actually easier to manage than the 3-5 cm gray zone cases
The most challenging cloacal repairs are those with 4-5 cm common channels combined with large vaginas, which create a wide common wall between vaginas and trigone with ureters passing through
Surgical decision-making in borderline cases (4-5 cm common channel) requires intraoperative judgment and 'feeling' that cannot be replaced by evidence-based protocols
To leave the common channel as a urethra, it must provide a straight catheterization path to the bladder; if catheterization is not possible even when fully exposed, it will not work as a future urethra
When separating vagina from urinary tract, one must leave a completely normal wall of one structure facing the suture line and never leave one suture line facing another to prevent fistula formation
Dividing the vaginal septum between hemivaginas does not contribute to fistula formation between vagina and urinary tract
In cloacal patients undergoing extensive perineal-to-abdominal surgery, vaginal septum should be divided at the same time for patient comfort with sexual function and menstrual hygiene, as it does not extend the procedure or increase fistula risk
Interventional radiology drainage of hydrocolpos risks going through the uterus or close to the cervix, which can compromise future fertility
Intermittent catheterization of the common channel for hydrocolpos drainage is unreliable because when inserting a tube into an unrepaired cloaca, there are 3 places it could go
External drainage tubes may provide tethering to the vagina that could interfere with total urogenital mobilization or make pulling the vagina to the perineum more complicated
Hydrocolpos can reaccumulate and become infected even with a catheter in place, requiring monitoring and sometimes irrigation with gentamicin solution
In very short common channels (less than 1 centimeter), the urethra can be left in place with some female hypospadias accepted, mobilizing only the vagina and rectum
Total urogenital mobilization requires at least 1 to 2 centimeters of urethral length from bladder neck to common channel confluence to avoid placing the bladder neck on the perineum and causing incontinence