Skip to main content
SpringerLink
Log in

The rectovaginal septum: visible on magnetic resonance images of women with Mayer-Rokitansky-Küster-Hauser syndrome (Müllerian agenesis)

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

Ongoing debate exists about whether the rectovaginal septum (Denonvilliers’ fascia) is myth or reality. This study evaluates magnetic resonance images (MRI) of women with Müllerian agenesis for the presence of fascial layers between the rectum and the bladder to test the hypothesis that this layer exists in the absence of the vagina.

Methods

This is a secondary analysis of a study describing MRI aspects in women with vaginal agenesis before and after laparoscopic Vecchietti procedure. Study participants (n = 16) had a multiplanar pelvic MR scan. Images were evaluated independently by two investigators (MH, JOLD) for the appearance of layers separate from the bladder and rectum in the area of interest, with characteristic anatomical features of the septum.

Results

Participants’ mean age was 19.4 ± 2.6 years ± standard deviation (SD). In 12 of 16 patients (75 %) a distinct layer between rectum and bladder was identified in either the axial (4/16; 25 %) or sagittal (12/16; 75 %) scan or both. Characteristic anatomical features included lateral attachment to the levator ani muscle, cranial fusion to the cul-de-sac peritoneum, and caudal insertion into the perineal body.

Conclusions

Three quarters of women with Müllerian agenesis have a visible layer between bladder and rectum. As none of the participants had a vagina, these results support the existence of a rectovaginal septum, separate from a vaginal adventitia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Boyles SH, Weber AM, Meyn L (2003) Procedures for pelvic organ prolapse in the United States, 1979–1997. Am J Obstet Gynecol 188(1):108–115. doi:10.1067/mob.2003.101

    Article  PubMed  Google Scholar 

  2. Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM (2006) Uterosacral ligament vault suspension: five-year outcomes. Obstet Gynecol 108(2):255–263. doi:10.1097/01.AOG.0000224610.83158.23

    Article  PubMed  Google Scholar 

  3. Cundiff GW, Fenner D (2004) Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 104(6):1403–1421. doi:10.1097/01.AOG.0000147598.50638.15

    Article  PubMed  Google Scholar 

  4. Debodinance P (2010) Patent for medical device: from design to marketing (example of Prolift(R)). J Gynecol Obstet Biol Reprod (Paris) 39(6):507–508. doi:10.1016/j.jgyn.2010.05.008

    Article  CAS  Google Scholar 

  5. Murphy M, Holzberg A, van Raalte H, Kohli N, Goldman HB, Lucente V (2012) Time to rethink: an evidence-based response from pelvic surgeons to the FDA safety communication: “UPDATE on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse”. Int Urogynecol J 23(1):5–9. doi:10.1007/s00192-011-1581-2

    Article  PubMed  Google Scholar 

  6. Uhlenhuth E, Wolfe WM et al (1948) The rectogenital septum. Surg Gynecol Obstet 86(2):148–163

    CAS  PubMed  Google Scholar 

  7. Ricci JV, Lisa JR et al (1947) The relationship of the vagina to adjacent organs in reconstructive surgery; a histologic study. Am J Surg 74(4):387–410

    Article  CAS  PubMed  Google Scholar 

  8. Curtis AH, Anson BJ, Beaton LF (1940) The anatomy of the subperitoneal tissues and legamentous structures in relation to surgery of the female pelvic viscera. Surg Gynecol Obstet 70:643–656

    Google Scholar 

  9. Goff BH (1931) An histologic study of the perivaginal fascia in a nullipara. Surg Gynecol Obstet 52:32–42

    Google Scholar 

  10. Krantz KE (1959) The gross and microscopic anatomy of the human vagina. Ann N Y Acad Sci 83:89–104

    Article  CAS  PubMed  Google Scholar 

  11. Zhai LD, Liu J, Li YS, Yuan W, He L (2009) Denonvilliers’ fascia in women and its relationship with the fascia propria of the rectum examined by successive slices of celloidin-embedded pelvic viscera. Dis Colon Rec 52(9):1564–1571. doi:10.1007/DCR.0b013e3181a8f75c

    Article  Google Scholar 

  12. Milley PS, Nichols DH (1969) A correlative investigation of the human rectovaginal septum. The Anat Rec 163(3):443–451. doi:10.1002/ar.1091630307

    Article  CAS  Google Scholar 

  13. Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 36(4):976–983

    Article  CAS  PubMed  Google Scholar 

  14. Kleeman SD, Westermann C, Karram MM (2005) Rectoceles and the anatomy of the posteriorvaginal wall: revisited. Am J Obstet Gynecol 193(6):2050–2055. doi:10.1016/j.ajog.2005.07.096

    Article  PubMed  Google Scholar 

  15. Rall K, Barresi G, Walter M, Poths S, Haebig K, Schaeferhoff K, Schoenfisch B, Riess O, Wallwiener D, Bonin M, Brucker S (2011) A combination of transcriptome and methylation analyses reveals embryologically-relevant candidate genes in MRKH patients. Orphanet J Rare Dis 6:32. doi:10.1186/1750-1172-6-32

    Article  PubMed Central  PubMed  Google Scholar 

  16. Brucker SY, Gegusch M, Zubke W, Rall K, Gauwerky JF, Wallwiener D (2008) Neovagina creation in vaginal agenesis: development of a new laparoscopic Vecchietti-based procedure and optimized instruments in a prospective comparative interventional study in 101 patients. Fertil Steril 90(5):1940–1952. doi:10.1016/j.fertnstert.2007.08.070

    Article  PubMed  Google Scholar 

  17. Hinata N, Sejima T, Takenaka A (2012) Progress in pelvic anatomy from the viewpoint of radical prostatectomy. Int J Urol. doi:10.1111/iju.12021

    Google Scholar 

  18. Ficarra V, Gan M, Borghesi M, Zattoni F, Mottrie A (2012) Posterior muscolofascial reconstruction incorporated into urethrovescical anastomosis during robot-assisted radical prostatectomy. J Endourol / Endourological Soc. doi:10.1089/end.2012.0554

    Google Scholar 

  19. Weber DC, Zilli T, Vallee JP, Rouzaud M, Miralbell R, Cozzi L (2012) Intensity modulated proton and photon therapy for early prostate cancer with or without transperineal injection of a polyethylen glycol spacer: a treatment planning comparison study. Int J Radiat Oncol Biol Phys 84(3):e311–318. doi:10.1016/j.ijrobp.2012.03.028

    Article  PubMed  Google Scholar 

  20. Dietz HP (2011) Can the rectovaginal septum be visualized by transvaginal three-dimensional ultrasound? Ultrasound Obstet Gynecol 37(3):348–352. doi:10.1002/uog.8896

    Article  CAS  PubMed  Google Scholar 

  21. Shobeiri SA, White D, Quiroz LH, Nihira MA (2012) Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison. Int Urogynecol J 23(8):1047–1053. doi:10.1007/s00192-012-1721-3

    Article  PubMed  Google Scholar 

  22. Margulies RU, Hsu Y, Kearney R, Stein T, Umek WH, DeLancey JO (2006) Appearance of the levator ani muscle subdivisions in magnetic resonance images. Obstet Gynecol 107(5):1064–1069. doi:10.1097/01.AOG.0000214952.28605.e8

    Article  PubMed Central  PubMed  Google Scholar 

  23. Hsu Y, Lewicky-Gaupp C, DeLancey JO (2008) Posterior compartment anatomy as seen in magnetic resonance imaging and 3-dimensional reconstruction from asymptomatic nulliparas. Am J Obstet Gynecol 198(6):651–e651-657. doi:10.1016/j.ajog.2007.11.032

    Article  PubMed Central  PubMed  Google Scholar 

  24. Huebner M, Margulies RU, DeLancey JO (2008) Pelvic architectural distortion is associated with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 19(6):863–867. doi:10.1007/s00192-007-0546-y

    Article  PubMed Central  PubMed  Google Scholar 

  25. Huebner M, Margulies RU, Fenner DE, Ashton-Miller JA, Bitar KN, DeLancey JO (2007) Age effects on internal anal sphincter thickness and diameter in nulliparous females. Dis Col Rec 50(9):1405–1411. doi:10.1007/s10350-006-0877-7

    Article  Google Scholar 

  26. Hsu Y, Huebner M, Chen L, Fenner DE, DeLancey JO (2007) Comparison of the main body of the external anal sphincter muscle cross-sectional area between women with and without prolapse. Int Urogynecol J Pelvic Floor Dysfunct 18(11):1303–1308. doi:10.1007/s00192-007-0340-x

    Article  PubMed Central  PubMed  Google Scholar 

  27. Margulies RU, Huebner M, DeLancey JO (2007) Origin and insertion points involved in levator ani muscle defects. Am J Obstet Gynecol 196

  28. Lewicky-Gaupp C, Yousuf A, Larson KA, Fenner DE, Delancey JO (2010) Structural position of the posterior vagina and pelvic floor in women with and without posterior vaginal prolapse. Am J Obstet Gyneco 202(5):497–e491-496. doi:10.1016/j.ajog.2010.01.001

    Google Scholar 

  29. DeLancey JO (1999) Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol 180(4):815–823

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

None.

Conflicts of interest

MH: none

KR: grant support Fortüne 2047-0-0, Germany

SYB: none

CR: Astellas, Johnson and Johnson

KSL: General Electrics

JOLD: grant support NIH R01 HD 44406; AMS, Kimberly Clark, Johnson and Johnson

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany

    Markus Huebner, Katharina Rall, Sara Yvonne Brucker & Christl Reisenauer

  2. Department of Radiology, Diagnostic and Interventional Radiology, University of Tuebingen, Tuebingen, Germany

    Katja Claudia Siegmann-Luz

  3. Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA

    John O. L. DeLancey

Authors
  1. Markus Huebner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katharina Rall
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sara Yvonne Brucker
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christl Reisenauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Katja Claudia Siegmann-Luz
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. John O. L. DeLancey
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Katharina Rall.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Huebner, M., Rall, K., Brucker, S.Y. et al. The rectovaginal septum: visible on magnetic resonance images of women with Mayer-Rokitansky-Küster-Hauser syndrome (Müllerian agenesis). Int Urogynecol J 25, 323–327 (2014). https://doi.org/10.1007/s00192-013-2214-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-013-2214-8

Keywords

Search

Navigation