Which kind of classication is more suitable for Herlyn–Werner– Wunderlich syndrome

of with (HWWs) in two Results: Type of average age at of diagnosis was signicantly longer than the other two types(13.06±2.55; 13.06±2.55). The menarche and the interval between menarche and time of diagnosis was signicant difference between types I and II. The average age at time of diagnosis, the menarche and the interval between menarche and time of diagnosis was signicant difference between classication I and II. Cystic mass in vaginal wall was a signicant difference between type I and II. Endometriosis of type I and II was a more common than type III. Sex life was a signicant difference between type I and II. Mediastinum of uterus of type II was a more common than type I and III. The time of diagnosis, menarche, interval between menarche and time of diagnosis, cystic mass in vaginal wall, abnormal vaginal discharge, sex life, changes of urination and defecation and mediastinum of uterus were signicant difference between classication 1 and classication 2. The site of olique septum vaginalis was signicant difference in two classication methods. The absence of kidney in HWWs type was signicant difference in two classication methods. Conclusion: Type I HWWs should be suspected in cases involving adolescent girls presenting with cyclical pelvic pain, change of urination and defecation. Two classication can be easy to treat in clinical work. associated with related with abnormal difference with


Background
Herlyn Werner Wunderlich syndrome (HWWs) includes duplication of uterus and vagina with semivaginal obstruction and ipsilateral renal hypoplasia [1]. In China, HWWs is de ned as vaginal septal syndrome, including double uterus, double cervix, double vagina, vaginal septum and ipsilateral urinary system abnormalities, such as renal hypoplasia. Patients with single cervix and uterus mediastinum are relatively rare [2][3].
HWWs is categorized into three types: Type I is nonporous oblique vaginal septum, type II is perforated oblique vaginal septum, type III is nonporous oblique vaginal septum and cervical stula. This classi cation was rst reported by Bian [4]. HWWs can also be classi ed according to complete or incomplete blocking, Classi cation 1, patients with a completely obstructed hemivagina, and Classi cation 2, patients with an incompletely obstructed hemivagina. This classi cation was reported by Lan Zhu [5]. Classi cation 1 included type I, classi cation 2 included type II and type III. Because HWWs is an uncommon syndrome, it is easily misdiagnosed, and the treatment is often delayed. Now an analysis of HWWs clinical characteristics in a large sample of patients (more than 80 cases) has been reported only one [6]. Most of the studies are in the form of case reports, and there are different manifestations of diseases [7][8][9][10][11]. Early accurate diagnosis and resection of the oblique vaginal septum are the objective. Therefore, it is important to recognize the syndrome early. This study retrospectively analyzed 87 patients diagnosed and treated at Shengjing hospital of China Medical University from April 2003 to June 2020.

Methods
Methods from April 2003 to June 2020, a total of 3551 cases of female reproductive system malformations in Shengjing Hospital of China Medical University were retrospectively analyzed. We classi ed the patients according to Bian and Zhu Lan's classi cation report [4][5].
We obtained the diagnosis through clinical manifestations, medical examination and ultrasonography mainly. The cystic mass in vaginal wall can be found through vaginal examination. The abnormal pus or blood could out ow from the hole of oblique vaginal septum by pressing the cystic mass in vaginal wall in type II, and could be aspirated by transvaginal paracentesis of the hematocolpus in types I and III. The abnormal pus or blood could out ow from the normal cervix in type III. HWWs can be also classi ed according to the complete or incomplete obstruction of the hemivagina as follows: Classi cation 1, patients with a completely obstructed hemivagina, and Classi cation 2, patients with an incompletely obstructed hemivagina. This classi cation was reported by Lan Zhu [5]. Ultrasonography could reveal the uterus didelphys, hematometrocolpos, and renal agenesis.
Statistical analyses were conducted using SPSS version 25.0 (IBM, Armonk, NY, USA). Data were compared between groups via χ2 test, Fisher exact test, ANOVA test and nonparametric correlation analysis. The signi cance level for all analyses was set at p 0.05.     HWWs occurred on the right of oblique septum vaginalis 47 patients (57.3 %; type I 32, type II 14, and type III 1), and on the left in 26 patients (31.7%; type I 15, type II 9, and type III 2), among 5 patients did not describe the location of the oblique diaphragm, and only one cervical in 9 patients (10.0%; type I 3, type II 6; type III 0). The site of olique septum vaginalis in HWWs type is signi cant difference. The results were shown in   HWWs occurred on the righe of oblique septum vaginalis 47 cases(57.3%; classi cation 1 32, classi cation 2 15), and on the left in 26 cases(31.7%; classi cation 1 15, classi cation 2 11), among 5 patients did not describe the location of the oblique diaphragm, and only one cervical in 9 patients (10.0%; classi cation 1 3, classi cation 2 6). It was a signi cant difference. The results were shown in Table 3.2.   defecation was related to time of diagnosis, menarche, interval between menarche and time of diagnosis and blood type(all P < 0.05).
Mediastinum was related to HWWs type, time of diagnosis, interval between menarche and time of diagnosis, sex life and the site of oblique septum vaginalis(all P < 0.05). The site of oblique septum vaginalis was related to cystic mass in vaginal wall, sex life, mediastinum of uterus and urinary malformation (all P < 0.05).Urinary malformation was related to cystic mass in vaginal wall, sex life and the site of oblique septum vaginalis(all P < 0.05). Blood type was related to changes of urination and defecation(P < 0.05). The results were shown in Table 6.1. Changes of urination and defecation was related to time of diagnosis, menarche, interval between menarche and time of diagnosis and blood type(all P < 0.05). Mediastinum was related to HWWs type, time of diagnosis, interval between menarche and time of diagnosis, sex life and the site of oblique septum vaginalis(all P < 0.05). The site of oblique septum vaginalis was related to cystic mass in vaginal wall, sex life, mediastinum of uterus and urinary malformation (all P < 0.05).Urinary malformation was related to cystic mass in vaginal wall and the site of oblique septum vaginalis(all P < 0.05). Blood type was related to changes of urination and defecation(P < 0.05). The results were shown in Table 6.2.

Discussion
Among the obstructive malformations of the female genital tract, HWWs is a common type [12]. There are three types of HWWs in the world. In recent years, some scholars divided them into two types according to the presence or absence of obstruction. HWWs can be also classi ed according to the complete or incomplete obstruction of the hemivagina as follows: Classi cation 1, patients with a completely obstructed hemivagina, and Classi cation 2, patients with an incompletely obstructed hemivagina. Classi cation 1 included type I, classi cation 2 included type II and III. We research the impact of the two classi cation methods on the clinical analysis. We study that it was 9(11%) patients single cervix in type I and II. In thepresent study, it was 7(8%) patients no urinary malformation in type II, but the affected kidney had no research function or polycystic kidney.
The age of diagnosis and the interval between menarche and diagnosis of type II were longer than those of type I and type III. as type II had vaginal oblique septal perforation, blood could ow out through meridians. Type III has vaginal septal atresia and cervical stula, blood can not ow out smoothly. The age at diagnosis and the interval between menarche and diagnosis of classi cation 1 were longer than those of classi cation 2.
Dysmenorrhea and cystic mass in vaginal wall were the most common clinical symptom. Dysmenorrhea was common in all type of HWWs, but cystic mass in vaginal wall was more common in type I. Abnormal vaginal discharge was more common in type II, but it is no difference. Endometriosis was common in type III, but it is no difference. Sex life was common in type II, because the age patients of type I was young. Changes of urination and defecation was more in type I. Type I and II was often associated with mediastinum of uterus. Cystic mass in vaginal wall and changes of urination and defecation were common in classi cation 1, abnormal vaginal discharge, sex life and mediastinum of uterus were common in classi cation 2. It may be associated with blood ow, bacterial retrograde infection.
The right of oblique septum vaginalis in HWWs was more common than left in two typing methods. 9 patients had a single cervix, so it was impossible to determine the position of the oblique diaphragm.
Most of the ipsilateral diaphragmas were associated with ipsilateral urinary malformations. Absence of right was more common than left in two typing methods. 7 patients had two kidney, but they had ipsilateral renal abnormalities.
Blood type was no associated with HWWs types. A type was common in type I and III, B type was common in type II. A type was common in classi cation 1, B type was common in classi cation 2, but it is no difference.
HWWs type was related to time of diagnosis, menarche, interval between menarche and time of diagnosis, abnormal vaginal discharge, endometriosism, sex life, and mediastinum of uterus. The difference was that HWWs classi cation was associated with endometriosis, but not with vaginal wall mass. Age at time of diagnosis in three categories was related to menarche, interval between menarche and time of diagnosis, cystic mass in vaginal wall, sex life and changes of urination and defecation. The difference was that time of diagnosis was associated with abnormal vaginal discharge and mediastinum of uterus, but not with cyctic mass in vaginal wall in two categories. Interval between menarche and time of diagnosis was related to sex life, changes of urination and defecation and mediastinum of uterus in three categories. The difference was that interval between menarche and time of diagnosis was associated with abnormal vaginal discharge, but not with mediastinum of uterus.
Most patiernts had clinical symptom after time of diagnosis, so HWWs was easy to miss diagnosis. What's interesting is that blood type was related to changes of urination and defecation. Scholars can expand the sample size to study the relationship between blood type and constipation.
For the patients with postoperative vaginal septal stenosis, re resection of the vaginal septum is still a better choice. With the development of surgical technology, more and more hysteroscopy and laparoscopy are used in the treatment of HWWs. Hysteroscopy and laparoscopy combined application can better diagnosis and treatment.
Most of the patients were lost in follow-up. 6 patients had birth history, 2 with spontaneous delivery, 4 with full-term cesarean section and 1 with abortion.

Conclusion
Type I should be suspected in cases involving adolescent girls presenting with cyclical pelvic pain, change of urination and defecation. It is di cult to distinguish type III in international classi cation, but it is easier to analyze in two classi cation. The second classi cation was related to cystic mass in vaginal wall, but the rst classi cation is not. However, it does not affect the diagnosis and treatment of the disease.