Introduction: We report a rare case of distal vaginal atresia not presented by primary amenorrhea but with the inability to have the first sexual intercourse after marriage. 
Case: The patient had normal menarche and regular cycles. Thus, the challenge was in diagnosing such cases with vaginal atresia with normal menses. The menstrual flow was small in amount. The complaint came after her marriage when her husband felt strong resistance. On examination, no vaginal opening was observed. When examined again during menses, a very small opening was observed, from which the menses flow was discharged: it admitted only a pediatric Foley catheter (denoting a small fistulous tract). 3D ultrasound revealed complete uterus, cervix, and vaginal pouch development. Vaginal atresia was identified: an operation was done under a 3D rectal ultrasound guide to identifying the dissection plane. Perineal dissection was done, and pull-through of the vaginal pouch, then suturing the lower end of the vagina to the perineum.
Conclusion: not all cases of vaginal atresia cause primary amenorrhea but may present later with sexual problems. 3D rectal ultrasound is an excellent aid in diagnosis and treatment aid.