Hematometrocolpos Disguised as Abdominal Pain

Hematocolpos due to imperforate hymen: a case report and literature systematic review

INTRODUCTION AND HYPOTHESIS

Hematocolpos is a rare condition, where menstrual blood fills the vagina, instead of being expelled, due to a series of uterovaginal pathologies, the most frequent of which is the imperforate hymen. To date, few cases of hematocolpos have been reported in the literature.

METHODS

We report a case of hematometrocolpos due to imperforate hymen initially misdiagnosed as constipation and subsequently as ovarian mass; moreover, the present study undertakes a systematic review of studies on hematometrocolpos due to imperforate hymen to synthesize available knowledge on epidemiology, diagnosis, and management about this rare condition.

RESULTS

A total of 35 studies, describing 61 patients, were identified. The presence of hematocolpos should be suspected in premenarchal patients complaining of low abdominal pain, abdominal swelling, and urinary retention. Genital examination disclosing a tender, pale hymen and ultrasound represent a useful tool for diagnosis. The goal of the management is to timely perform hymenotomy to drain the hematocolpos, followed by hymenectomy to prevent recurrence. Follow-up is needed to diagnose possible recurrences.

CONCLUSIONS

In the case of an adolescent girl complaining of genital pain associated with primary amenorrhea, hematocolpos due to imperforate hymen should be suspected.

Hymen-saving hymenotomy of imperforate hymen in neonates and adolescents: tertiary medical center experience

Background

Imperforate hymen (IH) is the most common obstructive anomaly of female genital tract. Hymen saving has a great importance for both cultural and religious reasons. Conventional surgical treatment for this condition is cruciate incision hymenotomy or hymen-saving central annular hymenotomy (HSCAH). This study aimed to review presentations and management of neonate and adolescents with IH at one tertiary hospital over 12 year’s period. The aim also was to stress upon importance of hymen saving to our Muslim community and improve knowledge, enable targeted education, and reduce unnecessary tests and diagnostic delay for this condition.

Methods

Twenty-five patients with IH were diagnosed and treated in this retrospective cohort study over 12 years, from January 2010 till December 2021. Demographic characteristics of the patients, their symptoms and signs, investigations, type of operations, recurrence, and infections were recorded and analyzed.

Results

Saudi accounted for the majority of IH cases (88%). There were fifteen adolescents, and ten were neonates. Bulging imperforate hymen, pelvic/abdominopelvic mass, constipation, acute urine retention, abdominal discomfort, and lower abdominal distension were among the signs and symptoms. All 25 patients had HSCAH, 21 of whom had primary HSCAH and four of whom had secondary HSCAH due to recurrence. To avoid recurrence, HSCAH was performed with suturing of the inner vaginal mucosa to the exterior vestibular mucosa.

Conclusion

Early diagnosis of imperforate hymen for neonate and adolescent girls and prompt definitive HSCAH could have positive impact on treatment outcome and decrease complications and fulfill integrity of hymen as virginity of high importance in our Muslim community and other similar culture, where hymen-sparing procedure is preferred by most of these patients and families.

Imperforate hymen mimicking acute appendicitis in an adolescent woman: a rare presentation

Imperforate hymen is a rare congenital malformation of the female genital tract. The condition poses several diagnostic challenges owing to its low incidence and often atypical presentation. Classical symptoms include amenorrhoea and cyclical abdominal pain. Delayed diagnosis leads to potentially irreversible and lifechanging sequelae including infertility, endometriosis and renal failure. A premenarchal 13-year-old girl with a background of chronic constipation presented with symptoms mimicking acute appendicitis. The underlying cause was imperforate hymen and retrograde menstruation. The diagnosis was made during diagnostic laparoscopy. As with this patient, pre-existing symptoms are often troublesome long before the true diagnosis is made. This case report highlights the importance of recognising imperforate hymen as a potential cause of acute abdominal pain in premenarchal adolescent girls. The clinical picture may present as right or left iliac fossa pain. Early identification reduces the risk of adverse complications and avoids unnecessary and potentially harmful interventions.

A Rare Pelvic "Mass-Querader": Acute Urinary Retention Secondary to Hematocolpos in a Preadolescent Patient

We report a case of acute urinary retention in an adolescent female secondary to hematocolpos. A 13-year-old female presented to the emergency department with acute urinary retention and suprapubic abdominal pain for 24 hours. She denied menstruation or sexual history. Bedside bladder ultrasound scan revealed 1.2 L of retained urine and a Foley catheter was placed. A formal renal ultrasound detected a debris-filled structure in the abdomino-pelvic cavity. Follow-up computed tomography of the abdomen and pelvis revealed an 8.5 cm × 9.3 cm × 12.1 cm mass-like structure in the pelvis. No formal pelvic exam was completed and the patient was taken to the operating room for exploratory laparotomy due to concern for large pelvic mass versus tubo-ovarian abscess. However, upon entering the abdominal cavity, no mass was found. At that point, an external genital exam was performed, revealing an imperforate hymen. Hymenotomy resulted in the evacuation of 2.5 L of clotted blood from the vagina and uterus. Hematocolpos resulting in acute urinary retention is exceedingly rare; however, it is an important differential diagnosis that can be ruled in or out by physical exam findings. Although it may be uncomfortable for adolescent patients and physicians, external genital exams should be conducted in young females with acute urinary retention and amenorrhea to evaluate for imperforate hymen. This can ensure appropriate treatment and avoidance of unnecessary invasive procedures.

Unenhanced MRI of the Abdomen and Pelvis in the Comprehensive Evaluation of Acute Atraumatic Abdominal Pain in Children

OBJECTIVE. The purpose of this study is to show the utility of rapid unenhanced MRI in the comprehensive assessment of acute atraumatic abdominal pain in children, including appendicitis and alternate diagnoses, and to review the MRI features of common acute abdominal and pelvic conditions in a large, single-institution cohort. CONCLUSION. Rapid unenhanced MRI is an excellent option for the initial, comprehensive evaluation of acute abdominal emergencies in pediatric patients because it can diagnose the full range of presenting abnormalities, including causes of abdominal pain warranting surgical and nonsurgical management.

Imperforate hymen: Retrospective review from a single tertiary centre of presenting symptoms and diagnostic process

AIM

To review presentations, diagnostic processes and time to diagnosis of presentations of imperforate hymen at one tertiary paediatric hospital over a 10-year period. The aim was to improve knowledge, enable targeted education and reduce unnecessary tests and diagnostic delay for this congenital obstructive disorder of the female reproductive tract.

METHODS

A pragmatic, retrospective, observational study was conducted of all female patients, aged younger than or equal to 18 years of age, presenting to the Royal Children's Hospital, Melbourne, over an 18-year period. Presenting symptom(s), time to diagnosis, investigations ordered and number of health-care professionals consulted prior to diagnosis were recorded.

RESULTS

A total of 27 patients met eligibility criteria, and 85% presented with pain (23/27). Pain was frequently associated with other symptoms (15/23). Over three quarters of patients consulted more than one health-care professional prior to diagnosis (22/27). Of the 27 patients, 19 had imaging undertaken prior to diagnosis.

CONCLUSIONS

Paediatric and adolescent females managed at our tertiary paediatric hospital are experiencing diagnostic uncertainty and the unnecessary ordering of imaging prior to a diagnosis of imperforate hymen. Targeted education is recommended to health professionals managing female paediatric and adolescent patients.

Vaginal reconstruction for distal vaginal atresia without anorectal malformation: is the approach different?

INTRODUCTION

Distal vaginal atresia is a rare condition and treatment approaches are varied, usually driven by symptoms.

METHODS

A retrospective review was performed to identify patients with distal vaginal atresia without anorectal malformation. Data collected included age and symptoms at presentation, type and number of operations, and associated anomalies.

RESULTS

Eight patients were identified. Four presented at birth with a hydrocolpos and four presented with hematometrocolpos after 12 years of age. Number of operations per patient ranged from one to seven with an average of three. The vaginal reconstruction was achieved by perineal vaginal mobilization in four patients and abdomino-perineal approach in four patients. One patient, with a proximal vagina approximately 7 cm from the perineum, required partial vaginal replacement with colon. In addition, she had hematometrocolpos with an acute inflammation at the time of reconstruction despite menstrual suppression and drainage which may have contributed to the difficulty in mobilizing the vagina. In five patients, distal vaginal atresia was an isolated anomaly. In the other three cases, associated anomalies included: mild hydronephrosis that improved after hydrocolpos decompression (2), cardiac anomaly (2), and vertebral anomaly (1).

CONCLUSION

In this series, a distended upper vagina/uterus was a common presentation and the time of reconstruction was driven by the presence of symptoms. Drainage of the hydrocolpos/hydrometrocolpos with menstrual suppression in post-pubertal patients, followed by further work-up, and planned reconstruction is a good surgical strategy.

Virginity-sparing management of hematocolpos with imperforate hymen: case report and literature review

Imperforate hymen results from failure of the endoderm of the urogenital sinus to completely canalize and has an incidence of 0.01% to 0.05%. This sometimes presents as a pelvic mass that compresses the bladder causing acute urinary retention. A 13-year-old girl was referred to our department with a history of primary amenorrhea, cyclic lower abdominal pain, abdominal–pelvic mass, constipation and acute urinary retention. She had an ultrasonography misdiagnosis of a huge ovarian mass before referral to our unit. On examination, the vagina was bulging and compressing the rectum. Repeat abdominal ultrasonography confirmed the diagnosis of hematometrocolpos. She underwent X-shaped hymenotomy with a favorable outcome. Diagnosis of imperforate hymen requires high suspicion index. Virginity-sparing surgery constitutes a good treatment option for cultural and religious reasons.