Adolescent and Young Adult Patients with Vaginal Graft-vs-Host Disease and Hematocolpos Managed with Vaginal Stents: A Case Series

STUDY OBJECTIVE

Vaginal stenosis can be acquired as a result of vaginal graft-vs-host disease (GVHD) in patients who have undergone hematopoietic stem cell transplant (HSCT). Little data exist to guide the management of vaginal GVHD, particularly in adolescent and young adult patients. The objective of this study was to detail the management of vaginal stenosis with lysis of adhesions and vaginal stent placement in 3 young patients with vaginal GVHD.

METHODS

A retrospective chart review was done for 3 patients with vaginal GVHD causing vaginal stenosis with hematometrocolpos. All 3 were treated using vaginal stent placement. Additionally, a literature review was conducted through PubMed and Google Scholar to identify 21 case reports (with a total of 35 patients) of menstrual obstruction due to GVHD.

RESULTS

Obstructive vaginal stenosis secondary to vaginal GVHD occurred in our patients at ages 15, 16, and 24 years. Resolution of hematocolpos was obtained with lysis of vaginal adhesions with vaginal stent placement in all patients, with varying regimens of systemic and topical hormones, topical corticosteroids, and dilator therapy.

DISCUSSION

Vaginal stenosis secondary to vaginal GVHD should be considered in patients with a history of allogeneic HSCT presenting with amenorrhea, especially those with a diagnosis of primary ovarian insufficiency. The use of vaginal stents, along with postoperative medical and dilator management as appropriate, may prevent re-stenosis, although more information is needed regarding the efficacy of treatments.

A Novel cause of abdominal pain presenting with anuria and renal failure

A girl in early adolescence with autism presented with 3 months of abdominal pain and 36 hours of anuria. She had recently received treatment for urinary tract infections, anxiety and menorrhagia (she had undergone menarche a few months earlier). Due to the pain, she had pulled out an incisor. Bladder scan showed 923 mL, creatinine was 829 mmol/L but urethral catheter insertion did not drain urine. An unenhanced CT scan revealed an absent left kidney, didelphys uterus and right-sided hydroureteronephrosis caused by haematocolpos in keeping with a diagnosis of OHVIRA syndrome and ureteric obstruction of a single kidney causing acute renal failure. She underwent vaginal septoplasty, drainage of the haematocolpos and right ureteric stent.

[Urinary Retention Due to Hematocolpos]

Hematocolpos is an obstruction of the menstrual flow due to an anomaly of the genital tract, with imperforate hymen being the most common one. It is an uncommon condition, with a prevalence of 1:1000 - 1:16 000. It is usually an asymptomatic condition until the onset of menarche, when there is accumulation of blood in the vagina (hematocolpos) or in the uterus (hematometra). A rare symptom of hematocolpos could be urinary retention. Our case report is about a 12-year-old girl, with no menarche and Tanner stage M4/P5, who was admitted to our emergency department with abdominal pain and urinary retention. A brief review of this rare condition is presented, in order to remind clinicians about its existence, so that it can be diagnosed and treated as quickly as possible.

Scoliosis in Herlyn-Werner-Wunderlich syndrome: a case report and literature review

Herlyn-Werner-Wunderlich syndrome (HWWS) is a congenital Müllerian duct anomaly characterized by uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. Little is reported about spinal deformity associated with this syndrome. This study presents a case of scoliosis occurring in the setting of HWWS and explores the possible association between the 2 diseases. A previously unreported scoliosis in HWWS is described. The patient is a 12-year-old Chinese female with scoliosis that underwent a posterior correction at thoracic 5-thoracic 12 (T5-T12) levels, using the Moss-SI (Johnson & Johnson, American) spinal system. At 24-month follow-up, the patient was clinically pain free and well balanced. Plain radiographs showed solid spine fusion with no loss of deformity correction. Six months after scoliosis correction surgery, the patient went to our clinics for the treatment of HWWS. She was performed a vaginal septum resection and detected with pyocolpos. Her follow-up was symptom free at the fourth postoperative month. The prevalence of scoliosis among patients with HWWS was 8.57% that is much higher than the incidence of congential scoliosis among general population (1/1000). To the best of our knowledge, this is the first report of HWWS with thoracic scoliosis. During surgery, surgeons and anesthesiologists must pay particular attention to the Müllerian duct anomaly and renal agenesis associated with HWWS. There is a potential association between congenital scoliosis and HWWS.

Fever of unknown origin attributable to haematocolpos infected with Salmonella enterica Serotypetyphi resistant to nalidixic acid: a case report

The prevalence of nalidixic acid-resistant Salmonella Typhi (NARST) infection is increasing worldwide. We are reporting an unusual case of infected haematocolpos presenting as urinary obstruction in a patient with fever of unknown origin (FUO). This case report highlights the importance of quinolone-resistant typhoid fever in the differential diagnosis of any acute febrile illness in countries, like India, where Salmonella infection is endemic.

Imperforate hymen with elevated serum CA 125 and CA 19-9 levels

OBJECTIVE

To report the clinical characteristics of 14 patients with imperforate hymen and their levels of tumor markers (CA 19-9 and CA 125).

STUDY DESIGN

Fourteen patients with imperforate hymen who followed-up between September 2006 and September 2010 in the Department of Obstetrics and Gynecology, Dicle University School of Medicine, Diyarbakir, Turkey, were evaluated retrospectively. The clinical features and the management of the patients are discussed.

RESULTS

The mean age of the patients was 13.8 years. All patients had primary amenorrhea and pelvic pain. The most common clinical symptoms were cryptomenorrhea in 14 patients, pelvic pain in 11, palpable abdominal mass in 6, voiding difficulties in 7, and defecation problems in 2. In 6 patients with palpable pelvic mass, the mean + standard deviation values of tumor markers were as follows: CA 125, 84.0 +/- 23.7 and CA 19-9, 162 +/- 189. One week after surgery we measured CA 125 and CA 19-9 levels once again. The postoperative mean CA 125 level was 13.8 +/- 3.6, and the mean postoperative CA 19-9 level was 17.5 +/- 3.5. Preoperative levels of CA 125 and CA 19-9 were significantly higher than those of the postoperative period (p < 0.001 for both comparisons). Six patients were treated by T-shaped incision and 8 patients by a central surgical incision through the hymenal membrane.

CONCLUSION

Diagnosis of imperforate hymen is very important before undergoing surgery in a different clinic. Many patients have seen several doctors before receiving a clear diagnosis and have had tumor markers evaluated because the presence of pelvic mass in patients suggests the possibility of a gynecologic malignancy. Imperforate hymen is one of the benign conditions that increase serum CA 125 and CA 19-9 levels and which is not listed in the classical medical textbooks. These markers are not needed for the diagnosis.

Imperforate hymen presenting with massive haematocolpos and acute urinary retention in a teenage girl: A case report

Imperforate hymen is relatively rare but it is the most frequently encountered obstructive anomaly of the female lower genital tract. The clinical presentation vary significantly from patient to patient depending on the age at diagnosis but in most cases the diagnosis is missed in early childhood and therefore the diagnosis is made after puberty when the patient present with haematocolpos, heamatometra.or both. When this happens, the presentation could even be tricky because the patient may presents with unlikely symptoms apart from cryptomenorhoea like, urinary retention or bowel obstruction or both. Here we present a 16 years old girl with imperforate hymen and presented with history of lower abdominal pain and distension associated with acute urinary retention. She was treated by hymenotomy and improved dramatically and was discharge 6th day post operatively. This case report is presented to address to clinicians the possibility of imperforate hymen with haematocolpos as a differential diagnosis in adolescent girls particularly those who have not started having their menses in their teens and present with acute urinary retention so that their external genitalia are carefully examined to exclude the possibility of imperforate hymen as a cause of acute urinary retention due to the haematocolpos.

[The role of MRI in congenital cystic lesions in the pelvis: a case of uterus didelphys with double vagina, hematocolpos, and ipsilateral renal agenesis.]

We report a case of uterus didelphys with blind hemivagina and ipsilateral renal agenesis. This is an uncommon anomaly of the development of the Mullerian ducts in which a defect in one of the Wolffian ducts leads to failed induction in kidney formation and in the fusion of the Mullerian ducts. MRI plays a decisive role in the diagnosis and characterization of the malformation.

Simultaneous occurrence of hematometrocolpos and consecutive pregnancies in uterine didelphys : a case report

Hematometrocolpos drained abdominally at laparotomy done, with suspicion of an ovarian torsion in an adolescent with ipsilateral renal agenesis, was eventually rediscovered to have in coexistent uterine didelphys in a 25 year P3+0 at the time repeat caesrean for breech in the event of third parturition, complicated by partum hemorrhage as in all her previous delivery (first vaginal delivery and retained placenta, second caesarean for obstructed labor by non pregnant half of didelphic uterus). This illustrates how simultaneous occurrence of hematometrocolpos can go unnoticed although there was every reason for this condition not to go unrecognized for the simple fact ofhemivaginal obstruction and hematometra with ipsilateral renal agenesis (on the left side) unaffecting the consecutive pregnancy in the other uterus.

Acute urinary retention as the presentation of imperforate hymen

Acute urinary retention is unusual in children and is usually a candidate for visiting the emergency department upon initial discovery. We report a 12-year-old girl who complained of acute urinary retention. Ultrasonography demonstrated a large echogenic mass over the vagina and mild dilation of the uterus. Imperforate hymen associated with hematocolpos and hematometrium was diagnosed. Cruciate hymenotomy was performed. The symptoms resolved after treatment. Adolescent girls who complain of urinary symptoms with no previous menstruation should have their external genitalia examined in order to rule out the possibility of imperforate hymen as the cause of acute urinary retention.

Hematocolpos with imperforate hemi-vagina and duplicated uterus: diagnosis and treatment

OBJECTIVE

To document the means of diagnosis and treatment of the exceptional malformation hematocolpos with imperforate hemi-vagina and duplicated uterus

CASES

Cases of four patients treated at La Marsa University Hospital, in the Department of Obstetrics and Gynecology between 2000 and 2004, were reported. Mean age=17.2 years (range: 15-22 years). Three left hematocolpos and a right one are observed. All patients underwent vaginal conservative surgical treatment (excision of vaginal septum) +/- radical treatment: hemi- colpohysterectomy in case of failure of conservative treatment. The clinical presentation was a primary dysmenorrhea associated with a pelvic collection. An ipsilateral renal agenesis is present in all cases. Sonography is essential to assess the diagnosis of renal anomalies. Pelvic MRI is the most important examination. It accurately localises the different collections and identifies their content. Conservative surgical management was effective in three cases out of four.

Imperforate hymen-a rare cause of abdominal pain: two cases and review of the literature

STUDY OBJECTIVE

To document an unusual cause of abdominal pain in premenarcheal adolescent girls.

DESIGN

Case report.

SETTING

A training and research hospital in Istanbul.

RESULTS

Two cases of hematocolpos in two adolescent girls due to imperforate hymen were reported. Both of them manifested lower abdominal pain and urinary retention. Hymenotomy was performed in both the cases.

CONCLUSION

Imperforate hymen is a rare diagnosis, but should be considered when dealing with premenarcheal adolescent girls with lower abdominal symptoms or back pain.

A case of retention of urine and haematocolpometra

SUMMARY

A 13-year-old local girl presented to the emergency department with a 12-h history of lower abdominal pain and inability to pass urine. Examination showed that she was in urinary retention and an imperforate hymen was found. Further investigation showed haematocolpos and haematometra. This is a rare cause of the retention of urine and the emergency physician should consider this condition in women between the ages of 12 and 18 years presenting with abdominal pain and obscure urinary complaints.

Haematocolpos--an uncommon cause of lower abdominal pain in adolescent girls

Two cases of haematocolpos in adolescent girls due to imperforate hymen are reported. Both of them presented with lower abdominal pain and urinary retention. Hymenotomy was performed in both the cases. The condition is discussed with brief review of literature.

Down's syndrome, precocious puberty, and transverse vaginal septum: an unusual cause of abdominal pain

Hematocolpos should be considered in adolescent girls who present with lower abdominal pain, a pelvic mass, and primary amenorrhea. The authors describe a rare case of a young child with Down's syndrome, precocious puberty, and hematocolpos caused by a transverse vaginal septum. The diagnosis was facilitated using a combination of computed tomography and ultrasound scanning. J Pediatr Surg 36:641-643.

Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis. A case report

BACKGROUND

Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis usually presents after menarche with progressive abdominal pain during menses secondary to hematocolpos. We describe a case with the unique presentation of rectal pain and constipation.

CASE

A 13-year-old girl presented to the emergency department complaining of lower abdominal and rectal pain and constipation of two weeks' duration. Pelvic ultrasound, physical examination and laparoscopic findings established a diagnosis of hematometracolpos secondary to uterus didelphys with unilateral imperforate hemivagina. An incision in the vaginal septum allowed drainage of the hematocolpos, providing relief of the patient's symptoms.

CONCLUSION

Uterus didelphys with unilateral imperforate hemivagina and ipsilateral renal agenesis may present with apparent gastrointestinal symptoms. With increased awareness of this problem, timely diagnosis may be achieved.

An unusual case of acute urinary retention in young females

Urinary retention is an unusual problem in females and may be psychogenic, especially in the young. However it is important to remember that there are also organic causes for retention. We present 2 cases of an uncommon cause of urinary retention in the young female, namely hematocolpos.

[Surgical treatment in a case of partial vaginal obliteration coexisting with hematometra, hematocolpos and other congenital defects]

A case history of 12 years old girl with transverse vaginal septum occurring with hematometra, hematocolpos and other congenital defects is presented. Operation was carried out twice because of vaginal prosthetic appliance after the first operation. The reoperation was done 6 months after the previous one and artificial vagina recanalised.

An unusual case of urinary retention due to imperforate hymen

A 15 year old girl presented to the accident and emergency (A&E) department with a 24 hour history of lower abdominal pain, and was found to have acute urinary retention. She was discovered to have an imperforate hymen with associated haematocolpos and haematometrium. This is rare and is hence a very unusual presentation to the A&E department. Patients presenting with retention of urine should be carefully assessed for the cause.

Backache: a rare diagnosis and unusual complication

We report an adolescent girl who presented with an acute exacerbation of a chronic backache of 6 months duration. She complained of dribbling micturition, constipation, and an irresistible urge to strain for 72 h. In the waiting area of the local hospital she developed sudden, severe chest pain with progressive swelling of the upper torso. This proved to be the mode of presentation of a haematocolpos due to an imperforate hymen with the unusual complication of mediastinal emphysema. Imperforate hymen is a rare diagnosis, but should be considered when dealing with an adolescent girl with lower abdominal symptoms or backache.

Hematocolpos. An unusual cause of sciatica in an adolescent girl

STUDY DESIGN

A case report.

OBJECTIVE

To document the occurrence of hematocolpos causing sciatica and leg weakness in an adolescent girl.

SUMMARY OF BACKGROUND DATA

Low back pain resulting from hematocolpos has been reported previously but not associated with symptoms of sciatica or neurologic weakness.

METHODS

The authors were involved in the care of this patient, and all medical records, radiologic investigations, and related literature were reviewed.

RESULTS

After being checked for longstanding symptoms of sciatica and leg weakness, the patient underwent a computed tomographic examination of lumbar spine, which showed a large collection in the pelvis consistent with hematocolpos. Surgical drainage of the collection was associated with complete resolution of her symptoms.

CONCLUSIONS

Awareness of hematocolpos as a possible cause for sciatica and neurologic symptoms in the lower limbs may lead to earlier diagnosis and, therefore, reduced morbidity in the investigation of the adolescent girl.

[Unilateral hematocolpos, blind vagina and agenesis of the homolateral urinary tract]

Hematocolpos with homolateral renal agenesis is a rare condition. Dysmenorrhea and paroxysmal abdominal pain are common symptoms in adolescent girls. Following a review of the literature, this article considers those procedures and investigations which can be used to help these patients before arriving at the stage of reconstructive surgery.

Acute urinary retention in two patients with imperforate hymen

Acute urinary retention in two adolescent girls with hematometrocolpos caused by imperforate hymen are reported. The accumulation of the menstrual blood in the vagina and uterus may form a mechanical effect on the urethra and bladder and lead to the obstructive urinary symptoms. Hymenotomy created individually by CO2 laser and cruciate incision was performed. The two patients were discharged on the same day after operation and made an uneventful recovery.

[Urinary retention caused by hematocolpos secondary to imperforate hymen]

We report on two adolescent girls with imperforate hymen that had presented clinically as urinary retention. In the second case described herein, hydrocolpos could have resulted from the imperforate hymen and might have caused the congenital hydronephrosis incorrectly diagnosed during the neonatal period and childhood as such.

Hematocolpometra presenting as urinary retention. A case report

Acute urinary retention is a symptom that often accompanies hematocolpometra. The imperforate hymen is a rare gynecologic abnormality that can be easily diagnosed on initial presentation. We report on a 14-year-old white girl with hematocolpometra and imperforate hymen. The symptoms, operative findings and postoperative involution of internal genitalia are described.

Hematocolpos as a cause of back pain in premenarchal adolescents

Persistent low back pain in children demands thorough investigation. An unusual cause of such discomfort is hematocolpos secondary to imperforate hymen in premenarchal girls. Experience with four patients whose initial primary symptom was low back pain has been documented. All had large pelvic masses with greater than 400 ml of old blood being drained at hymenotomy in all patients. Irritation of the sacral plexus or nerve roots is postulated as a mechanism for the referred back pain. Hematocolpos should be included in the differential diagnosis of prepubertal girls who have low back pain.

[Imperforated hymen with hematocolpos diagnosed by urinary symptoms]

We inform of the case of a hymenal membrane imperforation in a 14-year-old patient who consulted for urological symptoms. It is, therefore, a case of an uncommon disorder of a gynecologic origin which, through the occurrence of the menarche and the accumulation of successive menstruations, causes a hematocolpos. This gives rise to a clinical pattern of urinary discomfort as a mechanical effect due to space commitment.

[Acute urinary retention caused by hematocolpos associated with uterus didelphys and ipsilateral renal agenesis]

Acute urinary retention from compressive hematocolpos is an uncommon form of presentation of the multi-malformation syndrome arising from failed fusion of the Müllerian ducts and is characterized by uterus didelphys, vaginal duplication (one with hematocolpos), and unilateral renal agenesis. A case is reported and the literature reviewed.

Acute urinary retention secondary to uterus didelphys with imperforate vagina

Cyclic dysmenorrhea, unilateral abdominopelvic mass, acute urinary retention and renal agenesis ipsilateral to the pelvic mass in a young woman suggest uterus didelphys with unilaterally imperforate vagina.

Uterus didelphys with unilateral hematocolpos, ipsilateral renal agenesis and menses. A case report and literature review

A 13-year-old girl with signs and symptoms of an acute abdomen was found to have uterus didelphys, unilateral hematocolpos, ipsilateral renal agenesis and menses. A review of the literature in English revealed 115 reported cases. This complex congenital anomaly is seen most commonly in adolescents with dysmenorrhea of progressive severity, abdominal pain and a pelvic mass.