"Hematocolpos on Hymeneal Imperforation: A Case Report and Literature Review"

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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.
Imperforate hymen is a relatively rare congenital anomaly which may lead to the development of hematocolpos during puberty. Clinical examination reveals imperforate hymen but abdominal ultrasound and tumor markers findings may be misleading. The presented case shows how MRI may contribute to confirm this diagnosis, define the extent of the collection exclude coexisting abnormalities and avoid an unnecessary surgical intervention.A case of an 11 years old girl is presented who was referred to our clinic with the symptoms of pelvic pain and urine retention. Transabdominal ultrasound findings of pelvic mass and an elevated tumor marker Ca 125 contributed to a referral for exploratory laparotomy with possible diagnosis of ovarian malignancy. After admission in our tertiary center a careful history raised the diagnosis of hematocolpos and the clinical examination showed an imperforate hymen. An MRI of the pelvis was performed to confirm the diagnosis of hematocolpos and exclude other coexisting congenital abnormalities. She was managed by crucial hymenectomy and drainage.The diagnosis of hematocolpos should always be considered in the differential of lower pelvic pain in a young adolescent girl. Detailed family history and clinical examination are mandatory to establish a diagnosis. MRI of the pelvis should be performed to confirm the clinical diagnosis, not only to evaluate the extent of the collection and the presence of possible coexisting anatomic variations of the urogenital tract, but also to avoid an unnecessary surgical intervention by laparoscopy or laparotomy.
Hydrocolpos is characterized by a vaginal accumulation of cervical and vaginal secretions. It often occurs in newborn child and infant. Imperforate hymen is frequently associated; in rare instances, complete higher vaginal diaphragm or partial vaginal atresia is diagnosed. Hydrocolpos can be treated by hymenectomy using imperforate hymen. Because of additional malformation, the treatment can be more complex for vaginal obstruction. The authors report a series of four patients with hydrocolpos: three neonates and one 2-month old infant. Ultrasonography confirmed the physical findings. Three patients with imperforate hymen underwent hymenectomy in X. The fourth which had a virginal atresia and pyocolpos drainage was treated using celioscopy. The three first patients outcome was favorable except for the patient with pyocolpos who died with septicemia.
A case of imperforate hymen discovered after a surgical complication is reported. We discuss the lessons to draw from this case in terms of diagnosis and therapeutic management. An 11-year-old girl was referred with fever and acute lower abdominal pain. A diagnosis of appendicitis was hypothesized because of rigidity located to the right iliac fossa, a psoas sign, polynuclear leukocytosis, and increased serum C-reactive protein. A McBurney laparotomy showed a brownish hemoperitoneum and a dilated right fallopian tube. The appendix appeared normal and an appendicectomy was done. A diagnosis of hematocolpos aggravated by hematometra, hematosalpinx, and hemoperitoneum was suspected. Pelvic examination revealed an imperforate hymen with a taut pelvic mass confirmed by transabdominal and endorectal ultrasonography. Hymenotomy was performed, which allowed the discharge of 400cc of chocolate-colored fluid. The history-taking revealed recurrent intermittent lower abdominal pain with several referrals to emergency departments. The patient recovered uneventfully and was discharged 2 days later. In case of acute abdominopelvic pain in pubertal girls with no previous menstruation, the possibility of an imperforate hymen must be suspected. Examination should include observation of secondary sexual characteristics and inspection of the external genitalia. Treatment is surgical and consists of a hymenotomy.
Hematocolpos is rarely presented as a pelvic mass which mechanically compresses the bladder and the urethra thereby causing urinary retention. A 12-year-old girl referred with the history of lower abdominal pain and retention of urine for 24 h. The patient had not started her menses yet. Three weeks before she also complained of discomfort on passing urine, frequency and urgency and was taken to a local outpatient clinic where she was given antibiotics with the diagnosis of urinary tract infection, she had also the history of intermittent urinary catheterization (three times before) in an emergency department because of acute severe urinary retention. Transabdominal ultrasonography revealed a pelvic semi-solid mass suggestive of hematocolpos. Pelvic examination revealed a pale blue imperforate hymen bulging from the vaginal introitus outwards. A cruciate incision was made over the hymen. Postoperative period was uneventful. In case of acute severe urinary retention in an adolescent girl, the clinicians should keep in mind that imperforate hymen may be a causative factor and this condition may easily be treated surgically.
Massive hematocolpos resulting from an imperforate hymen is quite a rare cause of acute urinary retention, in an adolescent girl admitted to the emergency department. A 12-year-old girl suffering from severe inguinal pain and dysuria together with difficulty in urination for about 1 month was admitted to the emergency department for acute urinary retention. On gynecological examination, imperforate hymen was observed to be the cause of the urinary difficulty. Pelvic magnetic resonance imaging revealed a dilated vagina exerting pressure on the bladder outlet suggestive of hematocolpos. Cruciate hymenotomy was performed. The postoperative period and three follow-up visits of the patient up to the 6th month were uneventful. The diagnosis of imperforate hymen can be missed if a genital examination is not performed in adolescent girls presenting to emergency departments with urinary difficulty. The purpose of this paper is to increase awareness among emergency physicians about the probability of imperforate hymen while examining adolescent girls with urinary retention and intermittent lower abdominal pain.
Some of the malformations affecting the female genital system are discovered too late and these may have serious repercussions on the subsequent genital activity of the adult woman. These abnormalities include partial aplasia and, in particular, total or unilateral menstrual retention. Obstructive malformations of this type (diaphragms, segmental atresia, unilateral menstrual retention or retention affecting both sides of the uterus, aplasia, isolated vagina etc...) deserve priority investigation because early correction is the only way of preventing the serious complications to which they may give rise (menstrual reflux, infection, sterility, pelvic endometriosis etc...). Other malformations, less obvious and less "urgent", are also described, but these require treatment only at a later stage.
Although numerous etiologies for endometriosis have been proposed, it is clear that retrograde menstruation and cell-mediated lymphocytotoxicity each play a significant role in the disease's development. A comprehensive theory of pathogenesis of endometriosis holds that development of the disorder depends upon amount of retrograde menstruation and the ability of the immune response to remove the debris. To test this theory, 64 women with mullerian anomalies and intra-abdominal surgery were evaluated for the presence or absence of endometriosis, patency of tubes, hematocolpos or hematometra, and outflow obstruction. Results demonstrated that endometriosis was present in ten of 13 women with functioning endometrium, patent tubes, and outflow obstruction, whereas it could be identified in only 16 of 43 women with no obstruction (77 versus 37%, P less than .01). Similarly, eight of nine women with hematocolpos or hematometra had endometriosis, while only 18 of 47 with functioning endometrium but no hematometra/hematocolpos had it (89 versus 38%, P less than .01). None of the eight women without endometrium had endometriosis. These data support the concept that an increase in retrograde menstruation will increase the likelihood of endometriosis.
Pregnancy success was evaluated in 48 women following surgical correction of a vaginal obstruction due to imperforate hymen (N = 22) or to a complete transverse vaginal septum (N = 26). Pregnancy success was more likely to occur following surgical correction of imperforate hymen (P less than .05). Patients with a complete transverse septum in the middle or upper vagina were less likely to conceive than were patients with a septum in the lower vagina. Prompt diagnosis and surgical correction to drain accumulated blood may preserve preserve fertility possibly through the prevention of endometriosis.
Complete duplication of the uterus and cervix with a unilaterally imperforate vagina must be suspected when a unilateral pelvic mass terminates in a purpuric bulge of the lateral vaginal wall in a young woman with severely progressive dysmenorrhea. Intravenous pyelography will reveal renal agenesis ipsilateral to the imperforate vagina. The prompt and accurate diagnosis of this unusual anomaly should lead to transvaginal drainage of the retained menstrual fluids prior to irreversible damage of the pelvic viscera from chronic cryptomenorrhea.
Imperforate hymen is a rare diagnosis to make in the emergency department and important to treat immediately. Hydronephrosis is a known but rare complication of an imperforate hymen. We present the case of a premenstrual adolescent with an undiagnosed imperforate hymen complaining of increasing abdominal pain. The article discusses the history, physical examination, evaluation, differential diagnosis, ultrasound findings, complications, and prompt surgical treatment necessary.
Congenital imperforate hymen is an external urogenital anomaly that has a small differential diagnosis. With careful antenatal sonographic evaluation of the female perineum, identification of a thin protruding membrane consistent with imperforate hymen can be made. We report a case in which an imperforate hymen was diagnosed in a fetus at 25 weeks' gestation. It appeared as a thin membrane that distended the vagina and spread the labia majora because of retained secretions. An associated renal abnormality was present, representing either a right multicystic dysplastic kidney or cystic dysplasia. Imperforate hymen and hydrocolpos can be diagnosed as early as the second trimester. Because of the additional renal anomaly in this case, it is suggested that the presence of prenatally diagnosed imperforate hymen warrants a careful survey of the remaining fetal anatomy to rule out associated abnormalities. The possibility of a familial occurrence should be considered, and the appropriate history should be obtained.
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.
Pyocolpos is a rare complication of hydrocolpos. Hydrocolpos usually presents during adolescence and is associated with an imperforate hymen. The following is a case of a 3-month-old girl with pyocolpos. Her history was significant for a urinary tract infection (UTI) at 7 weeks of age. The authors believe that her UTI was caused by urinary retention secondary to hydrocolpos. A complete evaluation may have prevented the complication of pyocolpos.
Our purpose was to analyse the reproductive performance of women with obstructed hemivagina after surgical treatment. After laparoscopic exploration of 42 cases (mean age: 18 years), didelphic and complete septate uterus were found in 78 and 22% of cases respectively. Resection of vaginal septum and hemihysterectomy with ipsilateral hemicolpectomy were performed in 88% and 12% of the cases, respectively, between 1970 and 1997. Long-term results were assessed by a questionnaire and obtained for 38 patients (mean years after treatment and range: 6.5; 1–23). Dysmenorrhoea and abdominal pain were resolved in 87% and 100% of the cases, respectively. Nine patients experienced 20 pregnancies (13 living children, four early spontaneous abortions, two early terminations and one ectopic pregnancy). Nine offspring (69% of live births) were delivered after 37 weeks. Four patients had four pregnancies ipsilateral to blind hemivagina after vaginal septum resection (two living children, one early spontaneous abortion and one ectopic pregnancy). These results suggest that laparoscopic exploration and resection of vaginal septum are the appropriate treatments for obstructed hemivagina. Subsequent reproductive performance was comparable to that reported following treatment of the associated uterine malformation.
To review all existing studies of genital anatomy in girls selected for nonabuse, clarify terminology used to describe hymenal morphology and nonspecific findings, and test consensus terminology in the reevaluation of hymenal morphology and nonspecific findings in 147 premenarchal girls selected for nonabuse. Over six months, the authors identified and evaluated 147 premenarchal girls without history of sexual abuse who were referred for gynecological examination. Parents and patients were screened for possible abuse or significant past medical or behavioral history, and each girl was interviewed and then received a complete examination including a genital examination documented by colposcopy with both 35 mm camera and video capabilities. Using established terminology(1) each case was then independently reviewed and hymenal morphology and nonspecific findings documented. The study population consisted of 147 premenarchal girls; 76.9% were Hispanic, 12.3% African-American, and 10.3% Caucasian. Subjects had a mean age of 63 months (+/minus sign 38). Hymenal configurations included: annular (concentric) 53%, crescentic (posterior rim) 29.2%, sleeve-like (redundant) 14.9%, septate 2%, and other (imperforate, cribriform) < 1%. Nonspecific findings included peri-hymenal bands, 91.8%; longitudinal intravaginal ridges, 93.8%; hymenal tags, 3.4%; hymenal bumps/mounds, 34%; linea vestibularis, 19%; ventral hymenal cleft/notch at 12 o'clock in 79% of annular or redundant hymens; ventral cleft/notch not at 12 o'clock, 19%; failure of midline fusion, 0.6%; hymenal opening size > 4 mm, 30.6%; erythema, 48.9%; change in vascularity, 37.4%; labial adhesions, 15.6%; posterior hymenal notch/cleft (partial), 18.3%; posterior notch/cleft (complete), 0%; posterior hymenal concavity or angularity, 29.5%. In addition, each case was assessed for the presence of a thickened (45.5%) or irregular (51.7%) and narrowed (22.4%) hymenal edge. Each case was also reviewed for exposed intravaginal anatomy (93%). The authors concluded that improved techniques and photo documentation have provided examiners with a better understanding of hymenal morphology and that nonspecific genital findings are commonly found in a population of girls selected for nonabuse. A thorough understanding of normal studies and a consistent application of established terminology can prevent the misinterpretation of nonspecific or congenital findings as posttraumatic changes.
To treatment of patients with imperforate hymen without damaging the structure of hymen. Foley catheter was applied to 15 patients with the history of pelvic pain and diagnosed as imperforate hymen in Department of Obstetric and Gynecology, Faculty of Medicine, Selcuk University, between 1 January 1996 and 25 December 2000. After performed oval-centralize closure on imperforate hymen membranes, Foley catheter was inserted through closure of hymen and then balloon of Foley catheter was insufflated 10 cm(3). Catheter was removed after 2 weeks. Mean age of patients was 14.3+/-2.6. After procedure, closure of hymen was open. Hymen was seen annular and intact. Following the patients, closing of the closure of hymen was not seen. After marriage of six patients, hymeneal bleeding and defloration was seen in all of them. Ceftriaxon (Rocephin, Roche, Istanbul) 1g was given to all patients only one dose as prophylactic antibiotheraphy. Any pelvic and vaginal infection were not seen due to this procedure during follow up. This new technique is less invasive than other methods and prevents many social problem by preventing destruction of the architecture of hymen and providing annular-intact hymeneal ring.
To evaluate presenting and long-term clinical consequences in females with obstructing vaginal anomalies. A retrospective study. A university hospital in southern Finland. Twenty-six females with obstructing vaginal malformations. The conditions were classified into transverse vaginal obstruction (transverse septum or imperforate hymen) and longitudinal vaginal obstruction (longitudinal vaginal septum). INTERVENTIOS: 13 out of 16 women with transverse vaginal obstruction underwent incision of the imperforate hymen and three underwent excision of a complete transverse vaginal septum. Ten patients with obstructing hemivagina had incision of the longitudinal vaginal septum. Presenting symptoms and delay in diagnosis, outcome of primary surgical treatment, possible late complaints associated with obstruction, fecundity, perinatal outcome, and presence of other anomalies were studied. The mean followup period in the transverse and longitudinal obstruction group respectively was 13 years (range 1-29) and 16 years (range 1-44). Transverse vaginal obstructions were diagnosed within less than a month from the primary symptoms, while the diagnosis of longitudinal obstruction was delayed for an average of 27 months. Two out of three females with transverse vaginal septum underwent re-operation for vaginal constriction and three out of 10 with longitudinal vaginal septum had re-excision of the septum. All females with longitudinal obstruction had uterine and renal malformations as opposed to those with transverse vaginal obstruction. In the transverse vaginal obstruction group, two out of the six females who had their renal status assessed had double ureters. Dysfunctional uterine bleeding (19% in the transverse and 40% in the longitudinal obstruction group), dyspareunia (30% and 0%) and dysmenorrhea (19% and 20%) were the most common complaints during the followup. No endometriosis was found in the group that underwent a subsequent laparotomy or laparoscopy (18/26). Female infertility was not found in those 14 females who were attempting to conceive. Twenty-five (89%) out of 28 pregnancies ended in delivery, the live birth rate being 82% in the longitudinal and 94% in the transverse obstruction group. Accurate diagnosis together with adequate treatment may reduce the need for re-operations in cases with obstructing vaginal malformations. No specific gynecologic long-term clinical symptoms were identified in obstructing vaginal anomalies.
The aim of this study was to demonstrate the clinical results of postoperative evaluation for a consecutive series of cases of imperforate hymen presenting at a tertiary medical center during an over 14-year period. We retrospectively reviewed the clinical records of 15 patients with imperforate hymen that had undergone hymenectomy between 1987 and 1998. After completing a questionnaire via a telephone interview regarding sexuality, fertility, menstrual problems, micturition and defecation after surgical correction, those patients were persuaded to come back to the hospital for further gynecological surveys during 2002. The mean postoperative follow-up was 8.5 years (range, 4-14 years). The mean age at diagnosis was 13.2 years (range, 11-16). The most common clinical symptom was cryptomenorrhea (15), followed by pelvic pain (11), palpable abdominal mass (9), urinary retention and other voiding problems (8) and problems of defecation (4). None admitted intercourse attempts before. Two patients also had uterine anomalies, but none had urinary tract or bowel anomalies. During the follow-up period, we found that the majority of patients had irregular menstrual cycles and were worried about their future fertility. Six patients suffered from dysmenorrhea; of 11 patients who began having intercourse two later delivered babies, and none complained of sexual dysfunction. After hymenectomy, the women with imperforate hymen were markedly relieved of cryptomenorrhea, and problems of micturition and defecation also greatly improved. Although complaints of irregular menstruation and dysmenorrhea gradually evolved as the center of attention during follow-up, most patients fared well in terms of fertility and sexual function.
Imperforate hymen is the most frequent congenital malformation of the female genital tract; it usually does not show symptoms until puberty. Only rarely, imperforate hymen manifests itself as an abdominal mass detectable in the prenatal period. We describe a rare case of voluminous hydrometrocolpos, antenatally diagnosed and successfully treated immediately after birth.
A history of unexplained low back pain associated with chronic constipation in an adolescent girl of menarchal age or in an obviously postmenarchal girl should make one consider an imperforate hymen with hematocolpos. This is a particular important differential diagnosis in the work-up of an adolescent who denies ever having had menses or sexual activity. The case of a girl with an imperforate hymen presenting with a six-month history of chronic constipation and intermittent low back pain is described.
Imperforate hymen is uncommon, occurring in 0.1 % of newborn females. Non-syndromic familial occurrence of imperforate hymen is extremely rare and has been reported only three times in the English literature. The authors describe two cases in a family across two generations, one presenting with chronic cyclical abdominal pain and the other acutely. There were no other significant reproductive or systemic abnormalities in either case. Imperforate hymen occurs mostly in a sporadic manner, although rare familial cases do occur. Both the recessive and the dominant modes of transmission have been suggested. However, no genetic markers or mutations have been proven as etiological factors. Evaluating all female relatives of the affected patients at an early age can lead to early diagnosis and treatment in an asymptomatic case.
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.
To determine the surgical outcome of 65 women with imperforate hymen treated with a central surgical incision and insertion of a Foley catheter. A prospective study. The study was carried out at Department of Obstetrics and Gynecology, Faculty of Meram Medicine, Selcuk University, between 1 January 1996 and 30 June 2006. A total of 65 women diagnosed as imperforate hymen. A central oval incision was performed to imperforate hymenal membrane, then 16F Foley catheter was protruded and the balloon was insufflated. Catheter was removed after 2 weeks duration. Estrogen cream was prescribed to all women for application onto hymenal structure for 2 weeks. Efficacy of procedure in treatment of imperforate hymen, preserving hymenal structural integrity that is accepted as important for virginity in some societies. After the procedure, hymenal orifice created remained open and intact in all women except two women. Closure of artificially created hymenal orifice in these two women was believed to be related to inappropriate administration of estrogen cream. Subsequent treatment with local estrogen treatment results in the hymenal orifice remaining opened in these two women. We have previously reported the technique in 2002, but now we are able to demonstrate results of our technique in an expanded number of women. This technique is less invasive than other methods and prevents many social problems related to virginity by preventing destruction of the integrity of the hymenal structure and providing an annular-intact hymenal ring.
Acute pelvic pain in women is a routine situation in any emergency unit. The radiologist should know how to explore the patient with regards to the history and clinical findings. Ultrasonography is the primary and sometimes the only necessary imaging tool in the assessment of acute pelvic pain in women. MRI is the preferred technique in pregnant or young women. CT is more valuable for assessing nongynecologic disorders or post-partum and post-operative infections. This article reviews the contribution of each imaging technique in this clinical situation. Emphasis is put on the importance of age and clinical findings in the diagnostic strategy.
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