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.

Hydrometrocolpos: a Contemporary Review of the Last 5 Years.

PURPOSE OF REVIEW: The goal of this review is to provide a comprehensive overview of hydrometrocolpos, covering disease etiology, pathophysiology, clinical presentation, and diagnostic and management techniques, and known outcomes. RECENT FINDINGS: This narrative review presents the literature on hydrometrocolpos in the pediatric population from the past 5 years. We highlight the 69 reported cases of hydrometrocolpos and classify them based on type of obstruction or associated anomaly, discuss new diagnostic algorithms based on imaging, and present novel and underutilized surgical techniques for definitive management. Hydrometrocolpos, a condition characterized by retained fluid causing a distended vagina and uterus in the setting of a distal vaginal outflow obstruction, has a wide range of presentation severity based on the type of obstruction. Whether hydrometrocolpos is due to an isolated condition like imperforate hymen, a complex abnormality like cloacal malformation, or a part of a large congenital syndrome, the mainstay of treatment is decompression of the dilated vagina and surgical correction of the outflow obstruction. Imaging-based diagnostic algorithms and new treatment techniques reported in the literature, as well as longitudinal and patient-reported outcome research, can improve the lives of children affected by this condition.

Fetal hydrometrocolpos: Challenges of prenatal differential diagnosis on ultrasound.

Hydrometrocolpos is a pelvic cystic mass representing the distension of the vagina and uterus due to a lower genital tract obstruction causing accumulation of utero-cervical-vaginal secretions or urine in the vagina and endometrial cavity. Prenatal diagnosis is uncommon and differential diagnosis of the underlying etiologies is quite challenging in the prenatal period. We present three cases of female fetuses with hydrometrocolpos and discuss the prenatal differential diagnoses in the light of ultrasound findings along with postnatal diagnoses and outcomes.

A Female Infant with Rectovestibular Fistula and Imperforate Hymen.

In a female neonate with anorectal malformation (ARM), the diagnosis is usually simple. But when there are two openings in the introitus and absent anal opening at the normal site, the scenario poses a diagnostic challenge. Careful and detailed evaluation of anomaly is therefore necessary before planning definitive correction. Imperforate hymen, although is not commonly associated with ARM should always be kept in mind as a differential diagnosis and other vaginal anomalies like Mayer-Rokitansky-Küster-Hauser syndrome should be ruled out before definitive surgical correction.

Characteristics of fetal physiological and pathological uterine effusion observed on prenatal ultrasonography: a case report.

BACKGROUND: The prenatal detection rate of fetal uterine effusion is very low, and current case reports mainly focus on pathological hydrometrocolpos. We presented two cases of fetal physiological uterine effusion with different ultrasonic characteristics and compared them with one case of hydrometrocolpos with the hope of identifying strategies to reduce misdiagnosis of fetal uterine effusion. CASE PRESENTATION: This paper reports the cases of two female fetuses with abnormal pelvic echoes in the third trimester, referred to a tertiary center to be screened for suspected pelvic teratoma and cystic mass, respectively. Ultrasound consultation revealed fetal uterine effusion. The two fetuses were delivered at our hospital after a full term. Re-examining the uterus and adnexa of the neonates revealed that the uterine effusion had subsided naturally. Another female fetus had a large cystic mass in the pelvic cavity in the third trimester, and prenatal examination indicated fetal hydrometrocolpos. The fetus was delivered at our hospital after a full term. The hydrometrocolpos existed even after birth. After consultation with a neonatal surgeon and gynecologist, the newborn was diagnosed with congenital imperforate hymen with hydrometrocolpos. Hymen puncture and open drainage led to a good prognosis. CONCLUSIONS: Prenatal ultrasonography plays an important role in diagnosing and differentiating between physiological and pathological fetal uterine effusion. It can help reduce misdiagnoses that can lead to incorrect clinical decisions.

Acute Urinary Retention due to Haematometrocolpos from Imperforate Hymen in a Pubescent Nigerian Girl.

BACKGROUND: Cryptomenorrhoea is an uncommon gynaecological condition in the adolescent age group. While cyclical abdominal pain is the usual clinical symptom, patients with atypical presentation require a high index of suspicion and meticulous evaluation. OBJECTIVE: This case report describes atypical presentation of haematometrocolpos in a pubescent Nigerian female. METHODS: A case of acute urinary retention in an adolescent girl, due to haematometrocolpos, is presented. A 13-year-old supposedly premenarcheal girl presented at the Children Emergency Unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria with acute urinary retention of twelve hours' duration. There was no preceding history of difficulty with voiding. About 1,200mls of urine was drained from the bladder with a self-retaining catheter. Examination revealed an 18-week-sized cystic abdomino-pelvic mass, and the vagina was closed with a bulging membrane at the introitus. Abdomino-pelvic ultrasonography revealed a distended uterus containing fluid with low level echo, typifying the ground-glass appearance. Trans-hymenal ultrasonography using a 2.5-7.5MHz endocavitary probe confirmed a ballooned-out vagina with similar content, with a 2mm thick hymen at the distal end. RESULTS: Hymenectomy was performed with spontaneous drainage of the menstruum. She was discharged after successful trial of voiding without catheter. CONCLUSION: Though uncommon, haematometrocolpos from lower genital obstruction should be considered as a differential diagnosis of lower urinary tract obstruction in pubescent girls. Trans-hymenal ultrasonography is accessible and accurate for assessing the level of obstruction and the thickness of the intervening tissue.

CONTEXTE: La cryptoménorrhée est une affection gynécologique rare dans le groupe d'âge des adolescents. Alors que la douleur abdominale cyclique est le symptôme clinique habituel, les patients présentant une présentation atypique nécessitent un indice de suspicion élevé et une évaluation méticuleuse. OBJECTIF: Ce rapport de cas décrit la présentation atypique de l'hématométrocolpos chez une femme nigériane pubère. MÉTHODES: Un cas de rétention urinaire aiguë chez une adolescente, due à un hématométrocolpos, est présenté. Une fillette de 13 ans prétendument prémenarchique s'est présentée à l'unité d'urgence pour enfants du complexe hospitalier universitaire Obafemi Awolowo, à Ile-Ife, au Nigéria, avec une rétention urinaire aiguë d'une durée de douze heures. Il n'y avait pas d'antécédents antérieurs de difficulté à la miction. Environ 1 200 ml d'urine ont été drainés de la vessie à l'aide d'un cathéter autobloquant. L'examen a révélé une masse kystique abdomino-pelvienne d'une taille de 18 semaines, et le vagin était fermé avec une membrane bombée à l'introït. L'échographie abdomino-pelvienne a révélé un utérus distendu contenant du liquide avec un écho de faible niveau, caractérisant l'aspect en verre dépoli. L'échographie trans-hyménale utilisant une sonde endocavitaire de 2,5 à 7,5 MHz a confirmé un vagin gonflé avec un contenu similaire, avec un hymen de 2 mm d'épaisseur à l'extrémité distale. RÉSULTATS: L'hyménectomie a été réalisée avec drainage spontané des menstrues. Elle a obtenu son congé après un essai réussi de miction sans cathéter. CONCLUSION: Bien que rare, l'hématométrocolpos d'une obstruction génitale inférieure doit être considéré comme un diagnostic différentiel de l'obstruction des voies urinaires inférieures chez les filles pubères. L'échographie trans-hyménale est accessible et précise pour évaluer le niveau d'obstruction et l'épaisseur du tissu intermédiaire. Mots clés: Rétention urinaire aiguë, cryptoménorrhée, hématométrocolpos, imperforation de l'hymen, adolescente avant la ménarche, scintigraphie trans-hyménale.

Recurrent formation of haematocolpos in a young girl with multiple congenital anomalies of the urogenital tract.

An 11-year-old girl, a known case of left crossed fused renal ectopia and sacral hypoplasia presented to the gynaecological OPD in Karachi, Pakistan, in February 2019 with complaints of abdominal pain. On examination, she was found to have a septum covering her vaginal orifice. She was subsequently diagnosed with haematocolpos secondary to imperforate hymen. Incision and drainage was done. However, despite surgical management, she continued to have recurrent formation of haematocolpos for the next two months secondary to multiple complete and partial transverse vaginal septa and post-operative formation of adhesions. Definitive management was done with ultrasound guided needle puncture and drainage, followed by post-operative tampon use to maintain patency.

Acute urinary retention in two adolescent girls with imperforate hymen.

Acute urinary retention is rare symptom in young adolescent girls. Imperforate hymen can be a cause of acute urinary retention possibly due to the pressure effect of the distended vagina (hematocolpos) on the lower urinary tract. However, the mechanism of progression to urinary retention is unknown. We report on two cases of adolescent girls with imperforate hymen who presented with acute urinary retention. A series of volume tolerance tests of the urinary bladder and urodynamic studies before operation revealed highly elevated urethral resistance, which was induced by interaction of large amount of urinary volume in the bladder and the large size of hematocolpos. After operation, urinary retention could not be observed and the urethral pressure returned to normal.

Imperforate Hymen Causing Hematocolpos and Urinary Retention.

BACKGROUND: Acute urinary retention is rare in the pediatric population and is typically caused by an obstructing entity. It may result from hematocolpos caused by imperforate hymen. Imperforate hymen is rare, with an associated incidence of 1 in 2000 people. Nonetheless, in a pediatric age female who presents with urinary retention and who has a history of primary amenorrhea or a history of cyclical pelvic pain an examination of the external genitalia should be performed to rule out this condition. CASE REPORT: A 12-year-old girl presented to the emergency department with urinary retention and was discharged with a diagnosis of urinary tract infection. She returned the following day to the emergency department with worsening abdominal pain. A computed tomography scan revealed a fluid-filled vagina measuring 12.5 cm. Her bladder measured 15.4 cm. The patient was taken to the operating room for further evaluation by the consulting gynecologist. At the time of surgery, 1000 mL of urine were evacuated after catheterization. Three hundred milliliters of chocolate-colored fluid, consistent with menstrual blood, were evacuated at time of hymenotomy. Hymenotomy was performed with a cruciate incision. No complications were encountered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To date, there have been >40 reported cases of imperforate hymen causing hematocolpos and subsequent urinary retention. However, given the rarity of imperforate hymen, hematocolpos leading to acute urinary retention can still be missed. Untreated urinary retention can lead to a compromise in bladder function and subsequent kidney damage.

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.

Hydrometrocolpos etiology and management: past beckons the present.

Hydrometrocolpos is a rare condition in which the uterus and the vagina are grossly distended with a retained fluid other than pus or blood. It may present during the neonatal period or later at puberty. Most cases reported earlier were stillbirths and were diagnosed only on autopsy. Antenatal diagnosis is now possible with the advent of ultrasound. An early diagnosis and speedy management is the key to survival. Many previous case reports have focused on the varied clinical presentations, multiple causes, associated syndromes and/or the radiological diagnosis of this condition. However, management options for different types of hydrometrocolpos have not yet been concisely discussed. We have reviewed the literature and tried to summarize the management options applicable to most case scenarios of hydrometrocolpos.

Fetal hydrometrocolpos and congenital imperforate hymen: Prenatal and postnatal imaging features.

Congenital imperforate hymen is probably the most common obstructive anomaly of the female reproductive tract. The accumulation of fluid in the genital tract leads to a distended uterus and vagina, causing hydrometrocolpos. Prenatal diagnosis of fetal hydrometrocolpos is uncommon, with only 22 cases reported in the literature and only a few cases of prenatal imaging of this condition available to date. The main ultrasound finding is a fetal pelvic mass posterior to the bladder and anterior to the rectum. We present the case of a 37-week female fetus with a fetal pelvic mass detected in a routine obstetric ultrasound examination, and the correlation between the prenatal and postnatal findings.

The interdigitating Y-plasty procedure for the correction of transverse vaginal septa.

Transverse vaginal septa are rare congenital abnormalities of the female genital tract, the surgical management of which is hardly described in the literature. While thicker septa might require complex reconstructive surgery, this paper proposes a simple technique for the surgical management of thin septa, utilising two interdigitating Y-plasties, without the need for excision of any septal tissue. The authors also present their series of eight consecutive cases where this technique was used, with no major complications or any cases of vaginal re-stenosis. This technique can also be used in imperforate hymen correction, therefore it might also be of interest to the general gynaecologist. TWEETABLE ABSTRACT: Interdigitating Y-plasties in transverse vaginal septa: presentation of a new technique.

Microperforate hymen presenting with incomplete abortion: A case report.

A 20-year-old patient with 3 months of amenorrhea presented in the labor room with bleeding per vaginum and having experienced lower abdominal pain for 2 h. She had a history of difficult intercourse and prolonged menstrual flow. Inspection revealed a bleeding point over an obstructing membrane at the level of the vaginal introitus. Subsequent vaginal examination confirmed the diagnosis of microperforate hymen. Her urine pregnancy test was positive and an ultrasound examination revealed the presence of retained products of conception in the endometrial cavity. Hymenectomy was carried out to evacuate the retained products of conception and the margins of the hymen were sutured to prevent restenosis. The outcome was uneventful. This case study suggests that even though subocclusive hymenal anomalies, such as microperforate hymen, can interfere with normal vaginal intercourse, it does not lead to infertility and can permit pregnancy. Hence, awareness about this rare entity may lead to early detection and improvement in the patient's quality of life.

Hematometrocolpos Disguised as Abdominal Pain.

BACKGROUND: Hematometrocolpos caused by an imperforate hymen is a common form of vaginal outflow obstruction. This is a rare pediatric anomaly that can present with atypical or vague symptomatology, such as abdominal pain or constipation or urinary retention in the setting of amenorrhea. It is essential to obtain a gynecologic history and inquire about menstrual cycles to properly evaluate a young female with such a common complaint as abdominal pain. Failure to perform a gynecologic examination in the emergency department setting may delay diagnosis and appropriate care for this rare condition, which can lead to serious complications. CASE REPORT: This case describes a 12-year-old female who presented to the emergency department with a complaint of abdominal pain and urinary symptoms. Because of the severity of the patient's pain on abdominal examination, we obtained a computed tomography scan of her abdomen and pelvis, which showed findings consistent with hematometrocolpos. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Obstruction of the female genital outflow tract is a rare occurrence. Because abdominal pain is such a common complaint, not only in the pediatric emergency department but also in the outpatient setting, the diagnosis of hematometrocolpos may easily go undiagnosed for months or even years. Obtaining a complete gynecologic history is key when evaluating young females with abdominal pain or urinary retention. Early detection and timely management can prevent serious complications and long-term sequelae. This patient had a successful outcome and early surgical management of her hematometrocolpos which was caused by an imperforate hymen.

Imperforate Hymen: Varied Presentation, New Associations, and Management.

AIM: Imperforate hymen is an isolated and sporadic event. The aim of this study was to report varied clinical and management problems of consecutive imperforate hymen in children and to compare the genetic review with literature. MATERIALS AND METHODS: This is a retrospective analysis of eight consecutive imperforate hymen children admitted during 2010-2015. RESULTS: Among eight girls, two were infants and six were in the adolescent group. Clinical presentations included varied degree of genitourinary obstruction (7) and incidental finding (1). Genetic analysis of imperforate hymen suggested sporadic event (5), associations (2), and syndromic (1). Ultrasound and magnetic resonance imaging revealed the level of obstruction. Hymenectomy was done in neonate (1), adolescent (6), and one has been under observation. Abdominoperineal pull-through was done in concomitant proximal vaginal atresia. CONCLUSIONS: Hymen development origin is variable and complex. Imperforate hymen is rarely a part of systemic/genetic anomaly. Genital examination at birth or during puberty is mandatory which often guides the timing of hymenectomy and prevents the sequelae of imperforate hymen. Hymenectomy is ideal during puberty and resolves all genitourinary obstructions.

Imperforate hymen presenting as vaginal cyst in a 16-month-old child - considerations for an early diagnosis.

Imperforate hymen is a congenital anomaly of female external genitalia, which is mostly diagnosed in puberty, at the age of 9-13 years, or very rarely at a younger age. Clinical picture varies from abdominal pain and low back pain to acute urinary retention. We describe a case of a 16-month-old female infant where the imperforate hymen presented as a vaginal cyst. The cyst was first observed by the patient's mother, although the child had been examined by a paediatrician on several occasions after birth. Complete workup performed for differential diagnosis, mostly to exclude other reproductive system anomalies, led to the final diagnosis of imperforate hymen. The aim of this report is to emphasise the necessity of thorough examination of genitalia in female newborns in order to avoid possible complications associated with this diagnosis later in life, as well as other, more severe differential diagnostic anomalies.