Case

A previously healthy ten-year-old girl presented to the pediatric emergency department, accompanied by her mother, with two days of lower abdominal pain and urinary frequency and urgency. She reported one episode of dysuria within the last two days. She denied nausea, vomiting, constipation, diarrhea, back or flank pain, fever, decreased PO intake or inability to take PO, chest pain, shortness of breath, fatigue, sore throat, cough, or rhinorrhea. She had no history of urinary tract infection. She had not yet experienced menarche. Neither she nor her mother noted any other complaints.

Vital signs were within normal limits. Physical examination was notable for mild suprapubic and bilateral lower quadrant abdominal tenderness, right greater than left, without rebound or guarding. There was no CVA tenderness. The remainder of the physical exam was unremarkable.

Laboratory evaluation, including a CBC and BMP, were unremarkable. Clean catch urinalysis was also unremarkable, with negative leukocyte esterase and nitrites. Urine pregnancy testing was negative. Abdominal and renal ultrasounds were obtained. The imaging revealed a distended vaginal canal with hypoechoic fluids, thought to represent hematocolpos. The uterus and adnexa were unremarkable. The kidneys were unremarkable, and there was no hydronephrosis.

Given the ultrasound findings, an external genitourinary (GU) examination was performed. This revealed a distended, imperforate hymen overlying a blueish bulging mass at the introitus. Bladder scan after voiding revealed 200cc of urine.

DIAGNOSIS

Hematocolpos

DISCUSSION

Hematocolpos is an uncommon condition, most often due to an imperforate hymen, wherein menstrual blood fills the vagina and is trapped there. The blood typically accumulates over the course of several menstrual cycles, eventually causing distention of the vaginal canal, with associated symptoms.  Hematocolpos typically presents with a variety of symptoms, such as lower abdominal pain, urinary complaints, back pain, and/or constipation. Physical exam reveals a thin membrane overlying a blueish bulging mass at the introitus, which is pathognomonic for the condition. Ultrasound can also be helpful to aid in the diagnosis, which may show a distended, fluid-filled vaginal canal. If the uterus also contains accumulated menstrual blood, the patient may appear to have a large pelvic mass on ultrasound, or a distended, fluid filled uterus. If the uterus is involved, the condition is termed hematometrocolpos (see Figure 1).

As aforementioned, the most common cause of hematocolpos is an imperforate hymen. The hymen is an embryologic remnant that normally perforates during the late stages of embryo development. If it does not, it can present at birth with mucocolpos, with a similar bulging introitus from vaginal secretions due to stimulation by maternal hormones. If not addressed, the mucus and secretions are absorbed over time. In these cases, the imperforate hymen presents in adolescence, most often with lack of menarche and with some degree of hematocolpos. Hematocolpos can also be associated with other anatomic anomalies, including a transverse vaginal septum, vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome), vaginal atresia, or other mullerian abnormalities.

Treatment is surgical hymenotomy. Most patients recover without complications and commence typical menstrual cycles.  

CASE RESOLUTION

Pediatric surgery was consulted, and the patient was admitted to the hospital. The following day, she went to the operating room for a hymenotomy, with evacuation of approximately 500cc of dark red and brown blood and clot. After the surgery, her urinary symptoms and abdominal pain resolved. She was discharged the same day as the surgery in good condition and instructed to follow up with her pediatrician.

TAKE-AWAYS

• Hematocolpos can present with a variety of symptoms, including abdominal or back pain, urinary symptoms, and constipation.

• The diagnosis can be made on history and physical examination, along with ultrasound.

• It is important to maintain a high intext of suspicion for this condition, and to consider GU examination in any patient with lower abdominal pain or urinary complaints.

Author: Alexandra Pusateri, MD, is a current third-year resident at Brown Emergency Medicine Residency.

 Faculty Reviewer: Michelle Myles, MD, is assistant professor and clinician educator at Brown Emergency Medicine.

REFERENCES

Dickson C, Saad S, Tesar JD. Imperforate hymen with hematocolpos. Annals of Emergency Medicine. Published online May 1, 1985. doi:https://doi.org/10.1016/s0196-0644 (85)80 293-6

Marino G, Alfieri N, Tessitore IV, Barba M, Manodoro S, Frigerio M. Hematocolpos due to imperforate hymen: a case report and literature systematic review. International Urogynecology Journal. Published online June 17, 2022. doi:https://doi.org/10.1007/s 00192-022-05270-x

Kotter H, Weingrow D, Canders C. Hematometrocolpos in a Pubescent Girl with Abdominal Pain. Clinical Practice and Cases in Emergency Medicine. 2017;1(3):218-220. doi:https: // doi.org/10.5811/cpcem.2017.3.33369

Pfeifer SM, Attaran M, Goldstein J, et al. ASRM müllerian anomalies classification 2021. Fertility and Sterility. 2021;116(5):1238-1252. doi:https://doi.org/10.1 016/j.fertnster t.2021 .09.025