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 Table of Contents  
CASE SERIES
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 216-218

A case series on imperforate hymen causing hematometra and hematocolpos with unusual presentations


1 Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India
2 Department of Radio-Diagnosis, Dr. Ulhas Patil Medical College, Jalgaon, Maharashtra, India

Date of Submission29-Mar-2021
Date of Decision30-Mar-2021
Date of Acceptance31-Mar-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Rohan Kumar Singh
Department of Radio-diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_130_21

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  Abstract 


Obstruction of the uterine or vaginal outlet causes hematometra or hematocolpos. The uterine or the vaginal cavity is distended with blood and its products causing abdominal pain, obstructive symptoms, and discomfort in adolescent patients. A proper diagnosis aids inadequate management through various surgical techniques and not only prevents any further complications but also preserves fertility in such individuals. In this article, we are presenting three cases of hematometra and hematocolpos, discussing their clinical presentations and imaging findings.

Keywords: Abdominal pain, amenorrhea in adolescent, hematocolpos, hematometra, imperforate hymen, magnetic resonance imaging


How to cite this article:
Patwa PA, Rathi R, Chaudhary K, Charan A, Singh RK, Mishra GV. A case series on imperforate hymen causing hematometra and hematocolpos with unusual presentations. J Datta Meghe Inst Med Sci Univ 2021;16:216-8

How to cite this URL:
Patwa PA, Rathi R, Chaudhary K, Charan A, Singh RK, Mishra GV. A case series on imperforate hymen causing hematometra and hematocolpos with unusual presentations. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 23];16:216-8. Available from: http://www.journaldmims.com/text.asp?2021/16/1/216/322594




  Introduction Top


Hematocolpos is the condition that results due to imperforate hymen where the vaginal cavity is distended with menstrual blood. Similarly, hematometra occurs due to obstruction to the uterine outflow like vaginal septum. Imperforate hymen is often sporadic in nature, although some familial cases have been reported in the literature. If there are variations in the anatomy of hymen, it remains undetected till menarche and presentation are of primary amenorrhea and abdominal pain of cyclic origin.[1],[2] The condition can also be diagnosed on physical examination when a bulging bluish membrane showing transillumination is noted at the introitus. Diagnosis is made when an adolescent girl comes with complaints of primary amenorrhea and intermittent or cyclical symptoms of pain in the abdomen, retention of urine. Imaging plays an important role in the diagnosis. Ultrasound is the preliminary modality where fluid or blood distended cavity is seen in posterior to the urinary bladder and in the vagina (hematocolpos) or in the uterus (hematometra). Cross-sectional imaging such as computed tomography scan and magnetic resonance imaging (MRI) is a higher modality and not just confirms the diagnosis but also can visualize the anatomy better. The treatment is done by hymenectomy procedure by creating an orifice for the flow of the menstrual blood.


  Case Reports Top


Case 1

A 13-year-old adolescent girl came to the emergency room with a history of a sudden onset urinary retention. She had intermittent complaints of lower abdominal pain of cramping type, dysuria, frequency, and urgency for which she was prescribed oral antibiotics; however, it did not prove to be effective. There was a history of primary amenorrhea and lower abdominal pain on cyclical type with large lower abdominal mass in the past 6 months but the patient did not give any history of having her menses started. The bladder was catheterized, which led to the relief of her symptoms and the passage of 450–500 mL urine. Urine examination showed a normal result. On palpation, there was a globular mass pelvis. On gynecological examination, an oval bluish-colored bulge was seen distal to the urethral opening. A clinical diagnosis of imperforate hymen with pelvic mass was made. Further assessment, she was done with ultrasound and MRI. On ultrasonography (USG), the kidneys showed hydronephrosis due to backpressure from the over distended bladder and a fluid-filled lesion was noted posterior to the bladder not separate from the uterus consistent with the findings of hematocolpos and hematometra with internal echoes. Following the ultrasound findings, she was referred to the gynecology department and underwent an MRI scan. On MRI, a 12.1 cm × 8.1 cm × 6 cm fluid-filled mass was noted lying in the pelvis and consisted of blood products. Superiorly, the fluid-filled mass was in continuation with the uterine cavity, and inferiorly, there was extension till the perineum. The MRI was consistent with a largely distended uterine cavity filled with menstrual blood products. On T1-weighted images (T1WI), hyperintense signal intensity mass extending down to the level of the hymen and on T2-weighted images (T2WI) hypointense endometrial fluid extending down to the level of the hymen was noted. A diagnosis of hematometra and hematocolpos was made [Figure 1].
Figure 1: (a) Sagittal T2-weighted images and (b) axial T2-weighted images: Shows hypointense fluid collection posterior to the bladder (green arrow) distended both the uterine cavity (red arrow) and vaginal cavity (blue arrow) extending till hymen

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Case 2

A 15-year-old girl came to the Gynecology Department with a history of amenorrhea. Six months back, she presented with a history of primary amenorrhea and abdominal pain. She gave no history of the beginning of her menses and there was no history of menarche. A diagnosis of the imperforate hymen was made after thorough imaging examination and she underwent hymenectomy for the same. Postsurgery her menses were regular for 4 months and she experienced symptoms of minor pain in the abdomen during this time. Now, the patient revisited the hospital with a complaint of amenorrhea for 2 months with abdomen discomfort and cyclic pain around the time of her menstrual cycles. Considering her previous history MRI was suggested. On MRI, there was distention of the vagina measuring 6.2 cm × 4.4 cm × 6.1 cm and filled with fluid appearing is to hyperintense on T2WI and hyperintense on T1WI. The uterus was displaced anterosuperiorly and urinary bladder anteriorly [Figure 2].
Figure 2: (a) Sagittal T2-weighted images and (b) T1-weighted images: Shows heterogeneous fluid-filled vaginal cavity (blue arrow) posterior to the bladder (green arrow) and superiorly, the uterine cavity (red arrow) appeared normal

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Case 3

A 16-year-old female patient came to the gynecology Outpatient Department (OPD) with complaints of primary amenorrhea and cyclic pain and discomfort in the abdomen. She gave no history of menarche in the previous 6 months. A thorough gynecological examination was performed where a bulging membranous structure was visualized, transillumination was positive and imperforate hymen was thought to be the reason for her complaints. An USG was performed which not just confirmed the diagnosis revealing a distended vaginal cavity, there was also evidence of a distended uterine cavity was a short segment narrowing at the lower end of the uterus. Further, MRI was performed which showed the presence of grossly dilated endometrial cavity measuring 3.8 cm × 3.2 cm × 3.1 cm and upper part of the vagina 5.4 cm × 4.5 cm × 4 cm showing signal intensity of fluid-filled with blood products appearing heterogeneously hyperintense on T1WI and T2WI suggesting the diagnosis of hematometra and hematocolpos. Few cysts were noted at the mid-vaginal level [Figure 3].
Figure 3: (a and b) Sagittal T2-weighted images and (c) coronal T2-weighted images: Shows uterine cavity (red arrow in and blue arrow in c) and the vaginal cavity (yellow arrow in b and maroon arrow in c) filled with hyperintense fluid collection consistent with blood products and a small narrowing below the uterus. Coronal images show the cystic cavity in vagina (green arrow)

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  Discussion Top


The hymen is a thin mucous membrane fold that stretches across the external vaginal opening. It partially or completely covers the external vaginal orifice and is located at the junction between the urogenital sinus and the sinovaginal bulb. There is a partial rupture in the hymen which occurs naturally during the 8th week of gestation at the inferior end, forming a patent connection between the vaginal lumen and exterior outlet. If there is complete failure of recanalization of this membranous vestige, imperforate hymen results. [1],[3],[4] Although the function of the hymen is not yet clear it is thought to be a physical barrier. During the prepubertal period, the vaginal mucosa is not completely developed and hymen gives protection from infection during this period.[3],[4] It is a common congenital abnormality of the female tract. The prevalence of this condition is 1 in 2000 cases and the girl presents at adolescent age or just after menarche is attained with pain in the abdomen and amenorrhea. These patients remain asymptomatic till menarche.[1] The common clinical manifestation of imperforate hymen is noted in adolescent girls and the common complaints as mentioned are abdominal pain and amenorrhea. Apart from this, other presentation complaints could be acute retention of urine due to overdistention of the vaginal cavity with menstrual blood or abdominal distention. On examination, imperforate hymen appears as a bluish bulging membrane showing transillumination at the introitus. A detailed gynecological history plays a key role in predicting the condition or examination while inserting Foley's catheter. The diagnosis is made then on abdominal USG by a radiologist. USG is an initial modality of choice and MRI is the gold standard. On ultrasound, there is a large blood-filled heterogeneous mass seen posterior to the bladder showing internal echoes which are seen filling the vaginal or uterine cavity. On MRI, blood signal intensity mass showing hyperintensity on T1WI and hypointensity on T2WI is seen in the vagina or uterus posterior to the bladder which shows fluid intensity. On MRI, we can also see the connection of the fluid-filled cavity to the obstructed lumen.[5] Once the diagnosis is made, management is planned to form an outflow tract for the passage of blood and its products. An opening is created for the vaginal tract outside by surgical hymenectomy which is performed under anesthesia. Various incisions are taken on the membranous hymen to create an outflow tract namely, T-shaped, simple vertical, cruciform, X-shaped, and cyclical. The X-shaped incision has shown to have the least risk of injury to the urethra.[6] It is of utmost importance to closely follow-up the patient after this surgery because few patients have recurrence or the symptoms persists. There can be abnormal menstruation or problems in micturition and defecation even after adequate surgical hymenectomy. [7],[8]


  Conclusion Top


Hematocolpometra a result of imperforate hymen is an unusual congenital anomaly which presents at prepubertal age with a history of noninitiation of menstruation and monthly abdominal pain. A thorough examination and a detailed history give a clue to the diagnosis. Imaging is important for confirmation of the same. Ultrasound is initial imaging and MRI is the gold standard. MRI not only confirms the diagnosis but also helps to rule out any associated genitourinary malformation and plan its management. A simple procedure called hymenotomy is carried out which causes the drainage of the collection and is the treatment of choice. Surgical treatment can prevent the complications of this disorder and preserve fertility in later stages of life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Walker DK, Salibian RA, Salibian AD, Belen KM, Palmer SL. Overlooked diseases of the vagina: A directed anatomic-pathologic approach for imaging assessment. Radiographics 2011;31:1583-98.  Back to cited text no. 1
    
2.
Salhan B, Omisore OT, Kumar P, Potter J. A rare presentation of imperforate hymen: A case report. Case Rep Urol 2013;2013:731019.  Back to cited text no. 2
    
3.
Messina M, Severi FM, Bocchi C, Ferrucci E, Di Maggio G, Petraglia F. Voluminous perinatal mass: A case of congenital hydrometrocolpos. J Matern Fetal Neonatal Med 2004;15:135-7.  Back to cited text no. 3
    
4.
Basaran M, Usal D, Aydemir C. Hymen sparing surgery for imperforate hymen: Case reports and review of literature. J Pediatr Adolesc Gynecol 2009;22:e61-4.  Back to cited text no. 4
    
5.
Chouhan M, Rachhoya P. Imperforated hymen with huge abdominal mass – A rare case. Int J Health Sci Res 2016;6:546-8.  Back to cited text no. 5
    
6.
Ercan CM, Karasahin KE, Alanbay I, Ulubay M, Baser I. Imperforate hymen causing hematocolpos and acute urinary retention in an adolescent girl. Taiwan J Obstet Gynecol 2011;50:118-20.  Back to cited text no. 6
    
7.
Liang CC, Chang SD, Soong YK. Long-term follow-up of women who underwent surgical correction for imperforate hymen. Arch Gynecol Obstet 2003;269:5-8.  Back to cited text no. 7
    
8.
Mou JW, Tang PM, Chan KW, Tam YH, Lee KH. Imperforate hymen: Cause of lower abdominal pain in teenage girls. Singapore Med J 2009;50:e378-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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