Imperforate Hymen Presenting with Massive Hematometra and Hematocolpos: A Case Report

Abstract

Background Imperforate hymen is a rare congenital malformation of the vagina. The incidence rates vary from 1 in 1000 to 1 in 10,000 females [1]. It occurs when the sinovaginal bulb fails to canalize with the rest of the vagina. The occurrence is sporadic, and typically presents at puberty with delayed menarche, cyclic lower abdominal pain and mass, and bulging vaginal membrane at the vaginal introitus that are secondary to the accumulation of menstrual blood as hematocolpos and hematometra above the imperforate hymen [2]. Other reported bizarre modes of presentations of the complications of untreated imperforate hymen include pelvic infection with tubo-ovarian abscess, obstructive acute renal failure, non-urological urine retention, hematosalpinx, peritonitis, endometriosis, mucometrocolpos, constipation, and recurrent urinary tract infection [3-6]. Clinicians should have high index of suspicision of imperforate hymen for them to make early diagnosis of these bizarre and challenging modes of presentations of the complications of untreated imperforate hymen. The diagnosis of an imperforate hymen can be made by the absence of the track of mucus at the posterior commissure of the labia majora in newborns or by visualization of the bulging hymen after puberty [4-6]. Transabdominal and transrectal ultrasounds can also assist in confirming the diagnosis of imperforate hymen [7]. Antenatal ultrasound can also detect the bulging imperforate hymen due to the accumulation of hydrocolpos or mucocolpos in the female fetus that occurred in response to maternal oestrogens. The differential diagnoses of imperforate hymen include vaginal septum, vaginal agenesis, vaginal cyst, ectopic ureter with ureterocele, hymenal cyst and periurethral cyst. The definite management of imperforate hymen is surgical excision of the hymen from the base (hymenecotomy) and evacuation of the accumulated menstrual blood from the vagina and the uterus. Only the central portion of the hymen can be excised as hymenotomy when there is the desire to preserve virginity. [2,8] The timing of surgical intervention is controversial. Surgery is always indicated when imperforate hymen becomes symptomatic we report the case of an imperforate hymen who presented late with delayed menarche, massive hematocolpos and hematometra. Case Report Miss UG is a 15-year-old girl who was referred to the gynecologic clinic of Enugu State University Teaching Hospital on account of eight-month history of cyclic abdominal pain, delayed menarche, and a three-week history of lower abdominal swelling. She admitted to occasional episodes of constipation and urinary retention. Her secondary sexual characteristics were normal for the age (Tanner stage III). A 20 cm-sized suprapubic, tender, cystic, and dull to percussion mass was found on abdominal examination. Perineal examination revealed a bulging pinkish imperforate hymen (Figure 1). Transabdominal ultrasound revealed a grossly dilated uterine cavity, and vagina that were containing 811.8 cm 3 of fluid with low level echoes. The urinary bladder was compressed by the fluid. The kidneys, ureters, uterus and ovaries were normal. The full blood count, serum urea, electrolyte and creatinine were also normal. The patient and her mother were counseled on the surgical treatment options and the possibility of loss of virginity during the surgery. They gave consent to the surgery that may preserve virginity. She had hymenotomy under general anesthesia on 31/8/2015. Over 1000 mls of coffee-colored menstrual blood was evacuated (Figures 2 and 3). The urethra was catheterized to avoid its iatrogenic damage before about 1.5 cm cruciate incisions were Abstract Background: Imperforate hymen is the commonest congenital anomaly that causes closure of the vagina. Ideally, diagnosis should be made early during fetal and neonatal examinations to prevent symptomatic presentations of its complications at puberty.