T h e new england journal o f medicine images in clinical medicine Imperforate Hymen with Hematocolpometra A B 15-year-old premenarchal girl presented with a 4-day history Ludger Wilhelm Poll, M.D. of increasing abdominal pain. Her medical history was unremarkable, and she Peter Flake, M.D. reported that she had never been sexually active. Physical examination revealed A Berufsgenossenschaftliche Unfallklinik a palpable, nontender, nonpulsatile midline mass extending from the pelvis to the Duisburg umbilicus. The patient declined a vaginal examination. Abdominal ultrasonography Duisburg, Germany revealed a large pelvic mass of uncertain origin. The uterus could not be identified [email protected] ultrasonographically. Computed tomographic images of the pelvis showed a hyper- dense, nonenhancing, fluid-filled pelvic mass measuring 25 cm by 11 cm by 12 cm (Panel A, axial image, white arrows; Panel B, sagittal image, white arrows) that was causing substantial compression of the bladder (Panels A and B, black arrows). A tubular structure at the superior pole of the mass was identified as the uterus (Panel B, arrowhead). The patient was given a presumptive diagnosis of hematocol- pometra (accumulation of menstrual blood in the vagina and uterus). Subsequent vaginal examination revealed a thickened imperforate hymen. After hymenotomy, two liters of coagulated blood drained from the vagina and uterus. The patient was discharged after 3 days without pain or vaginal bleeding. Copyright © 2011 Massachusetts Medical Society. n engl j med 365;2 nejm.org july 14, 2011 157 The New England Journal of Medicine Downloaded from nejm.org on June 18, 2015. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved. Hindawi Publishing Corporation Case Reports in Urology Volume 2013, Article ID 731019, 3 pages http://dx.doi.org/10.1155/2013/731019 Case Report A Rare Presentation of Imperforate Hymen: A Case Report Beena Salhan, Olufunmilayo Theresa Omisore, Priyadarshi Kumar, and John Potter Northampton General Hospital, Cliftonville, Northampton NN15BD, UK Correspondence should be addressed to Olufunmilayo Theresa Omisore; [email protected] Received 3 July 2013; Accepted 18 August 2013 Academic Editors: S.-S. Chen, N. Eke, and S. K. Hong Copyright © 2013 Beena Salhan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Acute urinary retention in a child is rare. Haematocolpos can cause a mechanical obstruction, resulting in acute urinary retention. Case Report. A 12-year-old girl presented to the surgical department with a one-day history of acute urinary retention and suprapubic tenderness. She had not started menses but had described period-like pains every month for the past six months. On examination, she had a palpable bladder with over 500 mls of residual urine and a bluish-grey bulge posterior to her urethral meatus. An US scan showed a large mass posterior to her bladder resembling a haematocolpos, and this was confirmed with an MRI scan. She was catheterised and eventually underwent a hymenectomy using a cruciate incision. She made a good recovery postoperatively. Conclusion. In the case of a peripubertal female presenting with acute urinary retention, haematocolpos should be considered as a diagnosis. 1. Introduction palpable and she was noted to have a nontender bluish-grey bulge posterior to the urethra on examination of her external Thisisacasereportofacuteurinaryretentionasa genitalia. Neurological examination was normal. result of an imperforate hymen causing haematocolpos. Urine dipstick was normal, and a urinary pregnancy test The incidence of imperforate hymen is 1 in 2000 girls, was negative. A bladder scan revealed over 500 mls of residual and approximately half of these will present with urinary urine; therefore, a 10 Ch urinary catheter was inserted, which retention [1]. Haematocolpos is a rare condition, where the relieved her suprapubic pain. On repeat examination, the vaginaisfilledwithmenstrualblood,causedbyuterovaginal bladder was no longer palpable and a PR examination was pathologies such as an imperforate hymen [2]. Most cases normal with no palpable masses. Initial blood tests showed a of imperforate hymen are sporadic in nature; however there mildly raised WCC at 11.7 and raised neutrophils at 10.15; all have been reports of familial cases, where both recessive other blood results were unremarkable. inheritance and dominant inheritance have been shown An ultrasound scan of the kidneys showed an 11 × [3]. 7.8 × 8 cm fluid-filled mass lying posterior to the bladder, inseparable from and lying immediately inferior to the uterus 2. Case (Figure 1). The mass had a fluid level, and findings were consistent with a hydrometra. The right kidney showed mild In September 2012, a 12-year-old girl presented to the acci- hydronephrosis. No other abnormal findings were detected. dent and emergency department with a one-day history Following the ultrasound findings, she was referred to of acute urinary retention associated with suprapubic pain the gynaecology department and underwent an MRI scan. anddysuria.Therewasnohistoryofvomitingorachange This showed an 11 × 7.8 × 8 cm mass lying within the in bowel habit. She reported cyclical abdominal cramping midline of the pelvis, which had several fluid layers indicating pains in the preceding six months but denied having started that it consisted of blood products (Figures 2(a) and 2(b)). menses. Her birth history and developmental history were Superiorly, the fluid was in continuation with a single uterine unremarkable. cavity, and inferiorly, it extended down to the perineum. On examination, her abdomen was soft with mild tender- Appearances were consistent with a hugely distended uterus ness suprapubically and in the left iliac fossa. Her bladder was filled with menstrual products. 2 Case Reports in Urology Figure 1: Ultrasound scan showing fluid-filled uterus. (a) (b) Figure 2: MRI scans showing the differential layers of fluid indicative of blood products. Subsequently, she underwent a hymenotomy (using a retention can subsequently occur due to the pressure effect cruciate incision) with drainage of her hydrocolpos. Postop- imposed on the bladder and urethra [5]. eratively, she made a good recovery with a successful removal This case serves to illustrate that in peripubertal females of the urinary catheter. Since returning home, she has started with amenorrhoea and acute urinary retention, even though experiencing normal menses and has had no further urinary uncommon, a diagnosis of haematocolpos should be consid- problems. ered and excluded. Conflict of interests 3. Discussion The authors declare that they have no conflict of interests. Acuteurinaryretentionisnotacommonpresentationinchil- dren and is more common in males [4]. When young females present, the causes can include mechanical obstructions References (urinary tract stones, urethral strictures, trauma to external [1] M. J. Lausten-Thomsen and H. Mogensen, “Hymen imperfora- genitalia, and imperforate hymen), neurological disorders, tus with atypical symptom presentation,” Ugeskrift for Laeger, and urinary tract infection [4]. vol. 169, no. 6, pp. 523–524, 2007. Imperforate hymen is a rare genital tract anomaly which [2] E. Deligeoroglou, C. Iavazzo, C. Sofoudis, T. Kalampokas, and has an incidence of about 1 in 2000 [1]. Acute urinary G. Creatsas, “Management of hematocolpos in adolescents Case Reports in Urology 3 with transverse vaginal septum,” Archives of Gynecology and Obstetrics,vol.285,no.4,pp.1083–1087,2012. [3] R. Sakalkale and U. Samarakkody, “Familial occurrence of imperforate hymen,” Journal of Pediatric and Adolescent Gyne- cology,vol.18,no.6,pp.427–429,2005. [4] S. A. Asgari, M. Mansour Ghanaie, N. Simforoosh, A. Kajbafzadeh, and A. Zare’, “Acute urinary retention on chil- dren,” Urology Journal,vol.2,no.1,pp.23–27,2005. [5] J. Burgis, “Obstructive Mullerian¨ anomalies: case report, diag- nosis, and management,” American Journal of Obstetrics and Gynecology,vol.185,no.2,pp.338–344,2001. Human Reproduction, Vol.27, No.6 pp. 1637–1639, 2012 Advanced Access publication on March 20, 2012 doi:10.1093/humrep/des084 CASE REPORT Gynaecology A uterovaginal septum and imperforate hymen with a double pyocolpos Luigi Fedele*, Giada Frontino, Francesca Motta, and Elisa Restelli Department of Obstetrics and Gynecology, Fondazione IRCCS Ca` Granda, Clinica Mangiagalli, University of Milano, Via della Commenda 12, 20122 Milan, Italy *Correspondence address. Fax: +39-0250320252; E-mail: [email protected] Submitted on January 11, 2012; resubmitted on February 1, 2012; accepted on February 16, 2012 Downloaded from abstract: The presence of both a uterovaginal septum and imperforate hymen is described in a young patient presenting with ongoing chronic pelvic pain and a double pyocolpos. Ultrasound and magnetic resonance imaging scans were performed. The patient underwent laparoscopic adesiolysis, hymenotomy with drainage of 200 mL of pus, and excision of a complete longitudinal vaginal septum. Over the past 5 years of regular follow-up examinations, the patient has always reported regular menstrual cycles and an absence of pelvic pain. http://humrep.oxfordjournals.org/ Key words: Mu¨llerian / uterovaginal septum / septate uterus / vaginal septum / imperforated hymen