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.

Imperforate Hymen: A Rare Cause of Abdominopelvic Mass in an Infant.

Symptomatic imperforate hymen is very rare in infants. Here we report a neonate who presented with imperforate hymen with abdominal distension, fever and loose stool. Imaging study showed large thick walled cystic lesion extending from pelvis to abdomen upto epigastric region with bilateral mild hydroureteronephrosis and lower part in between urinary bladder and rectum suggesting hydrometrocolpos. There was spontaneous rupture leading to flow of collection. It leads to spontaneous resolution of the mass which was confirmed with pelvic ultrasound and computed tomography. Keywords: Hydrometrocolpos; hydroureteronephrosis; imperforate hymen.

Mimics of malignancy caused by concurrent imperforate hymen and transverse vaginal septum: an instructive case and review of the literature.

The coexistence of imperforate hymen and vaginal septum is rare and their ability to mimic malignant manifestations have not been frequently reported. This current case report describes a 13-year-old girl that presented with cyclic abdominal pain for 6 months. She was found to have a huge mass via abdominal plain film X-ray and sonography, with inexplicably high levels of serum carcinoembryonic antigen, cancer antigen (CA)-19-9 and CA-125. Pelvic computed tomography imaging disclosed two huge cystic lesions in the uterine and upper vaginal cavities. Surgical intervention conformed the diagnosis of a concurrent imperforate hymen and transverse vaginal septum, echoing the imaging findings of haematocolpometra. Her tumour marker levels gradually returned to normal after surgery. This rare case of concomitant imperforate hymen and transverse vaginal septum highlights that haematocolpometra, a benign disease that might mimic malignancy, should be taken into consideration in any adolescent females with an abdominal mass and amenorrhoea to ensure an early diagnosis and timely appropriate management.

Symptomatic Imperforate Hymen in Early Infancy: A Case Report.

Imperforate hymen, though a congenital anomaly, usually presents late in puberty as lower abdominal pain, primary amenorrhea, and cyclical pain. Blood collects in vagina and uterus, proximal to imperforate hymen leading to their distention. Its presentation at infancy is a rare entity. We report such a rare case of symptomatic imperforate hymen in infancy, who presented with acute retention of urine, chills and rigor. Abdominal examination revealed an intra-abdominal mass in the lower abdomen and pelvis with the absence of vaginal opening on perineal examination. Contrast enhanced computed tomography abdomen showed large abdominopelvic cystic lesion posterior to the urinary bladder and anterior to the rectum consistent with a highly distended vagina. She was managed by the incision of the imperforate hymen and drainage of the pus. A high index of suspicion is necessary whenever a female infant presents with abdomino-pelvic mass with symptoms of fever or urinary retention.

Diagnosis and Management of Hymenal Variants: ACOG Committee Opinion, Number 780.

At puberty, a patient with an imperforate hymen typically presents with a vaginal bulge of thin hymenal tissue with a dark or bluish hue caused by the hematocolpos behind it. Other findings that may be present include an abdominal mass, urinary retention, dysuria, constipation, and dyschezia. On evaluation, the goal is to differentiate an imperforate hymen from other obstructing anatomic etiologies, such as labial adhesions, urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Surgical intervention is necessary only in symptomatic prepubertal patients. After confirmation of the diagnosis, surgical intervention usually is deferred until pubertal estrogenization has occurred because the imperforate hymen may open spontaneously at puberty. It is important to complete an abdominal and a perineal examination. If the physical examination reveals a bulging hymen and ultrasonography reveals hematocolpos, further imaging is not required. However, if the diagnosis is not certain or there is a concern for a distal vaginal atresia, cervical atresia, an obstructed uterine horn, or transverse or longitudinal vaginal septum, magnetic resonance imaging is recommended. The ideal time for surgical intervention on hymenal tissue is before the onset of pain and after onset of pubertal development, when the vaginal tissue is estrogenized. Surgical management of clinically significant hymenal variations involves excision of the hymenal tissue and rarely is associated with long-term sequelae. If there is concern that the patient has a distal vaginal atresia or a transverse vaginal septum, the patient should be referred to a center with expertise in the management of these conditions.

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.

Pelvic pain in young girls: not only dysmenorrhoea!

Imperforate hymen is the most frequent cause of haematocolpos, although it is a rare malformation (1:2000). We present two cases of young girls with cyclic abdominal pain and urinary symptoms. At gynaecological examination, they all presented imperforate hymen and ultrasound revealed significant vaginal distension. X-shaped hymenectomy was performed in all patients. The later the diagnosis of imperforate hymen, the higher the risk of complications like haematometra, haematosalpinx, haemoperitoneum and infections such as tubo-ovarian abscesses, peritonitis and endometriosis (retrograde menstruation theory).

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.

Imperforate hymen in a pediatric patient. Case report / Himen imperforado en paciente pediátrico. reporte de caso

Los trastornos congénitos del tracto genital femenino se presentan con una incidencia de 1: 10 000-20 000 nacidas vivas, tienen un amplio espectro de manifestaciones clínicas, se describe su detección de manera bimodal, con complicaciones que incluso pueden amenazar con la vida, sin embargo, con un tratamiento oportuno las pacientes pueden tener un buen pronóstico. Se reporta el caso de una paciente de 13 años con cuadro de retención urinaria súbita, estreñimiento agudo, sin menarca y características sexuales adecuadas para la edad, en quien se identificó himen imperforado, hematocolpos. Se descartaron otros posibles diagnósticos diferenciales y el manejo definitivo fue himenotomía más himenoplastía. El himen imperforado hace parte de los trastornos más frecuentes del desarrollo de los genitales femeninos, puede tener múltiples manifestaciones clínicas, leves y severas, con una adecuada identificación, se puede brindar un tratamiento oportuno, y evitar secuelas.

Congenital disorders of female genital tract occurs with an incidence of 1: 10 000 - 20 000 born alive, have a broad spectrum of clinical manifestations, their detection is described bimodally, with complications that may even threaten life, however, with timely treatment patients can have a good prognosis. We report the case of a 13-year-old patient with a sudden urinary retention, acute constipation, no menarche, and age appropriate sexual characteristics, in whom an imperforate hymen, hematocolpos was identified. Other possible differential diagnoses were ruled out and the management was hymenotomy plus hymenoplasty. The imperforate hymen is part of the most frequent developmental disorders of the female genitals, it can have multiple clinical manifestations, mild and severe, however, with an adequate identification, it can be given an opportune treatment, good prognosis and avoiding consequences.

[Imperforate hymen ­ an often missed diagnosis]. / Hymen imperforatus är en diagnos som ofta missas - Risk för långdragna symtom om adekvat undersökning inte genomförs.

Imperforate hymen - an often missed diagnosis Imperforate hymen is the most common congenital malformation in the female reproduction system that give rise to obstructive symptoms. If the diagnosis is not made in the newborn girl, symptoms often first arise at menarche. The diagnosis is easy to make but has to be suspected. This case reports describes the typical clinical picture of a late diagnosed imperforate hymen. As shown in this case and from a review of the literature, these girls often have symptoms for a long time before the diagnosis is made. Further, they are often initially misdiagnosed, and a thorough history and examination is seldom performed despite repeated contacts with the primary care.

MRI in the evaluation of obstructive reproductive tract anomalies in paediatric patients.

AIM: To outline the anatomical variations of obstructive reproductive tract anomalies (ORTA) using magnetic resonance imaging (MRI) and its role in preoperative evaluation. MATERIALS AND METHODS: MRI and treatment of 21 paediatric patients with ORTA were reviewed and analysed. MRI findings were correlated with ultrasound and surgical findings. RESULTS: Patients presented in two distinct ways: primary amenorrhoea with cyclic pelvic pain, or progressive dysmenorrhoea. MRI showed haematocolpos, haematocervix, haematometra, and/or haematosalpinx; it also provided detailed information regarding uterine morphology, ipsilateral kidney absence, and endometriosis. Diagnosis at MRI of the obstruction sites correlated completely (100%) with the surgical diagnosis. Obstruction occurred at different levels of the genital tract, and surgical treatment was given based on the obstruction sites. One patient underwent excision of the hymen tissue for imperforate hymen. Four cases of lower vaginal atresia were treated with vaginoplasty. Three patients with typical Herlyn-Werner-Wunderlich (HWW) syndrome underwent resection of the vaginal septum, and one patient with concurrent post-partum placenta increta was treated accordingly; one patient with atypical HWW syndrome had the left uterus resected. There were 11 cases of cervical agenesis or cervicovaginal dysgenesis, eight of which were complicated with uterine anomalies, and in all cases the uterus was removed. Among the 10 obstructive cervical anomalies, there were three cases of cervical agenesis and seven cases of cervical dysgenesis, including five obliterated cervical os (cervical obstruction), one cervical fibrous cord, and one cervical fragmentation. CONCLUSION: ORTA can occur from the hymen to the lower segment of the uterus and requires surgical intervention. The preoperative evaluation is vital to guide proper surgery. MRI, with its imaging advantages, is the imaging technique of choice to assess the obstructed sites and complicated anomalies of ORTA.