DOI:10.2214/AJR.05.0907
AJR 2006; 186:1469-1470
© American Roentgen Ray Society
Hematometrocolpos Due To Imperforate Hymen in a Patient with Bicornuate Uterus
Jeffrey M. Levsky1 and
Ross T. Mondshine2
1 Montefiore Medical Center Bronx, NY 10467
2 New York University New York, NY 10016
Imperforate hymen is a classical, although rare, easily curable cause of
primary amenorrhea. For some time, further investigation of these patients for
concomitant urogenital abnormalities has been thought to be unnecessary
because the finding is seldom associated with other congenital defects
[1]. However, a recent case
indicates that this strategy may not be optimal management.
A 14-year-old girl presented to our community hospital's emergency
department with a complaint of lower abdominal pain. Her history included an
emergency department visit 25 days earlier for a urinary tract infection and
an ongoing workup for a large right-sided adnexal mass by a private practice
gynecologist. She described her pain as "on and off" for 2 months
and as increasing in severity. On physical examination, she was afebrile with
normal vital signs. She was found to have bilateral pelvic pain without
guarding and normal-appearing Tanner stage III genitalia. Initial laboratory
values were unremarkable, including a total WBC count of 8,600/mL, a
hemoglobin level of 13.9 g/dL, and a quantitative serum ß-HCG level of
less than 2 mIU/mL.
Transabdominal pelvic sonography was performed directly from the emergency
department. The night-shift technician performing the examination was unable
to visualize the normal pelvic anatomy and reported only a large
well-circumscribed mass in the lower abdomen
(Fig. 2A). A contrast-enhanced
CT scan of the abdomen and pelvis was obtained; it revealed significant
hematocolpos that was causing marked distention of the cervix and vagina
(Fig. 2B). Images through the
uterus were remarkable for the appearance of a longitudinal septum, which was
highlighted by hematometra (Fig.
2C). The presumptive diagnosis of hematometrocolpos due to an
obstructing lesion was made, and the patient was taken to the operating room.
Examination under anesthesia revealed imperforate hymen. Hymenotomy was
performed, yielding approximately 500 mL of coagulated blood. Repeat pelvic
sonography on the first postoperative day revealed a bicornuate uterus
(Fig. 2D) and normal
ovaries.
View larger version (105K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —Hematometrocolpos in 14-year-old girl who presented with lower
abdominal pain. Transabdominal sonogram (transverse view) shows large
well-defined mass, which was later identified as markedly distended
uterus.
|
|
View larger version (107K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D —Hematometrocolpos in 14-year-old girl who presented with lower
abdominal pain. Postoperative transabdominal sonogram (transverse view) shows
resolution of hematometra and well-defined endometrial stripes for both cornua
of uterus.
|
|
In most cases of obstructive vaginal lesions, physical examination combined
with sonography is sufficient to establish a working diagnosis
[2]. In this case, the initial
examination and sonogram were inconclusive. In this emergency setting of a
patient with severe pain and an undiagnosed pelvic mass, CT was diagnostic. As
an alternative, endorectal sonography can be considered
[3]. In patients with complex
anomalies, MRI can be used for the delineation of anatomy. This technique has
been shown to correlate well with surgical diagnoses
[4].
In this case, the patient's presenting disease was relieved by a
hymenotomy. Serious sequelae are not expected on the basis of retrospective
study of similar patients [1].
Of more important long-term concern is infertility due to her incidentally
detected bicornuate uterus. In cases in which the primary complaint is
diagnosed by clinical examination, no further information regarding the pelvic
anatomy may be obtained. As a result, we suggest postoperative sonography of
the pelvis, not only to verify the resolution of hematocolpos but also to
screen for concomitant anomalies that can have high clinical significance in
the long term.
References
- 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[Medline]
- Blask AR, Sanders RC, Rock JA. Obstructed uterovaginal anomalies:
demonstration with sonography. Part II. Teenagers.
Radiology 1991;179
: 84-88[Abstract/Free Full Text]
- Kushnir O, Garde K, Blankstein J. Rectal sonography for diagnosing
hematocolpometra: a case report. J Reprod Med1997; 42:519
-520[Medline]
- Reinhold C, Hricak H, Forstner R, et al. Primary amenorrhea:
evaluation with MR imaging. Radiology1997; 203:383
-390[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
References
