DOI:10.2214/AJR.05.1560
AJR 2007; 189:W23-W25
© American Roentgen Ray Society
Congenital Imperforate Hymen with Hydrocolpos Diagnosed Using Prenatal MRI
Ibrahim Adaletli1,
Harun Ozer1,
Sebuh Kurugoglu1,
Haluk Emir2 and
Riza Madazli3
1 Department of Radiology, Istanbul University, Cerrahpasa Medical Faculty,
Kocamustafapa
a, Istanbul 34300, Turkey.
2 Department of Pediatric Surgery, Istanbul University, Cerrahpasa Medical
Faculty, Kocamustafapaa, Istanbul, Turkey.
3 Department of Obstetrics and Gynecology, Istanbul University, Cerrahpasa
Medical Faculty, Kocamustafapaa, Istanbul, Turkey.
Received September 2, 2005;
accepted after revision October 20, 2005.
Address correspondence to I. Adaletli
(iadaletli{at}yahoo.com).
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Keywords: congenital abnormalities • fetal imaging • genitourinary imaging • imperforate hymen • MRI • prenatal MRI
Introduction
Imperforate hymen is a rare genital anomaly in which a layer of epithelized
connective tissue that forms the hymen has no opening and completely obstructs
the vaginal introitus. Hydrocolpos and hydrometrocolpos may occur secondary to
this condition. Imperforate hymen usually does not cause symptoms until
puberty [1]. This anomaly
manifests as an abdominal mass that is detectable during the prenatal period
only rarely [2].
We present a case of bilateral hydroureteronephrosis caused by hydrocolpos
in a female fetus with an imperforate hymen that was diagnosed using prenatal
MRI.
Case Report
A 35-year-old woman, gravida 2, para 1, underwent prenatal sonography
examination because the results of a serum triple-marker screening test were
positive (1/130). For Down syndrome screening, a risk of more than one in 270,
the midtrimester risk of a woman who is 35 years old, is used as the cutoff
for performing prenatal sonography. The result of amniocentesis came back as
46, XX, and no chromosomal abnormalities were detected.
Prenatal sonography of a female fetus was performed at both 18 and 22 weeks
of gestation. Sonography showed bilateral hydronephrosis, megacystis, and
polyhydramnios. The initial interpretation of the perinatologist was
megacystis-microcolon-intestinal hypoperistalsis syndrome.
For these findings to be evaluated further and to be validated, prenatal
MRI was performed at 22 weeks of gestation. The mother was in a supine
position for the examination, and the images were acquired during maximal
inspiration. The fetal urogenital system was examined in sagittal, transverse,
and coronal orientations using a T2-weighted sequence (HASTE; TR/TE,
1,380/103; field of view, 250 mm; slice thickness, 4 mm; matrix, 256 x
256; number of excitations, 1). MRI showed bilateral hydronephrosis,
megaureters, and a huge cystic mass extending from the mid abdomen to the
perineum (Figs. 1A and
1B). The bladder was visualized
anterior to the cystic mass (Fig.
1C).
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Fig. 1A —Prenatal T2-weighted sequence (HASTE; TR/TE, 1,100/120; field
of view, 250 mm; slice thickness, 4 mm; matrix, 256 x 256; number of
excitations, 1) and postnatal sonography and physical examination findings.
Coronal image shows bilateral hydroureteronephrosis (stars).
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Fig. 1B —Prenatal T2-weighted sequence (HASTE; TR/TE, 1,100/120; field
of view, 250 mm; slice thickness, 4 mm; matrix, 256 x 256; number of
excitations, 1) and postnatal sonography and physical examination findings.
Sagittal T2-weighted image reveals huge cystic mass (star) that
extends from mid abdomen to perineum (arrows).
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Fig. 1C —Prenatal T2-weighted sequence (HASTE; TR/TE, 1,100/120; field
of view, 250 mm; slice thickness, 4 mm; matrix, 256 x 256; number of
excitations, 1) and postnatal sonography and physical examination findings.
Axial T2-weighted image shows bladder (arrow) anterior to cystic mass
(star).
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Visualization of the small bladder ruled out
megacystis-microcolon-intestinal hypoperistalsis syndrome. MRI findings of the
cystic pelvic mass suggested imperforated hymen with hydrocolpos. There were
no accompanying congenital anomalies. The differential diagnosis of a pelvic
cystic mass in a fetus includes sacrococcygeal teratoma and anterior
meningomyelocele, both of which were ruled out on the basis of the
characteristic MRI appearance of imperforate hymen with hydrocolpos and the
extension of the lesion.
The infant was born at 38 weeks' gestation by cesarean delivery. The Apgar
scores was normal, and a thin protruding vaginal membrane and abdominal
distention were noted on physical examination. Postnatal sonography showed
bilateral hydroureteronephrosis and a huge cystic mass with heterogeneous
interior echo in the pelvis and lower abdomen
(Fig. 1D).
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Fig. 1D —Prenatal T2-weighted sequence (HASTE; TR/TE, 1,100/120; field
of view, 250 mm; slice thickness, 4 mm; matrix, 256 x 256; number of
excitations, 1) and postnatal sonography and physical examination findings.
Postnatal sonogram shows huge cystic mass (star) with internal echoes
and thin cortex of left kidney (arrows) with dilated collecting
system.
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Voiding cystourethrography revealed a small bladder displaced to the
anterior abdominal wall due to the mass effect of the hydrocolpos. Neither
reflux nor ureteroceles were seen. The patient was referred to pediatric
surgery. Hymenotomy was performed and caused discharge of 200 mL of clear
serous and mucoid fluid (Fig.
1E). The infant died on the fifth postnatal day due to
urosepsis.
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Fig. 1E —Prenatal T2-weighted sequence (HASTE; TR/TE, 1,100/120; field
of view, 250 mm; slice thickness, 4 mm; matrix, 256 x 256; number of
excitations, 1) and postnatal sonography and physical examination findings.
Photograph obtained during postnatal urogenital physical examination shows
thin protruding membrane.
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Discussion
Congenital imperforate hymen is an external urogenital anomaly that usually
presents in infancy and early childhood. Although it is a congenital anomaly,
imperforate hymen diagnosed during the antenatal period is very rare because
it seldom causes hydrocolpos or hydrometrocolpos in utero. In the literature,
sonography has been the imaging technique of choice for the prenatal diagnosis
of imperforate hymen with hydrocolpos
[3].
The association of an imperforate hymen with other genitourinary anomalies
is well known, and the investigation for associated anomalies is almost always
performed by sonography. Although sonography is useful for evaluating fetal
anatomy and showing abnormalities, its capability in detecting fetal
abnormalities decreases if the mother is obese or has oligohydramnios and when
the fetus is in certain positions
[4].
MRI has become an alternative and complementary method for some of the
equivocal prenatal cases owing to the recent developments in MRI technology.
It provides excellent anatomic detail and soft-tissue contrast with multiple
reconstruction planes and a large field of view. In the past, fetal motion and
longer acquisition times limited the role of MRI in fetal imaging. Ultrafast
MRI has overcome these problems, so MRI has become more valuable in this
setting and its role is still expanding
[5].
In the present case, prenatal sonography failed to yield findings for a
diagnosis, so MRI was ordered. MRI showed the exact location and extension of
the cystic mass from the mid abdomen to the perineum in addition to the
findings seen on sonography. The bladder was clearly shown on MRI as well. The
cystic mass was diagnosed as hydrocolpos because it extended to the perineum
and because a bladder abnormality could be excluded. The differential
diagnosis of a pelvic cystic mass includes sacrococcygeal teratoma and
anterior meningomyelocele. The sacrococcygeal teratoma mostly contains
internal septations and solid components and has an extrafetal extension.
Anterior meningomyelocele characteristically extends to the spinal canal and
usually has dysraphism findings
[6,
7].
The prenatal MRI diagnosis was also confirmed at physical examination,
which revealed a thin protruding vaginal membrane, and by postnatal
sonography. In retrospective analysis, we thought that the bladder could not
be visualized on sonography because of the compressive effect of the huge
cystic mass.
In conclusion, we suggest that MRI should be used as an alternative method
to sonography in equivocal prenatal cases of imperforate hymen with
hydrocolpos and that MRI is a more useful tool than sonography for the
investigation of associated anomalies.
References
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Introduction
Case Report
