Case # 6: Hematocolpos secondary to imperforate hymen
A 12-year-old female was sent by her pediatrician to the emergency department for investigation of severe suprapubic abdominal pain that radiated to her lower back. She reported that the pain had waxed and waned for approximately 1 month, but the previous evening it was so severe that it had awakened her from sleep. She denied any nausea, vomiting, or diarrhea, and reported only some mild urinary retention. She reported that she had yet to reach menarche.
Vital signs were within normal limits, and physical examination revealed a healthy adolescent with evidence of thelarche and adrenarche. Her abdomen was soft and nontender, but significant for a palpable suprapubic mass. Highly suspicious of the diagnosis, seeing that the patient was stable and knowing that she was virginal, the pelvic exam was deferred for gynecologic consultation. (It, too, would have been confirmatory of the diagnosis.) All labs were normal and a transabdominal US confirmed the suspected diagnosis and revealed the extent of the abnormality.
US examination showed a 13.7 x 8.0 x 8.8 cm complex fluid-filled structure that extended inferiorly from the uterus and obscured visualization of the cervicovaginal junction. Genitourinary exam revealed an imperforate hymen, and surgery confirmed hematocolpos when the hymen was incised.
Imperforate hymen occurs in approximately 1 in 1,000 females and is often found incidentally on genitourinary exam.19 At that point, it is easily treatable and causes no symptoms.20,21 If the condition is not found early, females often present at menarche complaining of cyclical abdominal pain and urinary retention secondary to hematocolpos.
On genitourinary exam, this can be seen as a bulging blue hymen, with a palpable mass on abdominal exam. A rare complication of this condition is ruptured hematosalpinx, making prompt evaluation and diagnosis important.22 Treatment is with either a vertical incision of the hymen to create an opening or complete hymenectomy, which is the gold standard for definitive treatment.23
Abdominal pain is one of the leading causes of pediatric visits to the emergency department and astute clinicians must keep in mind less common, but more dangerous, conditions in their differential before determining a definitive diagnosis.
Brian T. Kloss, DO, JD, PA-C, is an emergency medicine physician at the Syracuse (N.Y.) VA Medical Center and at SUNY Upstate Medical University (Syracuse), where he is also the program director for the Upstate Physician Assistant Fellowship in Emergency Medicine.
Rhonda Diescher, MD, is a resident in the Emergency Medicine Residency Program at the University of Connecticut in Hartford.
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All electronic documents accessed on December 12, 2014.