Teaching Case

A 12-year-old female presented to the Emergency Department with a 48-hour history of abdominal pain localised in the hypogastrium, which had progressively worsened in the last few hours. The patient mentioned previous episodes of less intense abdominal pain. Considering the clinical suspicion of acute appendicitis, an abdominal ultrasound was requested.

Abdominal ultrasound revealed a significant distension of the vagina, measuring 8.3 x 8.8 x 14 mm (maximal axes), with its lumen occupied by abundant echogenic material, except for the most anti-declining portion, which displayed hypo/anechoic material. The uterus appeared slightly lateralised to the right, demonstrating a pubertal morphology, and showed no signs of distension or occupation of its lumen. The cecal appendix appeared normal in size, with no evidence of acute inflammation. No other significant findings were observed during the ultrasound study.

Background

Hematocolpos refers to a blood-filled dilated vagina resulting from menstrual blood accumulation due to anatomical obstruction, commonly caused by an imperforate hymen. When accompanied by uterine distention, the term hematometrocolpos is used [1]. The reported incidence of this condition is approximately 0.006% [2].

Hydrocolpos, secondary to congenital urogenital anomalies, may be detected prenatally or postnatally due to the accumulation of secretions in the obstructed vagina under the influence of maternal hormones. However, most patients receive a diagnosis during puberty when hematocolpos or hematometrocolpos develop [3].

Based on the level of obstruction and its association with congenital anomalies in the urinary tract (urogenital sinus) and/or anorectal area (cloaca), this condition can be classified into five types: type I (imperforate hymen), type II (vaginal septum), type III (distal vaginal atresia), type IV (vaginal atresia with persistent urogenital sinus), and type V (vaginal atresia with cloacal abnormality). Initial classification may be aided by inspecting the external genitalia [2,3].

The most common cause of hematocolpos is the presence of an imperforate hymen, which may occur in isolation or in association with other malformations, such as imperforate anus, bifid clitoris, or polycystic kidney [4].

Clinical Perspective

Symptoms of hematocolpos are often non-specific and may include cyclical pain in the hypogastrium, vomiting, urinary symptoms (dysuria, urinary infection, or even bilateral hydronephrosis), sensation of a pelvic mass, and, in some cases, can be mistaken for ovarian torsion, urinary infection, or acute appendicitis [3].

Imaging Perspective

Ultrasonography, computed tomography, and magnetic resonance imaging are used to evaluate patients with hemato/hydrocolpos. Ultrasound is the initial diagnostic option, especially in children, and in cases where imperforation of the hymen is confirmed during physical examination, it may be the only test required. In instances where there are doubts or when vaginal atresia or other complex congenital anomalies are suspected, MRI is usually the indicated test [3].

Outcome

For hydrometrocolpos caused by an imperforate hymen, hymenectomy is the treatment of choice. In the case of our patient, 500 ml of bloody fluid was drained.

Take Home Message / Teaching Points

• Hematocolpos/hematometrocolpos should be included in the differential diagnoses of abdominal pain in adolescents with amenorrhea.
• Hematocolpos may be the first sign that leads to the detection of congenital malformations.

Written informed consent for publication has been obtained from the patient.