Hymenal atresia - a rare congenital anomaly with the risk of late diagnosis

OBJECTIVE

Comprehensive analysis of causes, clinical signs, dia-gnostic process, differential dia-gnosis and therapy of hymenal atresia.

METHODS

Literature search using the Web of Science, Google Scholar and PubMed databases with keywords and analysis of articles published in high impact and reviewed journals.

RESULTS

Hymenal atresia is a congenital malformation of a womans genitals, which is manifested by complete obstruction of the vaginal introitus by a closed hymen. It should be dia-gnosed in the neonatal period, but clinically it usually manifests itself only during puberty as a result of menstrual blood retention (cryptomenorrhea) with the cyclic abdominal pain at monthly intervals. The therapy is based on optimally timed surgical creation of communication in the hymen (hymenotomy, hymenectomy) enabling free evacuation of menstrual contents. The aim of this simple treatment method is immediate subjective relief from pain and a permanent solution to this congenital anomaly.

CONCLUSION

Knowledge of all types of congenital malformations of the female genitalia is a basic condition for an early and effective dia-gnostic process in adolescent girls with abdominal pain. The girl who has not yet menstruated and has cyclic lower abdominal pain and a tumor behind the pubic symphysis should be examined by a specialist in pediatric and adolescent gynecology who will confirm hymenal atresia according to a bluish and closed hymen, and suggest prompt and effective therapy.

Imperforate Hymen Causing Hematocolpos and Urinary Retention

BACKGROUND

Acute urinary retention is rare in the pediatric population and is typically caused by an obstructing entity. It may result from hematocolpos caused by imperforate hymen. Imperforate hymen is rare, with an associated incidence of 1 in 2000 people. Nonetheless, in a pediatric age female who presents with urinary retention and who has a history of primary amenorrhea or a history of cyclical pelvic pain an examination of the external genitalia should be performed to rule out this condition.

CASE REPORT

A 12-year-old girl presented to the emergency department with urinary retention and was discharged with a diagnosis of urinary tract infection. She returned the following day to the emergency department with worsening abdominal pain. A computed tomography scan revealed a fluid-filled vagina measuring 12.5 cm. Her bladder measured 15.4 cm. The patient was taken to the operating room for further evaluation by the consulting gynecologist. At the time of surgery, 1000 mL of urine were evacuated after catheterization. Three hundred milliliters of chocolate-colored fluid, consistent with menstrual blood, were evacuated at time of hymenotomy. Hymenotomy was performed with a cruciate incision. No complications were encountered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To date, there have been >40 reported cases of imperforate hymen causing hematocolpos and subsequent urinary retention. However, given the rarity of imperforate hymen, hematocolpos leading to acute urinary retention can still be missed. Untreated urinary retention can lead to a compromise in bladder function and subsequent kidney damage.

Imperforate Hymen and Vaginal Atresia and their Associated Anomalies

The presenting features and associated abnormalities of imperforate hymen and vaginal atresia were studied in 24 girls under the age of 16 years. Hydrocolpos or hydrometrocolpos occurred in 8 infants, 13 older girls developed haematocolpos, but 3 of the girls had no distension of the genital tract. Seven of the older girls were diagnosed as having appendicitis. Anorectal anomalies were present in 9 of the children. Intravenous pyelography was performed on 16 girls and was normal in only one. Urinary tract investigations are indicated in all girls with vaginal outlet obstruction, and the vaginal orifice should be inspected in all girls with anorectal abnormalities.

[Hematocolpos : an unappreciated diagnosis of hymen imperforation]

The imperforation of the hymen is a relatively rare congenital malformation. It usually manifests itself in adolescence by a hematocolpos. Hematocolpos is the vaginal retention of menstrual blood at puberty. It results clinically in painful amenorrhea and more rarely in a pelvic mass syndrome. The diagnosis is easy, it is primarily clinical. Pelvic ultrasound and nuclear magnetic resonance are the complementary examinations to be performed as a preoperative assessment and to detect any associated genito-urinary malformations.

Atresia Hymenalis with Haematometrocolpos: A Benefit of Teaching a Case Series and Review of the Literature

We present four cases of atresia hymenalis with resultant haematometrocolpos diagnosed in quick succession in the emergency department with a literature review.

Isolated Recurrent Hematotrachelos After Abdominal Myomectomy A Case Report

BACKGROUND

Isolated hematotrachelos is an ex- tremely rare condition. More commonly it is associated with hematometra and/or hematocolpos. It may devel- op secondary to congenital anomalies of the reproductive tract or may be an acquired condition following cervical surgery or manipulation. No case has been reported fol- lowing abdominal myomec- tomy.

CASE

A 40-year-old, nul- ligravid woman was diag- nosed with isolated hemato- trachelos when she presented with severe abdominal pain following ovulation induction with clomiphene citrate. After the diagnosis was obtained, she recounted 2 similar presentations occurring months earlier. Both episodes had been attributed to gastroenteritis, but each had re- solved with "explosive" onset of menses. All 3 episodes plus 1 later recurrence happened within a 36-month period following an abdominal myomectomy.

CONCLUSION

Acquired hematotrachelos is a rare condition, and the diagnosis is often missed. To our knowledge, this is the first reported case of isolated, recurrent hematotrachelos following the use of a uterine manipulator cannula in association with an abdominal myomectomy.

Uterus didelphys with unilateral obstructed hemivagina and haematocolpos with ipsilateral renal agenesis - a case report

Mullerian anomalies are a relatively uncommon occurrence with implication for adolescents and adults as they may result in specific gynaecologic, fertility and obstetrical issues. Uterus didelphys with blind hemivagina and ipsilateral renal agenesis is a rare congenital anomaly. Patient may be asymptomatic and unaware of having double uterus or may present with severe dysmenorrhoea or dyspareunia or a palpable mass due to unilateral haematocolpos. We report a case of 12 year old girl with this condition who was diagnosed as uterus didelphys with unilateral haematocolpos with ipsilateral renal agenesis on the basis of clinical association, physical examination and sonography and intravenous urogram.

[Primary amenorrhea by transverse vaginal septum: a case report and review of the literature]

The transverse vaginal septum is one of the rarest anomalies of the reproductive tract classified depending on location. It is manifested by primary amenorrhea, cyclic pain and progressive mass growth at abdominopelvic level, ultrasound and magnetic resonance imaging provides the diagnosis, location and thickness of a transverse vaginal septum, treatment is surgical. We present a case of a teenage patient with primary amenorrhea due to lower transverse vaginal septum with surgical resection and satisfactory follow-up with successful vaginal patency.

[Müllerian anomalies. Obstructed hemivagina and ipsilateral renal anomaly syndrome (OHVIRA)]

Müllerian duct anomalies are a group of uncommon and underdiagnosed entities, which cause specific symptoms in adolescent females and may be associated with infertility as well as adverse pregnancy outcomes. These malformations occur as a result of an arrest or abnormal development of the Müllerian ducts in different stages of the female reproductive tract during gestation. Obstructed hemivagina and ipsilateral renal anomaly syndrome (OHVIRA), formerly known as the Herlyn-Werner-Wunderlich syndrome, is a rare entity characterized by the presence of a uterus didelphys with an obstructed hemivagina cause by a vaginal septum and the association of a renal anomaly (most commonly renal agenesis) ipsilateral to the obstruction. This syndrome may remain undiagnosed during childhood and usually becomes symptomatic after menarche, causing obstructive symptoms. Occasionally it may be identified after the evaluation of a patient with infertility or recurrent pregnancy loss. The clinical diagnosis is very challenging and requires imaging studies in which ultrasound and MRI play an essential role in the diagnosis, classification and treatment plan. Opportune diagnosis and treatment achieve complete improvement of symptoms, adequate reproductive prognosis and avoid major complications such as endometriosis, pelvic adhesions and infertility. The purpose of this review is to demonstrate the pathophysiology, clinical manifestations, diagnostic methods and treatment of the obstructed hemivagina and ipsilateral renal anomaly syndrome.

[Pelvic inflammatory disease due to Herlyn-Werner-Wunderlich syndrome]

BACKGROUND

Herlyn-Werner-Wunderlich syndrome is a congenital urogenital malformation that is associated with a uterus didelphys and a longitudinal vaginal septum, resulting in a blind hemivagina and ipsilateral renal agenesis. Clinical presentation is highly variable, delaying diagnosis and leading to important complications.

CLINICAL CASE

We present the case of a 13-year-old female who was diagnosed with Herlyn-Werner-Wunderlich syndrome following an acute abdomen due to a right tubo-ovarian abscess. She had a vaginal septum giving rise to a right blind hemivagina. It was microperforated, causing intermittent genital bleeding. This hematocolpos was colonized by microorganisms that ascended to the pelvic cavity, causing right tuboovarian abscess. Nuclear magnetic resonance imaging provided theWernermost diagnostic information. We performed a vaginal septum resection, and both hemiuteros communicated with a single vagina, resulting in an asymptomatic patient.

CONCLUSION

Herlyn-Werner-Wunderlich syndrome is a little known entity and can be presented atypically, resulting in diagnostic difficulty and treatment delay. It is important to be aware of this syndrome in order to avoid irreversible complications.

Cervical dysgenesis with transverse vaginal septum with imperforate hymen in an 11 year old girl presenting with acute abdomen

This case highlights the importance of careful evaluation of girls presenting with imperforate hymen as this is accompanied by other female reproductive tract anomalies. It is of utmost importance that a correct timely diagnosis is made so that the right treatment can be chosen with the perspective of future fertility. Cervical dysgenesis associated with vaginal septum and imperforate hymen has not been reported in literature so far. Present case highlights the simple mode of management with a successful outcome.

Herlyn-Werner-Wunderlich syndrome: a rare presentation with pyocolpos

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), also known as Herlyn-Werner-Wunderlich syndrome, is a rare syndrome with only a few hundred reported cases described since 1922. Only a handful of these cases have been associated with pyocolpos. Mullerian duct anomalies have an incidence of 2-3%. While OHVIRA constitutes 0.16-10% of these Mullerian duct anomalies. Symptoms usually present shortly after menarche when hematocolpos develops during menstruation resulting in dysmenorrhea and a pelvic mass. The pelvic mass is the collection of blood products within the obstructed hemivagina. The first study in the diagnostic work-up is usually ultrasonography, which typically demonstrates a pelvic fluid collection which can simulate other disease processes thus confounding the diagnosis. MRI findings of the pelvis reveal a didelphic uterus. Imaging of the abdomen reveals agenesis of the ipsilateral kidney. MRI is beneficial in characterizing the didelphic uterus and vaginal septum for pre-operative planning. Understanding the imaging findings, in conjunction with the clinical presentation, is critical for early diagnosis in attempting to prevent complications such as endometriosis or adhesions from chronic infections with subsequent infertility.

[Imperforate hymen: a series of 13 cases]

BACKGROUND

Imperforate hymen is a rare congenital malformation. Patients often remain asymptomatic until puberty and present in early adolescence with cyclic abdominal pain. Early diagnosis and treatment must be performed in order to prevent morbidity. THE AIM of this study was to asses management of this disease.

METHODS

A retrospective study of 13 cases of imporforate hymen diagnosed in the department of obstetrics and gynecology "A" of Charles Nicolle hospital of Tunis from January 1980 to December 2008. The clinical features and the management are discussed.

RESULTS

The mean age was 14 years. All patients were single and had primary amenorrhea. They presented with pelvic pain in 9 cases and bladder urinary retention in 4 cases. Secondary sexual characters were present and normal in all cases. Inspection of the vulva could establish the diagnosis in all cases. Pelvic ultrasounds showed the hematocolpos in all cases. The latter was associated to a hematometria and a Douglas pouch liquid in 2 cases. Hematocolpos was evacuated by hymeneotomy under oxytocin infusion in all cases. Eight patients were treated by cruciform incisions and five patients were treated by radial incisions of the hymen. The volume of hematocolpos varied from 250 ml to 2000 ml. One patient underwent surgery twice for restenosis of the imperforate hymen.

CONCLUSION

Imperforate hymen is a rare anomaly. Its diagnosis is simple and could be established at birth by a systematic screening. More frequently, the diagnosis must be suspected in front of a primary amenorrhea associated to abdominal pain in order to prevent complications.

Hematometrocolpos in an adolescent female treated for pelvic Ewing sarcoma

Radiation therapy is often used to achieve local control of pelvic Ewing sarcoma in children. The effects of radiation on the female reproductive tract have been well documented in adults with gynecological malignancies, but the long-term consequences of pelvic radiation in pre-pubertal or adolescent girls are not as well described. We report a case of hematometrocolpos developing in an adolescent previously treated with chemotherapy and radiation therapy for pelvic Ewing sarcoma. We describe the clinical presentation, radiographic features, gross pathology, treatment strategies, outcome, as well as putative predisposing factors and preventative interventions.

Uterus didelphys with blind hemivagina and ipsilateral renal agenesis complicated by pyocolpos and presenting as acute abdomen 11 years after menarche: presentation of a rare case with review of the literature

BACKGROUND

Congenital anomaly of the Müllerian duct system can result in various urogenital anomalies including uterus didelphys with blind hemivagina and ipsilateral renal agenesis. The diagnosis of this condition is usually made after menarche, but its rarity and variable clinical features may contribute to a diagnostic delay for years after menarche.

CASE

A 24-year-old woman presented to the emergency room of the Department of Obstetrics and Gynecology complaining of severe worsening lower abdominal pain, vomiting and pus-like vaginal discharge. Physical examination revealed acute abdomen with diffuse lower abdominal tenderness, rebound and muscular resistance. Cervical and vaginal observation was impossible because of the patient's discomfort. Bimanual gynecological examination showed high tenderness cervical motion. Transabdominal ultrasound scan was performed and the radiologist interpreted the ultrasonographic findings as existence of a pelvic mass with mixed echogenicity. The preoperative diagnosis was ruptured tubo-ovarian abscess and emergency laparotomy was performed. Free pus in the pelvis was found. Also, a double uterus with an elongated and inflammatory right fallopian tube with pus passing out of its fimbrial end was observed. Vaginal examination under general anesthesia revealed an obstructed right hemivagina with vaginal pus-like discharge from a small fistula hole on the septate vagina. The final diagnosis was uterus didelphys with unilateral imperforate right hemivagina and pyocolpos. Transvaginal resection of the vaginal septum was performed and a large amount of pus and blood was spilled out. Postoperatively, intravenous pyelography demonstrated agenesis of the right kidney.

CONCLUSION

We demonstrated the difficulty in making a correct diagnosis of this rare congenital anomaly of the female genital tract, especially after many years since menarche. This condition should be considered to prevent misdiagnosis or suboptimal treatment and decrease morbidity and unnecessary surgical procedures.

[Hymen imperforatus with atypical symptom presentation]

One in every 2,000 girls has hymen imperforatus. A few are recognized at birth because of mucocolpos. The rest are not detected before puberty. Typical symptoms are abdominal pain and distension of the lower abdomen, and half of the girls present with acute urinary retention. A case is presented where the symptoms started after a minor trauma. Diagnosis and treatment are easy. Complications can be infertility, endometriosis and adhesions.

Congenital vaginal obstructions: varied presentation and outcome

Congenital obstructing lesions of vagina, hydrometrocolpos, and hematocolpos, present at a variable time during early childhood and adolescence to different medical and surgical specialties. Twenty-six cases presenting over an 18-years period (1987-2005) were divided into three groups; Group A: neonates (6), Group B: adolescents (18), and Group C: adults (2). Common presentations in neonates (Group A) were abdominal mass (5), neonatal sepsis (3), and respiratory distress (2); whereas abdominal pain (18), voiding dysfunctions (13), and backache (7) were prevalent in adolescents (Group B). Adults (Group C) presented with inability to consummate and infertility (2). Four patients received erroneous treatment; exploratory laparotomy (1) and appendectomy (3). Urinary symptoms and associated urinary abnormalities were present in more than 50% of cases, especially those with complex anomalies. Management included excision of imperforate hymen (16) and transverse vaginal septum (8) through perineal (20) and abdominoperineal approach (4). Patients with urogenital sinus (1) and cloacal malformation (1) had staged reconstruction at 2.5 years of age following preliminary vesicostomy and colostomy at birth. On follow up (range 1-15 years; mean 7) more than 60% patients have menstrual irregularity (11), endometriosis (5), and infertility (4). In conclusion, rarity and variable presentation of congenital vaginal obstructions can lead to delayed diagnosis and erroneous management. A high index of suspicion and cross-sectional imaging help in early diagnosis and associated renal anomalies. A comprehensive management is imperative to preserve the reproductive potentials, as significant proportion of patients may experience sexual difficulties, menstrual irregularity, and infertility.

[Uterus duplex with hematometrocolpos and ipsilateral agenesis of the kidney]

BACKGROUND

Malformations of the mullerian-duct-system occur with an incidence of about 0.001-0.005% of the population, and they are frequently associated with unilateral agenesis of the kidney.

CASE

A 12-year-old girl presented to our emergency department with cyclic abdominal pain which increased with each of her menses. Ultrasound investigation showed a uterus duplex with obstructed hemivagina and hematometrocolpos as well as an ipsilateral absence of the kidney. Additionally, a cystic expansion in the small pelvis was detected which required further investigations (MRT and MR-angiography) to establish the diagnosis of a hematosalpinx. Excision of the vaginal septum resulted in drainage of the hemato-metrocolpos and the hematosalpinx.

CONCLUSION

Unilateral hematometrocolpos should be considered as an important differential diagnosis in female adolescents with relapsing lower abdominal pain, even if normal menstruation occurs.

[Hematocolpos due to obstructed hemivagina. About three cases]

Abnormalities of the reproductive tract interest a little more than 1% of the women. The symptoms are not specific: abdominal pain seems like appendicitis, invalidating dysmenorrheas in the girl, urinary manifestations. They should be discovered and treated because they could bring about obstetric complications later. We present three observations, illustrated with a recent review of the literature, and describe the diagnostic difficulties and their surgical treatments.

Uterus didelphys with obstructed hemivagina and multicystic dysplastic kidney

Müllerian malformations include a broad range of anomalies, resulting from the incomplete formation and/or differentiation of the Müllerian ducts. The uterus didelphys with obstructed hemivagina represents the result of a lateral nonfusion of the Müllerian ducts with asymmetric obstruction, and it is almost always associated with renal agenesis. We report a case of incidental discovery of this anomaly in a 12-year-old girl during a routine renal ultrasound. A right multicystic dysplastic kidney had been detected in the prenatal and neonatal period with no evidence of uterine anomaly. Postnatal ultrasound examinations performed regularly had never detected either right renal tissue or the uterine anomaly before menarche. Hematocolpos after menarche made uterine anomaly detection easier. Magnetic resonance imaging performed to evaluate the uterine malformation detected a dysplastic right kidney. We review the present knowledge and recommendations for the diagnosis and treatment of this anomaly, and we emphasize the use of magnetic resonance imaging not only for the evaluation and classification of Müllerian malformations, but also for the detection of the persistence of renal tissue missed with other studies.

Imperforate hymen presenting with chronic constipation and lumbago: report of one case

A history of unexplained low back pain associated with chronic constipation in an adolescent girl of menarchal age or in an obviously postmenarchal girl should make one consider an imperforate hymen with hematocolpos. This is a particular important differential diagnosis in the work-up of an adolescent who denies ever having had menses or sexual activity. The case of a girl with an imperforate hymen presenting with a six-month history of chronic constipation and intermittent low back pain is described.

Hematocolpos associated with a remote history of chronic vaginitis and a diagnostic vaginal biopsy: a case report

Bacterial vaginitis is commonly seen in the pediatric population. Severe or recurrent cases may be associated with ulcerative lesions. We report a case of vaginal biopsies of ulcerative lesions in a 9-year-old which led to severe vaginal adhesions, stenosis, and hematocolpos. A vaginoscopy and resection from below were not successful and an exploratory laparotomy with uterine perforation and sounding into the upper vagina were required to reopen the lower vaginal canal. We recommend the limited use of vaginal biopsies in the face of a typical vaginitis presentation, and aggressive treatment to promote mucosa healing when biopsies are required.

Role of laparoscopy in vaginal malformation

BACKGROUND

The aim of this study was to assess the role of laparoscopy in the management of vaginal malformations in children, a subject not often discussed in the literature.

METHODS

Between 1980 and 2002, we treated 22 children for vaginal malformations. Two main patient populations were distinguished: younger children with asymptomatic hymenal imperforation and hydrocolpos, and adolescents with hematocolpos. A third of the malformations were identified on systematic clinic examination, a third on the basis of abdominal pain, and a third due to various other symptoms. Nine of the girls had associated malformations of the uterus, external genital organs, or urinary tract. Eight patients underwent laparoscopy, either to look for endometriosis in cases of hematocolpos, to make an accurate determination of malformations in cases where clinical and paraclinical methods failed, or to manage an abnormality.

RESULTS

Eleven laparoscopic procedures were performed in eight patients. Three diagnostic laparoscopies enabled us to determine the exact nature of the malformations. One newborn underwent two laparoscopic procedures to treat peritoneal fibrous bands that had caused repeated episodes of obstruction. Six patients underwent exploratory laparoscopy to look for endometriosis, but none was found.

CONCLUSION

Laparoscopy is not applied systematically in the management of any malformation, but it can be useful when complementary exams fail to make an accurate diagnosis of the anomaly or for the management of the rare complication of adhesions and bands. When used to search for endometriosis, MRI detects ~50% of lesions, but laparoscopy is certainly still appropriate for that purpose. However, the optimal timing of the procedure still needs to be established.

[Imperforate hymen: undiagnosed at birth, surgical emergency in adolescence]

Imperforate hymen is a malformation that is easy to diagnose, even in countries with limited health care coverage. Unrecognized at birth, it becomes evident at puberty because of the development of a hematocolpos, which requires surgical intervention. This situation can be avoided with a complete examination of the infant at birth. This case report describes four patients whom we saw from 1995 through 2001 at the Bangui (Central African Republic) Pediatric Center and Community Hospital.

Imperforate hymen: Report of an unusual familial occurrence

Imperforate hymen is an uncommon obstructive anomaly of the female reproductive tract, which usually presents with intermittent and cyclical abdominal pain. Although it is usually sporadic, four cases of familial occurrence of imperforate hymen have been reported so far. Imperforate hymen is seldom associated with complications if it is detected early. In view of the possible familial occurrence, it is important to have a high index of suspicion in women who present with imperforate hymen. A detailed menstrual history of other female family members is necessary to enable early detection.

[Abnormalities of external and internal genitalia]

The gynecologic examination of the female genitalia of children and young adults belongs in the hands of specialists and should be performed in the appropriate environment. The most important task of such an examination is the distinction between true developmental anomalies and anatomical findings mimicking such anomalies. Even newborn females can be successfully examined without any large effort expenditure. In most cases, the external inspection of the vestibule is enough to reach a diagnosis. In other case scenarios, vaginoscopy and gynecological speculum examination may be necessary. Additional imaging studies include abdominal sonography and magnetic resonance imaging. Normal variations of a child's hymenal membrane, fusion of the labia minora, hymenal polyps and hypertrophy of the preputium of the clitoris are the entities most likely to be mistaken for real developmental malformations. The most important asymptomatic developmental anomaly of the vagina and the uterus is the Mayer-Rokitansky-Kuster-Hauser syndrome (uterine and vaginal agenesis). Developmental malformations, such as hymenal atresia, vaginal septum formation and Millerian anomalies in general, tend to be symptomatic, presenting with hematometra, hematocolpos or dysmenorrhea. The treatment of genital developmental anomalies is generally not difficult but requires the appropriate clinical and surgical expertise.

Hematocolpos in double vagina associated with uterus didelphus: US and MR findings

The malformative syndrome of double vagina in association with uterus didelphus and kidney agenesis is a rare condition, often asymptomatic: if this condition is accompanied by imperforated obstructed hemivagina, the clinical manifestations depend on the presence of hematocolpos. MRI plays an important role for diagnosis because it allows to characterize the nature of the lesion and to evaluate the anatomical details of the uterine malformation. The authors describe this complex genital malformation and discuss the main US and MRI features.

[Complete utero-vaginal duplication with hematocolpos and homolateral renal agenesis]

We relate one observation about a rare case of genital malformation, where is on association of unilateral hematocopos, bicorn uterine and homolateral renal agenesis. The diagnostic was suspected upon the association with a progressive dysmenorrhe and vaginal mass. II was confirmed by ethnographie and IRM. The treatment has been conservative and consisted only in the section of the vaginal partition.

[Diagnostic image (15). Hematocolpus due to atresia of the hymen]

In a 14-year-old girl who suffered from anuria and abdominal pain, atresia of the hymen was diagnosed.