Background : Imperforate hymen remains the leading female genital tract malformation. However, its presentation as acute urinary retention and lower abdominal pain in children is relatively uncommon.
Case report : We present a case of 13 year old pre-menarchal female who presented with acute urinary retention and a painful suprapubic lump in emergency department. Foleys catheterization was done to relief her urinary retention. On detailed examination, she was diagnosed with imperforate hymen and palpable lump in abdomen. Ultrasonography revealed hematometrocolpos. Patient underwent hymenotomy and passive drainage of collected menstrual blood.
Discussion : Imperforate hymen presents as amenorrhea, recurrent cyclical lower abdominal/pelvic pains, acute urinary retention or palpable lump due to hematometrocolpos.
Abdominal Pain, Amenorrhoea, Urinary Retention, Hymen, Pelvic Pain.
Imperforate hymen is the most common obstructive congenital lesion of the female genital tract. It occurs in approximately 0.05% to 0.1% of newborn girls. It is characterized by a crescentic thin membrane that covers the intraoitus. It may be recognised because of mucocolpos at birth, but the diagnosis is usually not detected before puberty. The symptoms that appear after the onset of puberty are due to accumulation of menstrual blood. Menstrual blood usually accumulates in the uterus and upper vagina resulting in abdominal pain, distension of the lower abdomen and often acute urinary retention. Symptoms can range from mild abdominal pain and tenesmus to urinary retention and a palpable lump in abdomen due to hematometra, hematocolpos or hydrocolpos. Haematocolpos is a rare condition seen with imperforate hymen or vaginal atresia in peripubertal age, where the vagina is filled with menstrual blood. The management of an imperforate hymen is simple, and involves making a cruciate shaped incision to open the vaginal orifice. A vast majority of these cases are sporadic in nature , however familial cases showing dominant as well as recessive inheritance patterns have also been studied., Here, we have presented a case of a young girl, 13yrs of age, with acute urinary retention and lump abdomen, due to imperforate hymen.
Case Report :
A 13 yr old, pre-menarchal girl, had presented in the Emergency department with urinary retention since 12 hours. She also complained of a painful lump abdomen that had been slowly growing in size over the past 4 months. On further questioning she gave history of cyclical lower abdominal pain since the last 5-6 months. Pain was colicky in nature, non-radiating, associated with lower back pain and would subside on taking analgesics as prescribed by a local physician. It was also associated with urinary symptoms such as increased frequency, associated with hesitancy to initiate micturition, followed by a sense of incomplete voiding. These symptoms had aggravated in the last two months. She had regular bowel movements and had no previous history of urinary retention, trauma or surgery. Birth history was unremarkable and there no delays in her developmental milestones. Routine blood investigations were carried out and her Hb was found to be 9.1 gm%, TLC - 8900/cu mm, Urea and Creatinine were 16mg/dl and 0.5mg/dl respectively. On catheterization (No. 10, Foleyís Catheter) 700 ml of clear urine was drained which was associated with almost instant relief of her lower abdominal discomfort and pain. A detailed examination was carried out with the following positive findings:
General Physical Examination: Mild pallor, No incterus, lymphadenopathy. Afebrile, PR - 100bpm, regular, good volume. BP 120/70mm Hg. JVP - not raised. CVS - S1, S2 +, No murmurs. RS - NVBS +, No added sounds.
Her sexual maturity rating on Tannerís Scale was II with regard to breast development and pubic hair growth. She had not attained her peak growth velocity yet.
P/Abd Findings : A midline, suprapubic mass, corresponding to 12-14 weeks of gestation, soft and tender to palpation, was found originating from the pelvis.
Perineal inspection revealed a central pinkish bulge covered with a thin membrane at the intraoitus. [Figure 1.] It was exaggerated on applying pressure over the suprapubic lump and when she was asked to cough / strain. External urethral meatus appeared normal.
On gentle Per rectal examination, the mass was found to be anterior to rectum and was cystic in consistency.
Ultrasonography abdomen revealed a large fluid collection of 8.3 X 6.5 X 5 cm with internal echoes (suggestive of blood) distending the vagina and uterus. There was minimal free fluid in the peritoneal cavity. Her USG features coupled with clinical presentation strongly suggested a diagnosis of imperforate hymen leading to hematocolpos and hematometra.
Routine pre-anesthetic investigations and evaluation was carried out and she was posted for surgery.
Procedure : She was placed under general anesthesia and put in lithotomy position for the procedure. Taking all aseptic precautions, the hymen was perforated at the centre of the distended and imperforate hymenal membrane using a sterile wide bore needle. Needle aspiration from the bulging hymenal membrane confirmed that the aspirate was collected blood. A cruciate incision was made on the membrane which allowed approximately 700 cc of collected blood to passively drain out [Figure 2]. Size of the suprapubic lump decreased dramatically during the procedure and by the end of the procedure, there was no palpable mass in the abdomen. The incised quadrants of the hymenal membrane were excised laterally and margins of the vaginal mucosa approximated with absorbable vicryl sutures. Post operatively, she received IV antibiotics, analgesics and local anesthetic cream. Post operative period was uneventful and she was discharged 5 days following the procedure and is presently asymptomatic on follow up.
The hymen is a thin membrane at the junction of the sinovaginal bulbs with the urogenital sinus. It is usually perforated during embryonic life to establish connection between the lumen of the vaginal canal and the vaginal vestibule and it is usually torn in the prepubertal years. If canalization failsand there are no perforations, the hymen is called imperforate hymen.It is usually an isolated finding with no associated anatomic abnormalities.
A careful inspection of the external genitalia usually diagnoses the condition at any age. However, most commonly it is not detected until puberty, with girls presenting at age 13 to 15yrs when symptoms begin to appear with no external evidence of menstruation. The symptoms of imperforate hymen at puberty are due to the accumulation of menstrual blood within the vaginal outlet tract. The blood of the first few cycles is collected in the vagina, and this is known as hematocolpos. With continuing menstruation, the vagina distends, cervical canal dilates and retrograde filling of the uterine cavity occurs, which is known as hematometra. Further retrograde filling will cause hematosalpinx and rarely blood passes freely into the peritoneal cavity causing features of peritonitits.
Most commonly, girls present with lower abdominal pain, low back pain. A tender mass may be palpable suprapubically and urination can be difficult due to pressure of the distended vagina which can compress the urethra and prevent emptying of the bladder. Bladder symptoms can present as frequency, urgency and sometimes even dysuria. 
Pelvic ultrasound should be performed in the evaluation of imperforate hymen particularly oprior to planning surgical intervention. Laparoscopy however, has not been included in the standard evaluation of imperforate hymen.
In the classical surgical treatment of imperforate hymen, stellate or cruciate incisions are made through the hymenal membrane. The individual quadrants are excised, and mucosal margins are approximated using fine delayed absorbable suture. Approach to the surgical management of imperforate hymen requires cultural sensitivity. The goals of surgical management are both long term and short term. In the short term, the obstruction of vagina is alleviated, while satisfactory cosmesis, sexual function and fertility preservation are long term goals. In cases of imperforate hymen presenting with urinary retention, retention should always be treated via Foleys catheterization until definitive treatment via hymenotomy can be achieved. Different types of incision are proven effective for hymentomy in literature such as cruciate incision, longitudinal incision, or excision of part of membrane. Hymenotomy is a minor procedure that does not cause significant morbidity and provides complete relief of all the symptoms. Follow up is always necessary to make sure there is no refusion of the hymen.
Despite being the commonest obstructive, congenital lesion of the female genital tract, imperforate hymen is not a frequent cause for acute urinary retention or lower abdominal pain in children and adolescents. Hence, It is a diagnosis that can easily be overlooked in the fast paced setting of the Emergency Department. It must be included, particularly, in the differential diagnosis of every pre-pubertal young female with abdominal pain or acute urinary retention. Hymenotomy, a simple surgical procedure is all that needed for the treatment of imperforate hymen patients who can present with acute surgical emergency.