A Rare Case of Imperforate Hymen Presenting with Perineal Pain

Abstract

Introduction: Imperforate hymen is a rare local fusion anomaly of the female reproductive tract and diagnosis can be easily missed. Cyclic lower abdominal pain and amenorrhea are common symptoms in cases left untreated after menarche. Perineal pain may be an unusual presenting symptom of imperforate hymen. In order to avert complications related to delayed treatment, hymenotomy is considered effective management.

Case Report: We herein describe a case of a 13-year-old adolescent girl with an imperforate hymen presenting with lower abdominal and perineal pain. The girl underwent and hymenotomy and postoperative period was uneventful. Perineal and pelvic pain relieved instantly after surgical treatment and during follow up her menstrual cycles were regular.

Keywords: Imperforate hymen; Hematocolpometra; Adolescence; Perineal pain

Introduction

The most common congenital anomaly of the female genital tract leading to vaginal outlet obstruction is imperforate hymen. During embryogenesis, a failure in canalization of the caudal segment of the vaginal plate at its juncture with the urogenital sinus leads to imperforate hymen [1]. The incidence is estimated among 0.05- 0.1 % of female newborns, although it may occur more frequently [2]. First symptoms may appear during adolescence; hence, the majority of cases pass unnoticed [1]. Cases with prenatal diagnosis via ultrasonography or clinical diagnosis during neonatal period have been also described [3]. Usually, primary amenorrhea is the presenting symptom in most patients. Cyclic pain of the lower abdomen, and hematocolpometra derivative to the accumulated menstrual blood. Atypical signs and symptoms of imperforate hymen have been also reported [4]. We herein present a case of an imperforate hymen as a cause of lower abdominal pain and perineal pain.

Case Presentation

A 13-year-old premenarchal adolescent girl presented to our outpatient department complaining of perineal pain and lower abdominal pain that started before 36 hours. She reported loss of appetite due to the pelvic pain. Patient described a feeling of heaviness deep within the pelvis and discomfort in the perineal area with a previously normal passage of stools on a daily base. From past medical history, patient reported several episodes of lower abdominal pain gradually worsened in the past six months, which improved without treatment. General examination of the patient revealed a normal phenotype and well developed secondary sexual characteristics (Stage 4 on Tanner scale). On abdominal examination, suprapubic tenderness was elicited and a mass corresponding to the size of a 13 weeks gravid uterus was palpated. A large mass was detected anteriorly by rectal examination. Examination of the external genital organs, showed a bulging hymenal membrane with bluish discoloration when retracting the labia. Patient’s, white blood cell count was 13.900 K/μL (Neutrophils: 78.9%), hemoglobin was 11.3 g/dL and C-reactive protein was 3.5 mg/L.

Accordingly, patient underwent a transabdominal ultrasonography; Findings included a normal-shaped uterus and the vagina was all filled up with hypoechoic fluid, indicating hematocolpos. Hence, the diagnosis of imperforate hymen was made. A magnetic resonance imaging took place in order to exclude congenital Müllerian anomalies (Figure 1). The patient was brought to the operating theater for surgery under general anesthesia, after obtaining informed consent from her guardian. A hymenotomy with crucial incision of the hymen took place and approximately 500ml of deep red colored fetid blood evacuated and intravenous antibiotics were administered (Figure 2). The postoperative course of the patient was uneventful and she was discharged on day 2. A follow-up took place six months after treatment. The patient was asymptomatic and she reported regular menstrual cycles.

    

    

    Figure 1: A, Sagittal T2 weighted MRI image showing distention of uterus
and vagina by dense fluid (old blood)-Hematocolpometra. B, Axial T2
weighted MRI image showing the lower third of the dilated vagina due to
imperforate hymen.
    

    

    

    Figure 2: Perioperative finding after hymenotomy with a crucial incision of the
hymen, showing the restore of the vaginal outflow.
    

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Citation: Zacharis K, Klimatsouda M, Donoudis C, Valasoulis G and Daponte A. A Rare Case of Imperforate Hymen Presenting with Perineal Pain. Austin J Obstet Gynecol. 2021; 8(1): 1161.

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