Diagnostic Ultrasound - Abdomen and Pelvis

Hematometrocolpos
Diagnoses: Female Pelvis
PATHOLOGY
General Features
• Etiology
○ Imperforate hymen
– Most frequent cause of vaginal outflow obstruction
○ Müllerian duct anomaly
– Vaginal septum: Transverse or vertical
– Vaginal agenesis
– Cervical agenesis
– Uterus didelphys with obstructed hemivagina is most
confusing as normal menstruation occurs through
nonobstructed side
○ Cloacal malformation
– Confluence of rectum, vagina, and urethra into single
common channel
– Often septated or bilobed due to müllerian
duplication
– Up to 50% present with hydrocolpos at birth
– Obstruction due to vaginal stenosis after
reconstruction, stenosis of persistent urogenital sinus
(no previous reconstruction), or cervical stenosis
○ Cervical/vaginal stenosis
– Post radiation therapy for gynecologic/colorectal
malignancies
– Post reconstructive surgery
– Vaginal stenosis described in chronic graft-vs.-host
disease
• Associated abnormalities
○ Renal anomalies
○ Endometriosis
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Primary amenorrhea
○ Cyclical pelvic pain/pressure
○ Low back pain
• Other signs/symptoms
○ Urinary retention secondary to pressure on
bladder/ureters
○ Constipation secondary to pressure on rectum
○ Presents at puberty if associated with MDA
– Uterus didelphys → duplicated vagina → normal
menses through unobstructed side with progressive
distension of obstructed side
○ Presents later if associated with cervical cancer
– Average age at diagnosis of CxCA is 50 years
– Radiation therapy induced cervical/vaginal stenosis
develops within a year of therapy
Demographics
• Epidemiology
○ Imperforate hymen 1:1,000
○ Vaginal agenesis 1:5,000
○ CM occurs exclusively in females, 1:20,000 live births
○ Vaginal stenosis occurs in up to 88% of cervical cancer
patients treated with radiation therapy
Natural History & Prognosis
• Depends on underlying etiology
○ Imperforate hymen easily corrected
○ CM requires complex repair with multiple surgeries
○ MDA repair varies with malformation: Simple septal
resection to more complex vaginal reconstruction
• Associated with endometriosis
○ Increased incidence of infertility/ectopic pregnancy
○ Chronic pelvic pain
Treatment
• Avoid aspiration as risk of infection → pyocolpos/pyometra
• Imperforate hymen
○ Cruciate incision with marsupialization of edges to
vaginal wall
○ Simple incision inadequate → does not guarantee
complete drainage → risk of infection
• MDA
○ Incision/removal of vaginal septum
○ Creation of perineal opening/vaginoplasty
○ Uterine surgery may also be required to improve chances
of successful pregnancy
• Radiation therapy related
○ Topical estrogen, anti-inflammatory ointment
○ Serial vaginal dilators
• CM
○ Surgical challenge is to create 3 perineal openings with
functional vagina, bladder/bowel control
○ Individual anatomy will direct reconstructive approach
DIAGNOSTIC CHECKLIST
Consider
• HM/HC should be considered in young female patients with
lower abdominal symptoms or back pain
Image Interpretation Pearls
• Distended uterine &/or vaginal cavities with heterogeneous
avascular material
SELECTED REFERENCES
1. Sakhel K et al: Begin with the basics: role of 3-dimensional sonography as a
first-line imaging technique in the cost-effective evaluation of gynecologic
pelvic disease. J Ultrasound Med. 32(3):381-8, 2013
2. Behr SC et al: Imaging of müllerian duct anomalies. Radiographics.
32(6):E233-50, 2012
3. Marcal L et al: Mullerian duct anomalies: MR imaging. Abdom Imaging.
36(6):756-64, 2011
4. Drakonaki EE et al: Hematocolpometra due to an imperforate hymen
presenting with back pain: sonographic diagnosis. J Ultrasound Med.
29(2):321-2, 2010
5. Junqueira BL et al: Müllerian duct anomalies and mimics in children and
adolescents: correlative intraoperative assessment with clinical imaging.
Radiographics. 29(4):1085-103, 2009
6. Dane C et al: Imperforate hymen-a rare cause of abdominal pain: two cases
and review of the literature. J Pediatr Adolesc Gynecol. 20(4):245-7, 2007
7. Sherer DM et al: Acquired hematometra and hematotrachelos in an
adolescent with dysfunctional uterine bleeding. J Ultrasound Med.
25(12):1599-602, 2006
8. Prada Arias M et al: Uterus didelphys with obstructed hemivagina and
multicystic dysplastic kidney. Eur J Pediatr Surg. 15(6):441-5, 2005
9. Warne SA et al: Long-term gynecological outcome of patients with
persistent cloaca. J Urol. 170(4 Pt 2):1493-6, 2003
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