CASE REPORT

Niger J Paed 2013; 40 (1): 79 –81

Gueye M

Seck SM

Ndiaye-Guèye MD

Thiam O

Imperforate hymen complicated by

obstructive acute renal failure

Gueye L

Diouf M

DOI:http://dx.doi.org/10.4314/njp.v40i1.15

Accepted: 18th June 2012

Abstract Imperforate hymen is a 14-year-old girl to emphasize the

rare malformation (1/ 1000 female possible misdiagnosis and its possi-

births). It is diagnosed most often ble consequences. This is the first

during puberty. Early diagnosis of case we encounter in our unit.

hematocolpos and evacuation is

Gueye M

(

)

Ndiaye-Guèye MD, Thiam O

Gueye L, Diouf M

Department of Obstetrics and

Gynaecology

necessary to avoid any conse- Keywords: Hymen, imperforate,

quences. We report a rare case of an hymenectomy

imperforate hymen complicated renal failure.

with acute urinary retention, hy-

, hydronephrosis,

Seck SM

Department of Hemodialysis,

Regional Hospital Lt. Colonel

Mamadou Diouf,

dronephrosis and renal failure in a

POBOX 401, Saint-Louis, Senegal.

Tel: 00221 776517272

Email: mamourmb@yahoo.fr

Introduction

tion was not possible due to the pelvic mass.

A hymenectomy was performed and 1400 ml of altered

blood was drained. Figure 1E shows the postoperative

aspect after hymenecotomy. Bladder catheterization was

then possible. The post-operative ultrasound examina-

tion showed a normal uterus. She was discharged on

postoperative day one with an uneventful recovery.

Sonographic morphology of left kidney was normalized

ten days after drainage of the hematocolpos (Fig.1F) and

creatinine level returned to normal after five weeks. The

nephrologist suggested weekly monitoring of renal func-

tion. Normal menses appeared six weeks after surgery.

Imperforate hymen is a rare and isolated malformation

of the female reproductive system (1/ 1000 female

births). It is diagnosed most often during puberty as

hematocolpos by retention of the first menses. Early

diagnosis of hematocolpos and evacuation is necessary

to avoid any consequences. We report a rare case of an

imperforate hymen complicated with acute urinary re-

tention, hydronephrosis and renal failure in a 14-year-

old girl.

1

Case

Fig1A: Suprapubic mass represented by the hematocol-

A 14-year-old girl was admitted to the gynaecologic

department for onset of abdominal pain and acute uri-

nary retention. She experienced four similar episodes

during the four last months. Secondary sexual character-

pos

istics were normal for her age (Tanner stage IV).

A

mass, around 15 cm in diameter, was palpable between

the ombilicus and the pubic bone . The mass was tense,

with regular contours and dull to percussion. Mobiliza-

tion was limited and painful. (Fig.1A). On perineal ex-

amination, a bulging and purplish imperforate hymen

was identified (Fig.1B). It was tender. Rectal examina-

tion revealed a large pelvic mass tense and sensitive .

Creatinine level was 50 mg/dl. Transabdominal ultra-

sound found a suprapubic homogeneous and fluid-filled

mass around 15.5 cm in diameter (Fig.1C) associated

with left hydronephrosis (Fig.1D). Urethral catheteriza-

8

0

Fig1B: Appearance of the imperforate hymen

Fig1E: Postoperative view of the hymenectomy

Fig1C: Left hydronephrosis

Fig1F: Appearance of the left kidney 10 days after the

drainage of hematocolpos

Fig1D: Sonographic appearance of hematocolpos

Vaginal secretions accumulated₆ in late pregnancy are

exacerbated by the genital crisis.

The result is a hydrocolpos which diagnosis can be

made by ultrasound examination during antenatal pe-

riod. Urinary retention, difficulty in breathing or delayed

passage of meconium are possible. At puberty, the diag-

nosis is often discovered by painful primary amenor-

rhea, abdominal pain (cyclical and more intense) or the

discovery of an abdominopelvic mass. Retention of

menstrual flow is responsible for the creation of a hema-

tocolpos. Some symptoms may be associated with: back

pain (38-40%), urinary retention (37-60%), constipation

7

(

27%). Vaginal distension might compresses the ure-

thra, bladder, ureters and rectum. Clinical examination

can find a suprapubic mass and vulvar inspection con-

firms the imperforate hymen that is thick with a bluish

color. Digital rectal examination found retention as a

renitent mass. Ultrasound is not necessary to make the

diagnosis but can be useful to assess the upstream im-

pact (haematometria or hématosalpynx). However, in

some doubtful cases, ultrasound allows for better plan-

Discussion

1

The imperforate hymen affects about one girl in 1000.

It results from the lack of resorption of the hymen mem-

brane that is part of the cloacal membrane. It is₂_,₃usually

sporadic, but familial cases have been reported. It was

4

3

first described by Ambroise Paré. Imperforate hymen is

ning of surgery. When the diagnosis is made late, com-

seldom associated with other malformations of the fe-

male reproductive system because t₅he hymen is not de-

rived from the Mullerian system. The diagnosis re-

quires a high index of suspicion. An examination of the

vulva is not always done before puberty and it is, there-

fore, not uncommon that the diagnosis is made in an

emergency context. In the neonatal period, the system-

atic examination of the vulva would usually reveal a thin

hymen, tense, bulging, bluish-white and non-tender.

plications as retrograde menstruation, rupture₅_,o₈f haema-

tosalpinx or hydronephrosis can be observed.

A case of spontaneous rupture of th₇ e hymen by a large

hematocolpos has been described. The treatment of

imperforate hymen is exclusively surgical. In the new-

born, the resection of the central part of the hymen is

easy and allows the preservation of a free edge. No

drainage is necessary. At puberty, a hymenectomy is

made.

8

1

7

Two techniques are mainly used: a simple incision or

Conclusion

excision of the membrane. Acar et al. advocated the use

of "mini-hymeneotomy" (0.5 cm incision) to₉gether with

keeping a Foley catheter in situ for 2 weeks. However,

this technique is not universally accepted due to the high

recurrence rate. Laparoscopy can be proposed to treat

adhesions secondary to reflux of menstrual blood in the

peritoneal cavity. In cultures where virginity is highly

prized for marriage, premarital hymen rupture can

shame a woman or her family. Hymeneotomy may cause

dyspareunia (fibrosis hymen) or conversely a defloration

when hymen membrane excised is important. We be-

lieve that in any case of hymeneotomy, a medical certifi-

cate must be given to parents to deal with potential con-

flicts that could result in the absence of bloody dis-

charge during the wedding night. In addition, hymeo-

plasty in these cases is a n₁₀ice alternative in accordance

with the ethical principles.

Imperforate hymen is a rare malformation that can be

troublesome when diagnosed late. The systematic gyne-

cological examination of newborns help to reduce the

complications caused by the menstrual retention in ado-

lescence. In addition, any pelvic pain in a young girl old

enough to have her menses, one of the The diagnoses of

imperforate hymen should be considered in a pubertal

girl who is complaining of cyclical abdominal pain.

Conflict of interest: None

Funding: None

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