What Is Causing Suprapubic Pain in a Prepubescent Girl?

Marilynn Chan; Joyce C. Arpilleda, MD; Ghazala Sharieff, MD


January 12, 2011

History and Physical Examination


Five days before being seen in the emergency department, intermittent umbilical and lower abdominal pain that radiated to the left lower quadrant developed. Pain in the suprapubic area, but not of the urethra, also developed when she was urinating. The patient had urgency without urethral discharge or frequency. She did not have any fever, vomiting, diarrhea, or constipation. She has not yet started menstruating.

Physical Examination

  • Vital signs: pulse 80 beats per minute, respirations 18 breaths per minute, temperature 36.6°C, blood pressure 103/64 mm Hg;

  • Oxygen saturation: 100% in room air;

  • Weight: 71.5 kg;

  • HEENT: normocephalic, atraumatic; pupils brisk and reactive, extraocular movements intact; nose patent, no rhinorrhea; mucous membranes moist, no tonsillar exudates;

  • Neck is supple with normal range of motion;

  • Lungs: clear to auscultation bilaterally;

  • Heart: regular rate and rhythm, no murmurs, rubs or gallops;

  • Musculoskeletal: no cyanosis, clubbing, or edema; patient was able to ambulate and jump 2 feet without difficulty or pain;

  • Neurologic: alert and oriented;

  • Skin: warm, capillary refill < 3 seconds, no rashes;

  • Abdomen: obese, normal active bowel sounds, no distention, rebound or guarding, initially only tender to palpation at midline lower abdomen and suprapubic area, but upon repeat examination, she reported pain throughout the entire upper abdomen except for the left upper quadrant; and

  • Genitourinary: imperforate hymen with protruding bulge with bluish hue.

Figure 1. Classic appearance of bulging, blue-domed, translucent membrane.. Source: Adams Hillard PJ. Imperforate Hymen. eMedicine. 2010. Available at: https://emedicine.medscape.com/article/269050-overview.

Laboratory Value and Imaging Results

Her workup for abdominal pain, including right lower quadrant pain, included:

  • Complete blood cell count: leukocytosis (14.1 x 103);

  • C-reactive protein: upper limit of normal (0.9 mg/dL);

  • Urinalysis: protein 2+, negative nitrites, negative leukocytes, red blood cell count 32/mm3, white blood cell count 37/mm3, many bacteria;

  • Abdominal CT: large, fluid-filled cystic lesion measuring 8.1 x 2.7 x 11.3 cm, distending the vagina and causing mild distention of the endometrial canal.


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