What Is Causing Suprapubic Pain in a Prepubescent Girl?

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

Disclosures

January 12, 2011

Discussion

Hydrometrocolpos is defined as any obstruction of the vaginal tract during the prenatal, perinatal, or adolescent period that results in the entrapment of vaginal and uterine secretions. Hydrocolpos is a condition in which fluid builds up in the vagina, causing vaginal distention. Hydrometrocolpos occurs when fluid in the vagina also extends into the uterus, distending both organs. Hematometrocolpos is when menstrual products are retained. These conditions are most commonly associated with imperforate hymen, vaginal atresia, cloacal anomalies, or transverse vaginal septum.[1,2] They usually present at times of high estrogen production (in infancy or early puberty) when the reproductive glands are stimulated to increase secretions, which if unable to escape, will eventually distend the vagina and uterus.[1] However, it is not uncommon to miss this diagnosis in infancy because the genitalia are smaller, and an obstruction is more difficult to detect.

In the newborn who is under the influence and structural changes induced by maternal estrogens, the labia majora are plump, the hymen is elastic and often fimbriated, and the mucosal surfaces are pale pink. These hymenal changes from estrogenization may lead to a false sense that the hymen is open. Regardless, approximately 80% of hydrometrocolpos cases will be diagnosed before 3 months of age.[3]The remainder of patients will seek care in early puberty.

Signs and Symptoms

In fetal development, the perinatal period, or infancy, patients may present with mucocolpos, which is the presence of mucoid secretions in the vagina from the ureterovaginal tract under the influence of maternal estrogens, or a bulging interlabial cyst able to be palpated in the lower abdominal quadrants. If not diagnosed in infancy, patients will often present between 9 and 15 years old with complaints of nonspecific intermittent or chronic lower abdominal pain around the time of menarche and may show development of secondary sex traits along with primary amenorrhea.

In adolescence, the retained secretions consist of menstrual products, and the resulting mass effect in the vagina and uterus are referred to as hematocolpos and hematometrocolpos, respectively.[3]These patients may describe the pain as "cramps" but they have not menstruated yet. They may present with symptoms typical of urinary tract infections -- such as dysuria, frequency, urgency, and suprapubic pain -- from the fluid collection pressing on the bladder.

Imperforate hymen is the most frequent and most distal obstructive anomaly of the female genital tract with estimates of its frequency ranging from 1:1000 to 1:10,000.[4] Specific etiologies for failure to establish patency are not evident. Imperforate hymen usually occurs sporadically, but there have been reports of familial occurrence.[5,6,7] In normal development, the central portion of the hymenal membrane is usually absent, which creates the typical configuration of a ring-like structure at the vaginal vestibule. Imperforate hymen and related genital tract anomalies result from abnormal or imcomplete embryologic development (eg, persistence of an intact hymenal membrane). The differential diagnosis of an imperforate hymen includes labial adhesions, incomplete hymenal obstruction, hymenal bands, obstructing longitudinal or transverse septa, and vaginal agenesis or androgen insensitivity.

Diagnosis

Clinical presentations of imperforate hymen range from an incidental finding on physical examination of an asymptomatic patient to findings discovered on an evaluation for abdominal pain which can be cyclical, back pain, or primary amenorrhea. Additional presenting symptoms of imperforate hymen include urinary retention and constipation.[8] The diagnosis of hematometrocolpos can be achieved with physical examination and abdominal ultrasonography or abdominal CT. Physical examination of the vagina will reveal a distensible, translucent, thin, bulging bluish membrane just inferior to the urethral meatus at the introitus between the labia. On abdominal ultrasonography, a hydrometrocolpos will present as a large midline translucent mass displacing the bladder forward. On abdominal CT, a large cystic lesion can be seen in the vagina and/or the uterus. Radiographic documentation must demonstrate that the true diagnosis is not an obstructing transverse vaginal septum or other anomaly. The diagnosis should not be confirmed by aspirating secretions beyond the obstruction because this procedure may result in iatrogenic pyocolpos, an accumulation of pus in the vagina.

Treatment

Observation of an imperforate hymen throughout childhood, with a planned surgical repair after the onset of puberty and before menarche, is an optimal approach in asymptomatic cases diagnosed in infancy or childhood. Surgery in the presence of adequate estrogenization avoids scarring and the potential need for repeat surgery. Avoidance of persistent obstruction preserves the patient's fertility by reducing the risk for secondary endometriosis, which can occur with hematosalpinx or reflux of the endometrial tissue through the fallopian tubes. If urinary symptoms or obstruction develop, treatment is surgical. The procedure is either a hymenotomy (incision and opening of the hymenal membrane which is not removed) or hymenectomy (removal of the hymenal ring).[3]

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