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An 11-year-old girl presumed to be premenarchal presented to the emergency department with a 24-hour history of constant periumbilical pain that radiated to both flanks. She also noted nausea, urinary frequency, and dysuria, which had preceded the onset of the abdominal discomfort by two days. The patient stated that she had never been sexually active and reported no vaginal discharge, difficulty with bowel movements, or fever, chills, or sweats. Her medical history was unremarkable, and she took no medications. Examination of the abdomen revealed tenderness of the left lower quadrant and suprapubic region on palpation, with rebound and voluntary guarding. Examination of the perineum revealed an imperforate hymen, which was vascular, bulging, bluish, and protruding from the introitus while the patient was supine (Panel A). Pelvic ultrasonography (Panel B) showed dilatation of the vagina (white arrow) and uterus (black arrow) caused by fluid — a finding that confirmed the clinical diagnosis of hematocolpometra. During hymenotomy, 300 ml of brown blood was drained from the vagina and uterus. At a 14-day follow-up visit, the patient reported that her symptoms had resolved.
Although rare, imperforate hymen with retrograde menstruation that causes dilatation of the vagina and uterus (i.e., hematocolpometra) is an important consideration in the differential diagnosis of abdominal pain in premenarchal girls. It is easily diagnosed by physical examination.
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