Disclaimer: This article is purely for education purpose & consent has been taken from the patients to display the images/ video. Some of the pictures & diagrams are uploaded from google images. Would like to thank all patients, contributors & owners for the google images for their pictures/video to be used in this article. 

Haematocolpos

What is Haematocolpos: It is a medical condition in which the vagina (colpos) is filled/pooled  with menstrual blood. It is  due to  the blockage of menstrual blood flow. The word hematocolpos stands for  'an accumulation of blood within the vagina'. It is often caused by obstruction to the outflow of menstrual blood flow through the vagina. Haematometra which is the collection of blood in the uterus is sometime related with haematocolpos. The intense pressure & back flow of the obstructed blood leads to formation of Haematometra. In this articles, i will confine our discussion to simple Haematocolpos only.  Below are example causes of haematocolpos. 

a. Imperforate hymen

b. vaginal atresia

c. transverse septum

d. Mullerian Duct Anomalies

Typical Clinical presentation are as below: all these case were manged by me. These cases presented in different scenarios with different physical findings. Tha manage are tailored based on the underlying cause/pathology and was dealt accordingly.

Case 1:

A 12 year old girl, presented to casualty with severe lower abdominal pain. She has this cyclical pain for few months before. She has not attain menarche yet. On examination, the secondary sex characteristics are present. On abdominal examination, there was a 16 week size pelvic mass & its tender on palpation. Perineal examination, there was bluish bulging from the vaginal out let. Pelvic Ultrasound sound showed a large Haematocolpos. The uterus was normal with slight thickened ET & there was some fluid in POD. DX: Imperforate Hymen. Investigation is usually pelvic ultrasound is sufficient. Treatment is usually a simple cruciate incision or elliptical incision of the hymen. Hymen can usually be spaced (hymen spacing surgery). In this case a cruciate incision was made. The staled blood was drained passively. Patient recovered uneventfully.

Case 2:

13 year old girl presented to the casualty with primary amenorrhea & cyclical abdominal pain and difficulty pass urine. On examination, the sexual characteris was normal. The abdomen was distended. Vaginal examination. there were no vaginal opening. There was no perineal bulging. PR there was a gap in between the forchette and the the upper border of the vaginal. The pelvic ultrasound showed a large haematocolpos and some haematometra ( blood collection in the uterus). DX:  Vaginal Atresia

Investigation: pelvic Ultrsaound/ MRI

Treament: Vaginaplasty & Recreation of vagina.

In this case, There was a 2.5 cm of fibrous tissue noted between the vaginal outlet and the lower margin of haematocolpos. The large haematocolpos has helped in stretching the vagina and made the recreation of vaginal easier. Care has to be taken to identify the anterior & Posterior structures. A CBD is useful to assess the anatomy of the urethra. A large bore needle and syringe can be used to find the correct plan between the outlet & haematocolpos. When the correct plane is identified, than, one can use a fine scissors to create a tunnel along the needle to reach the haematocolpos. The upper vaginal margin can be opened & the Haematocolpos can be drained. The upper vaginal margin are than stretched & reattached with the forchette/ or the vaginal outlet. A small fenton operation may be necessary in some cases to facilitate the attachment. The create tunnel/vaginal than be dilated with large hegar dilators to provide a reasonable vaginal diameter.  Patient are also advised to continue to dilated the vagina once the healing process taken place. Dilatation prevents vaginal stenosis.  

Case 3: 

 

!2 plus girl presented with recurrent pelvic pain, aw vomiting & urinary frequency. Examination revealed mass in the lower abdomen with tense swelling. VE finding showed a small vaginal opening & there was a thick septum about 1.5 com from the vaginal outlet. The hymen was seen. A diagnosis of complete transverse septum was made. The septum was excised & the haematocoplos was released without any issues. Patient recovered well. She obtained her  regular periods after the procedure & there were no further heamatocolpos.

Case 4. 

33 yrs, patient who was married for 7 year.  c/o chronic pv discharge & occasional pelvic pain and primary infertility. Has normal periods monthly. No dysmenorrhea. Abdominal examination: flabby abdomen. VE= deep vagina, difficult to see the cervix. moderate bulging at the left vaginal wall.  Ultrasound of pelvis: Large ? Haematometra with Didelphys uterus. The left kidney was absent. Both ovaries seen and appeared normal.

CT Scan: Didelphys uterus with large left vaginal collection (Abscess). The Right kidney normal. Left kidney absent. DX: Ohira syndrome: Delayed & atypical presentation (Left Pyocolpos)

Treatment: EUA, Excision of the septum & Diagnostic Laparoscopy was carried out

Conclusion:

The causes for Hematocolpos are diverse. The above 4 causes are the mostly encountered.  The treat is usually surgical. There are different surgical treatments which needs to be undertaken to cure it. In extreme case like congenital cervical atresia, a complete  hysterectomy may be necessary.

For the women who have an imperforate hymen, a minor surgery is sufficient. An incising for the hymenic membrane or hymenotomy is sufficient to facilitate menstrual flow. In some case with tight outlet, patients may be required to insert dilators into the vagina for a few minutes each day for a few days post the surgery to avoid the incision being closed on its own or to maintain it patency. The surgical correction of a transverse septum and vaginal atresia can be difficult if the surgery is not carefully planned. Postoperative complications, such as vaginal stenosis and re-obstruction can occur, especially when the septum/vagina is thick. In such cases long term dilation with vaginal dilators may be necessary.The thickness and location of the septum is most commonly evaluated by transperineal ultrasound or MRI before attempting its resection. Mullerian duct anomalies can be changing & the surgical treatment planned need to be tailored toward relieve the acute symptoms & long term maintenance for the sexual & reproduction function in such patients. In such cases a preoperative assessment with imaging techniques and multi discipline approach may be necessary to provide effective & long term good outcome. 

GENITAL INFECTION IN GYNAECOLOGY 

( MEDICAL STUDENTS LECTURE & NOTES) 2022

The Nature and Role of Physiological Vaginal Discharge.

● Normal for woman to have some degree of vaginal discharge. 

● Normal - white to yellowish (d/t oxidation). 

● Contents: Mucous, desquamated epithelial cells, bacteria and fluid from endometrial.

● There is slight odour but it’s not strong. pH: acidic (4-5). 

● The role : ○ To carry away dead cells and bacteria thus keeps the vagina clean.

                    ○ Acidic - act as defense mechanism against pathogens.

COMMON GENITAL INFECTION IN GYNAECOLOGY:

Vulvovaginal Candidiasis

Causal organism: Candida albicans (gram +ve oval yeast). 

Predisposing factors: Pregnancy (40%), DM, high-dose combined OCP, HIV. 

Signs & symptoms: Vulval itching, thick white curdy discharge (vaginal thrush), dyspareunia, dysuria, vulval oedema, redness, normal vaginal pH. 

Diagnosis: High vaginal swab -> gram stain/wet film examination. 

Treatment: Imidazole oral/pessary (oral contraindicated to pregnant women), nystatin cream/pessary, 

Tricomoniasis 

Causal organism: Trichomonas vaginalis (flagellate protozoa). 

Predisposing factors: Multiple sexual partners, unprotected sex. 

Signs & symptoms: Vulval itching, frothy yellowish green discharge, dysuria, strawberry cervix. Diagnosis: 

Investigation: High vaginal swab, μscopy of vaginal discharge, saline wet mount.

 

Treatment; Metronidazole

Bacterial Vaginosis 

Bacterial Vaginosis Causal organism: Gardnerella vaginalis, Mycoplasma hominis, Bacteroides spp., Mobilincus spp.

Predisposing factors: Multiple sex partners, douching, lack of good lactobacilli. 

Signs & symptoms: Fishy malodourous discharge, more common during menses. 

Diagnosis: Amsel criteria (≥3 criteria for diagnosing bacterial vaginosis) a) Presence of clue cells (stippled appearance) - μscopic examination. b) Creamy greyish white discharge - naked eye. c) Vaginal pH > 4.5. d) Release of a characteristic fishy odour on addition of alkali. 

Treatment: Metronidazole, clindamycin.

Gonorrhoea 

Causal organism: Neisseria gonorrhoeae (gram -ve diplococcus). 

Predisposing factors: Multiple sex partners, early age of onset of sexual activity. 

Signs & symptoms: Greenish mucopurulent discharge, pelvic tenderness, proctitis, rectal bleeding.

Diagnosis: Vaginal swab -> gram stain/Thayer-Martin agar (blood chocolate agar with antibiotics).

Treatment: Cefixime, ceftriaxone, spectinomycin.

Genitourinary Chlamydia

Causal organism: Chlamydia trachomatis (gram -ve, obligate intracellular parasite).

Predisposing factors: Multiple sex partners, early age of onset of sexual activity.

Signs & symptoms: Mucopurulent discharge, postcoital and intermenstrual bleeding, dysuria. Late stage: Conjunctivitis and pneumonia. 

Diagnosis: Nucleic acid amplification technique, RT-PCR, culture. 

Treatment: Doxycycline, azithromycin, erythromycin, amoxicillin.

 Clerking Format for FEMALE PATIENTS (all, Obstetrics little different)

(INTRO)My Patient name is ………………………..,she is a (age)….. old (Race )……….. lady,  Gravida…….. Para……….   IF PREGNANT GRAVIDA ….,  IF NOT PREGNANT & HAS CHILDREN PARA………. .

She is known case of ……………..( any Medical Problem or issues) eg Diabetse for 10 years and Hypertensive for 3 years. If any MEDICAL PROBLEMS

EG Diagnose as pulm TB , 3 months ago and currently on anti Tb treatment

(CHIEF COMPLAIN)

She presented with history of ………………………………etc…EG.she presented with low grade fever & vomiting for 2 days

(HPI): HISTORY OF PRENSENT ILLNESS

Mrs ………. Eg  case describe c/o in detail, ass factors, aggravating & relieving factors

She was well until last Friday when she develop low grade fever, the fever was of sudden onset, there were no chills or rigor. She denied any body aches, headaches or pain behind her eyes( periorbital pain). The fever settle after one day but on the 2^nd day she experience severe vomiting

She vomited between 15-120 times, the vomitus is basically food & water she took, there is no bilous or blood in the vomitus. It was non projectile. There were no obvious aggravating factors. The vomiting slowly improved after taking some medication…….???

On further questioning, she denied any diarrhea, abdominal cramps or pain, she has no history of taking food in any unhygienic places.  Etc etc

Inview of this she seek medical advice from the health  clinic (KKIK……..) from there she was referred to serdang hospital for further management……… She has been in the ward for last 2 days. She was put on intravenous fluid & given some medication. She condition has improve since then. She has been investigated for………… &  what is the treatment & management in the hospital……………

SYSTEMIC REVIEW:…………………………………….No headaches, blurring of vision, no body rashes, etc etc related to your history

MENSTRUAL HISTORY

She attained her menarche at the age of 12 ( …….) age. The cycle has been regular with 28-30 cycles. Her flow is between 5-7 days. There were no menorrhagia (heavy period) or dysmenorrhea (painful periods). Her LMP (last Normal Menstrual Period ) is on the 12. October 2016. She is up to date with her pap smears. Her last pap smear was done in 2016, and she was told it was normal

PAST OBSTETRICS HISTORY

She is para 2, has 2 children age 7 & 2. Both the children were delivered by caesarean section for breech presentation ( baby upside down). The weigh 3 & 3.3 kg. There were no intrapartum & postpartum ( during & after delivery) complications. Both the children are well & alive. She breast fed her children for 6 months….( breast feeding or bottle feeding or mix)

In between pregnancy she took contraception ( OCP, IUCD etc…..)

(PAST MEDICAL HISTORY)

In terms of his past medical hIstory,  He  was diagnosed to have PTb in Sandakan , She was diagnose PTB after she presented with chronic cough & history of LOA, LOW…………, Full assessment was carried out & the diagnosis was confirmed by + sputum for AFB. She was subsequently started with anti-Tb treatment. She has taken the anti TB treatment for last 3 months at the chest clinic/ Health clinic. She is very compliant to the treatment. All her family members were screened & they tested negative.

 SHE IS NOT ALLERGIC TO ANY MEDICATIONS OR FOOD ( Better to put after medical h/o so don’t forget)

 PAST SURGICAL HISTORY

She never had any operations before………

If got operations…….. ? what op & years any complications ( eg……. She had 2 CSection on 2009 & 2017)

 FAMILY HISTORY

She is the youngest of 8 siblings / the third of 4 siblings. His parents are still alive & well. His mother is also diabetic but not hypertensive. His father has no medical illness. All his sibling is well and has no similar illness. There were no one in her family with PTB

 PERSONAL/SOCIAL HISTORY

She is married to EN………………………, she works as a………………., her partner works as……………………….. they live in a flat/ single storey teres / double storey teres/ single or double storey bungalow/condominium I ……………………………kajang/serdang………. The house is well  equipped with adequate basic amenities like water & electricity. Their combine monthly income is RM 2000. They have ……….children. She  and her partner does not smoke cigarette or consume alcohol. He also does not indulge in high risk behaviors’. She take s balance diet with 2-3 serving of meat per week. Recently after contracting with PTB she had loss about 3 kg

 IN SUMMARY, MY PATIENT  Pn/madam…………….., A KNOWN CASE OF DIABETES PTb diagnosed 3 months ago & still on anti-TB treatment presented with low grade fever with severe vomiting

 PROVISIONAL DIAGNOSIS:……………………………………………….

 DIFFERENTIAL DIAGNOSIS:1 …………………………………………

                                                        2………………………………………….

                                                       3. …………………………………………

HOW WOULD YOU MANAGE:………………………………………..

I would like to do some investigation:, l would like to do FBC to see any evidence of infection. I also would like to check his renal function to see if there any evidence of renal impairment. LFT to look for hypoalbuminemia. As per symptoms an ECG & Chest x-ray may provide me with any evidence of pleural effusion or cardiac failure. Others…………………………..

1.       Blood test FBC, RP, LFT …………whey & reasons

2.       Sputum AFB, C&S

3.       Cxray, ecg, echo whey & interpretations

4.       Other test d-dimer, Doppler studies, CT scan, MRI etc………..

5. The options for this patient are A. CONSERVATIVE MANAGEMENT LIKE...

                                                          B. MEDICAL TREATMENT LIKE.....

                                                          C. SURGICAL OPTIONS INCLUDING .........