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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.