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Severe Pelvic Pain with Dysuria — Managing Genital Emergencies in Pediatric Girls October 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , trackback
A 15-year-old adolescent girl is brought into the ED by her mother for severe abdominal and pelvic pain with dysuria. The patient is otherwise healthy, with no significant past medical history. She is not sexually active and denies any trauma. Upon questioning, the patient states that she has had cyclical abdominal pain over the past year and a half, which typically lasts 2 to 3 days, and then self resolves. She has not yet started her menses. This is the first time that the pain has been 10/10 in severity, and she has new urinary urgency, with inability to fully empty her bladder. On physical examination, she is Tanner stage V for breast and pubic hair development, her abdomen is soft with no palpable mass, and she has no costovertebral angle tenderness. On visual inspection of her perineum, she is noted to have a large, bulging purplish mass in her vaginal area with a small leak of blood. 
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Are there any laboratory tests that you should order? What imaging—if any—would be the best choice for confirming the diagnosis? Should you try to release the pressure and evacuate the blood?
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Comments»

1. Vipin Agarwalla - October 7, 2018

This patient has hematocolpos.
Imperforate hymen.

2. Peter J. Murphy - October 7, 2018

It certainly appears that this unfortunate child does not have a patent vagina and her cyclical abdominal pain indicates otherwise normal menstrual cycles. Simple incision in the emergency department relies on too many assumptions that things are exactly as they appear to be. Prudence dictates imaging (ultrasound should be sufficient) and management in the OR by a gynecologist.

3. barbara ehler - October 7, 2018

imperforate hymen

4. John - October 7, 2018

The clinical picture seems to fit with a diagnosis of imperforate hymen at menarche. I would check H/H and UA with hcg for completeness but probably wouldn’t get imaging, at least not before evacuating the accumulated blood for relief of pain. Then I would consider pelvic ultrasound for further evaluation.

5. Andrew Heiser - October 7, 2018

Signs and symptoms consistent with imperforate hymen with hematoculpos. Labs that should be ordered include CBC with differential, BMP, CRP and blood culture if febrile, urinalysis with reflex culture. Abdominal/Renal US to confirm the diagnosis though not required as well as to examine the kidneys for signs of hydronephrosis.

Management includes Pain IV narcotics with or without zofran, IVF, antibiotics if signs of sepsis or urinary tract infection and consultation to OB/GYN for imperforate hymen with hematoculpos. The mass does not need to be manipulated by the EM physician.

6. wchotas@gmail.com - October 7, 2018

Would obtain urinalysis (culture pending urinalysis results) and send for CBC with hemoglobin/hematocrit and platelet count. Transabdominal Ultrasound would be my first method of imaging to visualize both bladder and uterus and adnexae along with vaginal blood collection. I would consider placing a urinary catheter for emergent bladder drainage. I would not evacuate but would allow for gynecology team to perform urgent evacuation of hematocolpos in OR. If in a low-resource setting I would attempt hymenotomy with irrigation of vagina under procedural sedation.

7. Christopher Cruz - October 7, 2018

Labs?- nothing absolutely indicated… maybe CBC to check she’s not anemic, maybe urine hcg to confirm primary amenorrhea and not pregnancy or malignancy-related diagnosis.

Imaging?- transabdominal pelvic US

Evacuate the blood? NOT in the emergency room, and NOT by emergency physician. Hymenectomy should be done by gynecologist in a controlled, sterile environment like the OR

8. Emily Thompson - October 7, 2018

Call OB

9. Dane O'Donnell - October 7, 2018

Imperforated hymen. No tests indicated unless gyn wants them. Trans-Abdominal ultrasound may show a uterus filled with hyper and hypoechoic material. One may try to release the pressure by needle aspiration using sterile technique but I believe this is best done after consulting gynecology.

10. Ramy Saleh - October 7, 2018

this is hematometrocolpos secondary to imperforate hymen. MRI abdomen/pelvis is preferable over CT to confirm diagnosis. Patient needs obgyn consultation for hymenectomy and evacuation of blood. Thanks.

11. Sadaf - October 7, 2018

Vaginal prolapse

12. Kenneth Dowler - October 7, 2018

Imperforate hymen with hematoculpos is dx. Confirm with ultrasound. I would call ob/gyn for consult and possible virginity sparing surgery.

13. Hassan Akel - October 7, 2018

Rhabdomyosarcoma

14. dcweerasuriya@yahoo.com - October 7, 2018

1.
1. Hematoculpos
2. US scan
3. Hymen sparing incision to release the pressure

15. Ahmed moursi - October 7, 2018

Imperferate hymen, hematometrocolopus
Abdominal ultrasound & congratulation of ob/gyn for virginity sparing surgery & evacuation of blood

16. Jotham - October 8, 2018

Ddx endometriosis,hematocolpos ,hematometra

17. kzagel@gmail.com - October 8, 2018

Imperforate hymen with imaging but no procedural technique. A GYN/OB consult is in order. Need a sterile and OR evacuation by specialist

18. Dev - October 8, 2018

Imperforated Hymen
U/S imaging for further Mx
Refer ObsGyn

19. Khadeejah Al-Arasi - October 8, 2018

The patient has imperforate hymen, we cas use Abdominal US to visualize hematocolpus, it can be relieved by cruciate inscion in the hymen.

20. rajeeb raj - October 8, 2018

At the usual age of menarche, the adolescent girl may present with amenorrhea (sometimes referred to as crypto-menarche), cyclic abdominal or pelvic pain, and hematocolpos, which may give the hymenal membrane a bluish discoloration. Marked distension of the vagina may also result in back pain, pain with defecation, or difficulties with urination. so the diagnosis is Imperforate hymen- The diagnosis can be confirmed with the use of a translabial or transperitoneal ultrasound .

21. Eva Soos-Kapusy - October 8, 2018

Hematocolpos, imperforated hymen,
Pelvic ultrasound would be recommended , but the physical exam and the history is already diagnostic

22. Kimia Kashkooli - October 8, 2018

Imperforate Hymen

23. Karen Genco - October 8, 2018

An ultrasound would help, but the history and physical scream imperforate hymen. Poor girl 🙁

24. naomifikrahsulaimah@gmail.com - October 9, 2018

fitri hemawati
amenorhea,

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