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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 4  |  Page : 251-254

Diagnostic dilemmas in management of neonatal hydrometrocolpos: A crucial role of magnetic resonance imaging


1 Department of Paediatric Surgery, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
2 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
3 Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India

Date of Web Publication16-Oct-2014

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.143066

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  Abstract 

Neonatal hydrometrocolpos is a rare abnormality and can present as an abdominal mass, urinary tract obstruction, anuria, hydroureteronephrosis, constipation or respiratory distress. Hydrometrocolpos in neonate can be due to imperforate hymen, vaginal atresia, vaginal septum, urogenital sinus or even cloaca. Clinical examination and routine ultrasonography cannot differentiate causes of hydrocolpos in all such cases. Surgical approach depends upon the underlying cause of hydrometrocolpos. We report an unusual case of neonatal hydrometrocolpos in which it was extremely difficult to differentiate urogenital sinus from imperforate hymen or vaginal atresia. The patient underwent magnetic resonance imaging (MRI) which clearly showed the imperforate hymen and was helpful in planning management of the case. Hence, there is the definitive role of MRI in the differential diagnosis of hydrometrocolpos and is equally helpful in making surgical decisions.

Keywords: Hydrometrocolpos, imperforate hymen, urogenital sinus, vaginal atresia


How to cite this article:
Gupta M, Bajwa SS, Gupta M. Diagnostic dilemmas in management of neonatal hydrometrocolpos: A crucial role of magnetic resonance imaging. Int J Health Allied Sci 2014;3:251-4

How to cite this URL:
Gupta M, Bajwa SS, Gupta M. Diagnostic dilemmas in management of neonatal hydrometrocolpos: A crucial role of magnetic resonance imaging. Int J Health Allied Sci [serial online] 2014 [cited 2019 Sep 21];3:251-4. Available from: http://www.ijhas.in/text.asp?2014/3/4/251/143066


  Introduction Top


Neonatal hydrometrocolpos is a rare abnormality occurring from the gross distension of uterus and vagina. [1] Hydrocolpos results from congenital vaginal obstruction along with maternal hormonal stimulation of fetal cervical glands. The common possible causes of hydrometrocolpos are imperforate hymen, transverse vaginal septum or vaginal atresia. [2] Imperforate hymen is a rare occurrence with an incidence of 0.014-0.1%. [3] It mostly presents during puberty although diagnosis in utero and during newborn period and childhood are also documented in the literature. [4],[5],[6],[7] It can present during the neonatal period as abdominal mass, urinary tract obstruction, hydroureteronephrosis and can rarely mimic abdominal ascites. [8],[9] Imperforate hymen needs to de differentiated from urethral prolapse or prolapsed ureterocoele as the diagnosis poses difficulties on clinical bases. [6] Surgical approach for imperforate hymen is from perineum whereas urogenital sinus and vaginal atresia need complex management. Genitoscopy, genitogram and sometimes initial laparotomy is needed. Apart from the surgical challenges, anesthetic management in complicated syndromes also poses numerous challenges during corrective procedures. Many a times, the therapeutic interventions have to be designed on an individual basis rather than just going by the traditionally practiced logical empiricism approach more so in the developing nations. [10]

Clinical examination and sonography can diagnose hydrometrocolpos in almost all the cases, yet it cannot differentiate causes of it which needs further evaluation by computed tomography (CT) scan or magnetic resonance imaging (MRI). We report such a case in which it was extremely difficult to decide surgical approach on the basis of clinical examination and ultrasonography (USG). MRI showed distended uterus and vagina extending up to perineum with absence of vaginal septum or urogenital sinus. Patient underwent uneventful hymenoplasty and was relieved of her symptoms.


  Case report Top


A 22-day-old female child was brought by her parents with the chief complaint of abdominal lump since birth. Lump was initially small but suddenly it increased in size associated with a decrease in urine output since 1 day. On examination, child had 3.9 kg weight with normal cry, tone and activity. There was lump 8 cm by 6 cm in size appearing to originate from pelvis and to reach up to umbilicus. Anal opening was normal in site and size. External genitalia showed a no bulging membrane in introitus and urethra was not visible separately from vagina.

Investigations revealed hemoglobin as 13.7 g/dl, total leukocyte count 7900/cumm, blood urea 25 mg/dl and creatinine as 0.7 mg/dl. USG was done, which showed 10.1 by 6.6 cm size cystic mass posterior to the urinary bladder with fine internal echoes. Urinary bladder was displaced anteriorly by the mass, and there was moderate hydronephrosis. A diagnosis of hydrometrocolpos was arrived at. Since causes of hydrometrocolpos could be imperforate hymen, vaginal atresia, vaginal septum or urogenital sinus, the patient underwent MRI so as diagnose the exact cause. MRI findings revealed a large fluid collection measuring 10.1 cm × 6.7 cm × 5.3 cm in pelvis extending inferiorly into perineum and superiorly up to body of L1 vertebra. Along with these findings, cervical canal and uterine cavity were also distended with fluid. Right  Fallopian tube More Details was also mildly distended. Urinary bladder was displaced anteriorly. Both kidneys showed mild to moderate hydronephrosis with hydroureters. No vaginal septum or urogenital sinus could be located on the Imaging modality. Since the distention of uterus and vagina extend up to perineum, final diagnosis of imperforate hymen was established. Antenatal USG was not done as a patient had no antenatal check-up due to poor socioeconomic status.

Patient was administered general anesthesia, catheterized and subsequently hymenoplasty was done. Cruciate incision was given on hymen and 50 cc of fluid was drained [Figure 1] and [Figure 2]. Foleys catheter was inserted in the vagina for drainage of fluid [Figure 3]. Postoperatively urinary bladder catheter was removed the following day, while Foleys catheter in vagina was removed after 2 days after it was observed that there is no drainage of fluid. Postoperative USG was done, which showed a decrease in hydronephrosis and absence of fluid in endometrium.
Figure 1: Distended uterus and vagina extending up to perineum and pressing bladder anteriorly

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Figure 2: Surgical approach to the imperforate hymen

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Figure 3: Catheterization into urinary bladder and vagina before surgery

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  Discussion Top


Neonatal hydrocolpos is a rare condition with the prevalence of 1 in 16,000 female births. [5] It occurs due to vaginal outflow obstruction along with a glandular secretion by maternal hormones. The causes of vaginal outflow obstruction could be imperforate hymen, vaginal septum, vaginal atresia or urogenital sinus. Urethral prolapse and prolapsed ureterocoele can also mimic imperforate hymen. [6] Most of cases of the imperforate hymen present during puberty although diagnosis in utero and neonates and infancy are also documented. [1],[3],[7],[8] The incidence of imperforate hymen is 0.014-1%. [3] Imperforate hymen can also present as pyocolpos in neonates. [11] Vaginal atresia, transverse vaginal septum and urogenital sinus need to be differentiated from imperforate hymen.

The presentation in neonate can be as the abdominal mass, respiratory distress, vomiting, constipation, obstructive uropathy, genitourinary anomalies. [1],[2] Rarely it can mimic neonatal ascites. [9] Imperforate hymen can be isolated disease or associated with other mesodermal anomalies like Mckusick- Kaufman syndrome More Details due to mullerian dysgenesis. [12] Hence, any female neonate with a pelvic mass, diagnosis of imperforate hymen should be kept in mind.

Diagnosis of imperforate hymen can be made by thorough physical examination of the genitalia which will show bulging membrane in vaginal introitus. However, vulvar bulge may not be present as has been reported in the literature and was seen in our case also. [10] Further diagnosis can be established by USG. USG can also diagnose prenatal cases of hydrocolpos. [4],[5] Advantage with prenatal diagnosis is that the patient can be dealt early before pressure effects on other organs.

However, sometimes clinical examination and USG cannot differentiate causes of hydrocolpos. This occurs if urethra is not clearly seen separate from vagina, or vaginal introital bulge is not much as it was there in our case. USG per se cannot differentiate between the urogenital sinus, vaginal septum or vaginal atresia. Such cases need further evaluation which can be genitography, contrast-enhanced CT (CECT) abdomen or MRI abdomen. Genitography in neonate is technically difficult and invasive procedure. CECT abdomen has radiation exposure. MRI is useful in such cases if there is a diagnostic dilemma. MRI has the advantage of being noninvasive, and there is no radiation exposure. Moreover, MRI can clearly describe anatomy of perineum whether it is septate vagina, septate uterus, cloaca or urogenital sinus. MRI can tell fluid dilated vagina and membrane protrusion at introitus in imperforate hymen. MRI is useful in the prenatal period also if USG findings suggest hydrocolpos. [4]

The advantage of early diagnosis is that prognosis and management of isolated imperforate hymen differs greatly from that of vaginal atresia, vaginal septum or urogenital sinus. For imperforate hymen, hymenoplasty is needed. [7] Vaginal atresia and urogenital sinus needs genitoscopy and sometimes laparotomy. [9],[12] In neonatal period initially tube vaginostomy to drain the fluid is done. The patient needs further genital reconstruction in the form of vaginoplasty if urogenital sinus is low. If common channel is, long patient may require an abdominoperineal approach. Besides administering general anesthesia for such procedures, caudal approach for supplementation of regional anesthesia should always be followed as it can provide a pain free immediate post op period. [13]

Aim of surgery is to create normal looking vaginal introitus and fully separate vaginal orifice from the urethral orifice. Thus, the baby can have less chances of urinary tract infection, menstrual irregularity endometriosis or infertility. It is also highly essential that nutritional aspects be given appropriate attention during this period as these can directly impact the surgical outcome.


  Conclusion Top


The diagnosis of hydrometrocolpos is not difficult. It has to be kept in mind in any female with pelvic abdominal mass especially in the neonatal age. It is also important to diagnose the cause of hydrometrocolpos. This can be done by thorough physical examination and genital examination. If there is a diagnosis difficulty, one can go ahead with MRI scan which can delineate exact anatomy of defect and helpful in planning management strategies. A team approach is needed to prognosticate the patient and to preserve reproductive potentials.

 
  References Top

1.
Vitale V, Cigliano B, Vallone G. Imperforate hymen causing congenital hydrometrocolpos. J Ultrasound 2013;16:37-9.  Back to cited text no. 1
    
2.
Lee KE, Cho OY, Sim EJ, Cho DJ, Kim DH, Min KS, et al. A case of neonatal hydrometrocolpos accompanying urinary tract obstruction. Korean J Pediatr 2004;47:789-93.  Back to cited text no. 2
    
3.
Mwenda AS. Imperforate Hymen - A rare cause of acute abdominal pain and tenesmus: Case report and review of the literature. Pan Afr Med J 2013;15:28.  Back to cited text no. 3
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4.
Tseng JJ, Ho JY, Chen WH, Chou MM. Prenatal diagnosis of isolated fetal hydrocolpos secondary to congenital imperforate hymen. J Chin Med Assoc 2008;71:325-8.  Back to cited text no. 4
    
5.
Ayaz UY, Dilli A, Api A. Ultrasonographic diagnosis of congenital hydrometrocolpos in prenatal and newborn period: A case report. Med Ultrason 2011;13:234-6.  Back to cited text no. 5
    
6.
Gupta P, Gadodia A, Seith A. Neonate with abdominal lump and anuria. West J Emerg Med 2010;11:226-7.  Back to cited text no. 6
    
7.
Sidatt M, Ould Sidi Mohamed Wedih A, Ould Boubaccar A, Ould Ely Litime A, Feil A, Ould Moussa A. Hydrocolpos and hydrometrocolpos in newborns. Arch Pediatr 2013;20:176-80.  Back to cited text no. 7
    
8.
Johal NS, Bogris S, Mushtaq I. Neonatal imperforate hymen causing obstruction of the urinary tract. Urology 2009;73:750-1.  Back to cited text no. 8
    
9.
Khan RA, Imran G, Shagufta W. Hydrometrocolpos due to persistent urogenital sinus mimicking neonatal ascites. Iran J Pediatr 2008;18:67-70.  Back to cited text no. 9
    
10.
Bajwa SJ, Kalra S. Logical empiricism in anesthesia: A step forward in modern day clinical practice. J Anaesthesiol Clin Pharmacol 2013;29:160-1.  Back to cited text no. 10
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11.
Ali MK, Ali AH, Elsayed AH, Shazly SA, Safwat AM. Pyocolpos with imperforate hymen in a 21 days old newborn. Sir Lanka J Obstet Gynaecol 2012;34:161-2.  Back to cited text no. 11
    
12.
Ekenze SO, Ezegwui HU. Hydrometrocolpos from a low vaginal atresia: An uncommon cause of neonatal intestinal and urinary obstruction. Afr J Paediatr Surg 2008;5:43-5.  Back to cited text no. 12
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Bajwa SJ, Kaur J, Bajwa SK, Bakshi G, Singh K, Panda A. Caudal ropivacaine-clonidine: A better post-operative analgesic approach. Indian J Anaesth 2010;54:226-30.  Back to cited text no. 13
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