Summary: 12-year-old female with lower abdominal pain.
Diagnosis
Hematocolpos
Findings
Axial and coronal enhanced CT images demonstrate distention of the vaginal canal with complex fluid that appears to layer dependently (representing blood products of varying ages). The endometrial canal contains a small amount of fluid and is displaced superiorly. Urinary bladder is displaced anteriorly.
Discussion
Hematocolpos is blood-filled distention of the vagina, whereas hematometra is blood-filled distention of the uterus. The term hematometrocolpos refers to the distention of both uterus and vagina by blood. On CT imaging, hematocolpos presents as fluid-filled mass with enhancing walls located in the lower pelvis between the bladder and rectum. Hematocolpos can be very large and may simulate early pregnancy in young girls. In contrast to hematocolpos, hematometra occurs higher in the pelvis and appears thick-walled due to the myometrium. Although hematocolpos is usually initially diagnosed on ultrasound, MR is often performed to confirm blood products and to further evaluate the pelvic anatomy.
Hematocolpos is caused by congenital or acquired malformation of the vagina. Imperforate hymen is the most common cause of vaginal obstruction and occurs in 1:1000 females. Vaginal agenesis occurs in 1:5000. Müllerian duct anomaly and cloacal malformation are rarer causes. Radiation treatment-induced vaginal stenosis is the most common acquired cause.
The most common clinical presentation is primary amenorrhea with or without cyclic pelvic pain. Pelvic pain may occur due to the pelvic fluid collection compressing on the rectum or bladder during defecation or urination. If associated with congenital malformations, then hematometrocolpos often presents during puberty or infancy. If associated with cervical cancer and treatment-induced changes, it usually occurs later in life. Treatment is surgical for congenital causes. Early diagnosis is critical to prevent fertility problems and complications such as peritonitis.
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