What Is Hematocolpos in Children?
It is a pathological condition in which the vagina and uterus contain retained menstrual blood due to an imperforate hymen. Hematocolpos is the most common obstructive lesion of the vagina that causes the hymen to bulge. Hematometra is the term that describes a uterus bulge due to the filling of blood from the extreme accumulation of menstrual products.
The blood accumulated within the vagina can be measured to a liter or more. It affects 1 in 1,000 to 10,000 females and is rare. Pediatricians can diagnose the condition at birth, but most cases are found during menarche between 12 to 16 years or before menopause of 45 to 55 years. It is typically seen in girls of pubertal age. Although hematocolpos can be noticed in more than one family member, mutations or genetic markers for the disease were not identified.
What Causes Hematocolpos in Children?
The leading cause of hematocolpos is imperforate hymen (congenital disease of the hymen), vaginal atresia (abnormally closed vagina), and complete vaginal septum. Hematocolpos develops because there is complete obstruction of the vagina at any level. The abnormality might begin during the fifth to twentieth week of pregnancy or damage caused to the vagina during childhood or adulthood.
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Congenital Causes: Imperforate hymen is a common malformation of the female genital tract caused by unknown etiology, resulting in hematocolpos. An absence or partial resorption of the hymen membrane during embryo development could cause hematocolpos. Other congenital disorders that cause hematocolpos are hymen atresia (complete overgrowth of the hymen), vaginal septa, and partial vaginal aplasia (congenital malformation in vagina development) with the normal functioning uterus.
Vaginal septa are categorized into transverse and longitudinal. The transverse vaginal septum in a fetus develops from failed tissue absorption between the vaginal plate and the caudal end of Mullerian ducts. Vaginal septa vary in location and thickness. A thicker septa is present closer to the cervix.
Teratogenicity can induce developmental defects in children. The external factors causing hematocolpos include infections, medications, and chemical teratogens like gasoline, alcohol, phenol, formaldehyde, hypo or hypervitaminosis, or ionizing radiation. Internal factors include endocrine-metabolic pathologies or hereditary mutation. Failure of the hymen rupture during the perinatal period can cause an imperforate hymen.
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Acquired Causes: During the prepubertal phase, hematocolpos develops by age-related factors like narrowing of the vaginal tube lumen, physiological hypoestrogenism, or immaturity of the immune system. The atresia of the vagina and hymen develops from inflammation. Inflammation is induced by vulvovaginitis (inflammation in the vagina and vulva), insufficient hygiene of external genitals, allergic reactions, or infections like herpes, chlamydia, mycoplasma, measles, and rubella. Adult women can develop hematocolpos due to birth injury or surgical intervention. Hematocolpos in adult women develop several months following traumatic exposure.
What Is the Mechanism of Hematocolpos Development in Children?
A female embryo develops its uterus and vagina from Muller ducts, which appear as two continuous strands during formation. The vaginal tube forms from the fusion of the Muller system, vaginal plate, and urogenital sinus. Congenital disabilities that induce hematocolpos are caused by disorders in Muller system development and their fusion with the urogenital sinus.
Acquired abnormalities of the vagina due to hematocolpos are adhesion of vaginal walls due to inflammation or gross scar deformities developing from injury or surgical operation.
What Are the Symptoms of Hematocolpos in Children?
The clinical presentation can range from asymptomatic to symptomatic due to obstruction of the genital tract. The symptoms of congenital and acquired vaginal defects appear during adolescence during menstruation onset.
Girls with hymen overgrowth have symptoms of false amenorrhea (absence of menstruation). Itching and pain syndrome develops gradually after several months when hematocolpos reaches a specific size. Lower abdomen pain develops during menstruation and later becomes more intense and permanent. Violation of urine (increase in the urine frequency followed by delay) and constipation develop. Due to the anatomical defect, the vagina becomes significantly large. It is sensed by the patient in the form of an internal tumor that extends beyond the pelvis and bulges into the genital slit.
Atresia or aplasia of the vagina also presents with false amenorrhea that causes severe pain and itching within the initial month of menstruation onset. The pain becomes permanent very quickly. Urine and defecation remain undisturbed, but blood accumulates in the hollow organ. If an additional uterus is present with a blind vagina, symptoms like scanty period and period pain accompanying hematocolpos are observed. At later stages, bloody-purulent discharge develops due to blind vagina perforation in the area of the adjacent wall.
Other symptoms include lower abdominal, lumbar, pelvic pain, dysuria (painful urination), urinary retention, pelvic swelling, and vaginal itching. Children rarely develop referred lower back pain from hematocolpos due to irritation of the sacral plexus or nerve roots.
How Is Hematocolpos in Children Diagnosed?
The diagnosis of hematocolpos is with a physical exam. Children with persistent back pain must be assessed for the condition. Physical examination reveals distention in the lower abdomen. Palpation shows a firm and suprapubic mass extending from the pelvic to the umbilicus and an imperforate hymen. Transabdominal ultrasonography helps diagnose imperforate hymen.
Computed tomography shows a vaginal mass with upward displacement of the uterus. MRI (magnetic resonance imaging) scans determine hymen thickness, which helps choose the appropriate surgical technique. Oral antibiotics are prescribed to treat vaginal infections.
How Is Hematocolpos in Children Treated?
Treatment is often performed immediately after diagnosis. Prenatal diagnosis without complications or hymen bulging warrants delaying treatment until puberty. Patients are often treated with hymenotomy (a surgical procedure to open or remove hymen) to drain malodorous blood. A thick hymen is resected surgically, whereas a thin hymen requires a vertical incision. When hematocolpos is emptied, there is instant resolution of the condition. Optimal healing is obtained with estrogen stimulation and reduces the risk of recurrence.
What Are the Complications Caused by Hematocolpos in Children?
If the condition is not diagnosed or treated, it presents complications during puberty. Blood collection within the vaginal cavity (hematocolpos) compresses the pelvic structure and causes pain during defecation, low back pain, difficulty in urination, and urinary retention. Other complications include amenorrhea, pelvic pain, and the risk of developing secondary endometriosis.
Conclusion
Hematocolpos is a pathological condition where menstrual blood is retained in the vaginal tube due to blockage. The condition is diagnosed before menarche in girls. Early diagnosis and treatment of these young girls will prevent further complications. In rare instances, secondary endometriosis can develop if hematocolpos remains untreated.
