Case Report: Surgical and cultural approaches to managing hematocolpos in adolescents: A Tunisian case report with video insights

Introduction

Hematocolpos is a gynecological pathology characterized by the accumulation of menstrual blood in the vagina due to an anatomical obstruction, with an incidence of approximately one case per 2,000 adolescents. In 90% of cases, the obstruction is caused by an imperforate hymen (IH), making it the most common cause of hematocolpos.^1–3 This condition often remains undiagnosed until adolescence, when the onset of menarche leads to the emergence of clinical symptoms.⁴ Clinically, hematocolpos presents with cyclical lower abdominal pain, primary amenorrhea, and, in some cases, a rapidly expanding pelvic tumor. In severe cases, hematocolpos can cause complications such as urinary retention or constipation due to the mass effect on adjacent organs.^5,6 In the adolescent population, the significance of hematocolpos is attributed to its potential to cause substantial morbidity if not promptly treated.⁷ Early diagnosis and timely intervention are essential for preventing complications, including infection, endometriosis, and infertility, which can result from retrograde menstruation.⁸ Timely and effective management is crucial, so healthcare providers must be aware of this condition, particularly when assessing young patients with primary amenorrhea and abdominal pain.⁹

In Tunisia, as in many other cultures, the hymen holds deep cultural and social significance, often symbolizing virginity and moral purity. Its integrity is closely tied to a woman’s social status and marital prospects.¹⁰ Consequently, the surgical management of hematocolpos, which typically involves hymenotomy or hymenectomy, presents a unique ethical dilemma.⁵ The possibility of compromising the hymen can cause considerable distress for both the patient and her family due to the potential social consequences.¹⁰ Therefore, medical decisions regarding treating hematocolpos must carefully balance medical necessity with cultural sensitivities, requiring thoughtful and compassionate communication between healthcare providers, patients, and their families.^4,11 Overall, treating hematocolpos in Tunisian adolescents involves medical and surgical considerations and an intricate interplay of cultural and ethical factors that must be navigated with care and sensitivity.⁷

This work aims to report the case of an adolescent diagnosed with hematocolpos, providing a detailed description of the intervention and the decision-making process involved in her treatment.

Case presentation

The patient is a 13-year-old Tunisian adolescent who presented to the gynecology and obstetrics emergency department at our maternity center in Monastir with primary amenorrhea, abdominopelvic pain radiating to the lumbosacral region, and a progressively developing pelvic mass. The patient also reported a history of pollakiuria over the past two months, along with dyschezia. The girl has no significant medical history, and this is her first presentation for gynecological evaluation. On clinical examination, her Tanner stage, an indicator of pubertal maturity, is consistent with her chronological age. Specifically, she is at Tanner stage III for breast development, characterized by further enlargement of the breast and areola with no separation of their contours, and Tanner stage IV for pubic hair, marked by coarse, typically covering the pubic area but not yet spreading to the inner thighs. She also exhibited other secondary sexual characteristics appropriate for her age, such as axillary hair growth and an increase in body fat distribution typical of pubertal development. The patient’s vital signs were stable and within the normal range. The abdomen was soft and non-tender on palpation. But it was distended, particularly in the lower quadrants, corresponding to a painless, homogenous, and soft pelvic mass. During the clinical gynecological examination, retraction of the labia minora revealed an imperforate hymen, bulging anteriorly with a bluish discoloration, consistent with hematocolpos. This indicated the accumulation of menstrual blood behind the distended hymenal membrane. Additionally, rectal digital examination identified a large, bulky mass located anteriorly.

Diagnostic assessment

Laboratory investigations showed a hemoglobin level of 12 g/dL and a white blood cell count of 10/nL, with CRP and tumor marker levels within normal limits. Additionally, the patient’s endocrine profile indicated a well-developed hypothalamic-pituitary axis, and urinalysis results were unremarkable.

A 2D transabdominal ultrasound revealed a structure measuring 23 cm in length and 10cm in width, located cranial to the umbilicus and closely aligned with the anterior abdominal wall. This structure was identified as a distended vaginal cavity filled with echogenic fluid, indicating retained menstrual blood, consistent with hematocolpos (Figure 1). The uterus appeared normal in size and morphology, with no signs of hematometra or other Müllerian duct anomalies. Both ovaries were of normal appearance, and both kidneys were present with no abnormalities or ureteral dilatation. These findings were indicative of an imperforate hymen as the underlying cause of the obstruction.

Figure 1. Ultrasound image showing a distended vagina in a 13-year-old female diagnosed with hematometrocolpos.

Chosen treatment

After extensive discussions with the patient and her legal guardians, hymenotomy was chosen as the preferred treatment approach to effectively resolve the hematocolpos while striving to preserve the hymen as much as possible, addressing both medical and cultural concerns.

Ethically, the preservation of the hymen is a culturally sensitive issue in Tunisia, as it is closely tied to a woman’s social status and marital prospects. The healthcare team faced the challenge of balancing the medical necessity of treating the hematocolpos with the cultural importance of maintaining hymenal integrity. To navigate this, open and culturally aware discussions were conducted with the patient and her family, ensuring they were fully informed about the condition, treatment options, and potential outcomes. The decision to proceed with hymenotomy was made with the family’s full understanding and consent, reflecting a careful balance between respecting cultural values and ensuring the patient’s medical and emotional well-being.

The surgical procedure of hymenotomy was performed in several steps (Figure 2), (video¹²):

• 1. Creation of the Orifice: A central annular orifice of approximately 1 cm in diameter was created in the hymen using a bipolar diathermy device. This method ensured precision and minimized bleeding.

• 2. Drainage of Enclosed Blood: Following the creation of the orifice, the accumulated menstrual blood was carefully drained from the vaginal cavity. About 600 ml of thick, dark, tarry menstrual blood, along with clots, were drained using manual suprapubic pressure. This step relieved the pressure and resolved the hematocolpos.

• 3. Vaginal Lavage: An abundant vaginal lavage was performed using normal saline to cleanse the vaginal cavity and remove any residual blood, reducing the risk of infection.

• 4. Stabilization of the Orifice: To prevent the newly created orifice from closing, a continuous suture with Vicryl 4/0 was placed around the edges. The inner vaginal mucosa was sutured to the external vestibular mucosa. The suturing technique was specifically designed to create an undulating pattern, mimicking the natural appearance of the hymenal orifice. This step was critical in both maintaining the functional opening to prevent restenosis and addressing cultural concerns about hymenal appearance.

• 5. Placement of Drainage: Finally, a drainage tube was inserted through the orifice to ensure continuous outflow and prevent the reaccumulation of blood during the immediate postoperative period.

This meticulous approach not only addressed the patient’s medical needs but also respected the cultural significance of hymen preservation.

Figure 2. Photographs illustrating the sequential steps of the hymenotomy procedure.

Discussion

This case underscores a rare and unusual cause of abdominal pain in a young girl nearing adolescence.⁸ Hematocolpos is a medical condition marked by the buildup of menstrual blood within the vaginal and uterine cavities.^13,14 This condition can result from various etiologies, including congenital abnormalities or acquired obstructions of the lower female genital tract.¹⁵ Congenital anomalies may involve an imperforate hymen (IH), a complete transverse vaginal septum, orvaginal or cervical atresia.^2,15 These issues may be identified at birth or during the early neonatal period. During birth or shortly thereafter in the neonatal period, infants may present with a distended introitus due to mucocolpos, triggered by vaginal secretions induced by maternal hormones.¹⁶ An IH is the most common cause during the pubertal period. it is an uncommon yet significant pathology. Severe cases may lead to complications such as urinary retention or constipation, secondary to the mass effect exerted by the distended vagina on adjacent pelvic organs.^9,8,14,17

In the adolescent population, the relevance of hematocolpos lies in its potential to cause significant morbidity if left untreated. Early diagnosis and timely intervention are critical to preventing complications such as infection, hydronephrosis, endometriosis, and infertility, which may arise from retrograde menstruation.^16,18,19

Ultrasound is typically the first-line imaging modality for diagnosing Müllerian duct anomalies and is sufficient to identify blood clots within the vaginal cavity. However, MRI provides more precise anatomical details, allowing for the detection of other congenital urogenital tract malformations associated with hematocolpos, as seen in syndromes like Rokitansky-Küster-Hauser and McKusick-Kaufman.^18,20,21

Once the diagnosis is established, hymen repair should be performed promptly. Several surgical interventions are available for the treatment of hematocolpos, with hymenotomy being one of the most commonly performed procedures.^18,22

The precise function of the hymen remains uncertain, but it is generally believed to serve as a protective barrier during the prepubertal period when vaginal defense mechanisms are still developing. Additionally, the hymen may represent an example of evolutionary adaptation, where positive selection favored women with an intact hymen despite its embryological origins.^8,18

An intact hymen is often associated with Arab-Muslim traditions, where it is considered a symbol of a woman’s purity.²³ Given these cultural and religious connotations, decisions regarding medical procedures such as hymenal repair or preservation can vary significantly.²⁴ Healthcare providers must navigate the delicate task of delivering culturally sensitive care that respects these beliefs while ensuring the patient’s medical needs are appropriately addressed.²⁵

Actually, the emphasis on virginity is prevalent in many other cultures as well. In Western countries also, where healthcare increasingly prioritizes culturally aware and personalized treatment options that address cosmetic and individual preferences, conservative approaches such as hymenal preservation are often considered viable alternatives for all individuals.^18,26

Since virginity is highly valued by many religions, cultures, and families, we report on a procedure involving the excision of an annular central hymenal membrane while preserving the peripheral hymenal ring.²⁷ The inner vaginal mucosa was sutured to the external vestibular mucosa to maintain the integrity of the hymen, ensuring that it remains intact with sufficient caliber to allow for the drainage of vaginal secretions and menstrual flow post-procedure.¹⁸

Surgical approaches to treat imperforate hymen have been documented in various literature methods.⁹ The standard treatment typically involves a hymenotomy, where a T-shaped incision is made in the hymenal membrane to allow drainage of trapped blood. This is followed by suturing the edges to maintain openness and prevent restenosis.¹⁸ In more severe cases, the removal of excess hymenal tissue and mucosa is often necessary. However, due to the risk of ascending infections and potential sepsis, simple incisions and drainage of hematocolpos in patients with this condition should be avoided.^8,18

It has been reported that women who underwent surgical correction of an imperforate hymen frequently experienced irregular menstrual cycles. A significant number of these women expressed concerns about their future fertility, and some of them experienced dysmenorrhea,.^18,22

Conclusion

hematocolpos is a critical condition that may lead to severe complications if not promptly addressed. Timely diagnosis during adolescence, along with comprehensive neonatal examinations at birth, are essential for achieving a favorable prognosis. Early intervention can help prevent complications such as infections, retrograde menstruation, and infertility.

Virginity-sparing surgery provides a suitable option in regions where virginity holds cultural and religious significance, effectively addressing both medical symptoms and the patient’s social concerns. Further research is needed to optimize such techniques and improve patient outcomes.

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