Case 1 Hematometrocolpos due to imperforate hymen (Primary

amenorrhea)
Identitas:
cc: not have period and lower abdominal pain
Hipotesis:
- Imperforate Hymen
- Endocrine abnormality (dicoret karena kadar hormone normal)
- Pregnancy (dicoret karena pregnancy test (-))
Diagnosis: Hematometrocolpos due to imperforate hymen.
Prognosis: Ad vitam ad bonam
Ad functionam ad bonam
FCM
LI
1. Anatomy of uterus & vagina
Organ genitalia wanita terdiri dari 2 bagian:
- Internal: ovarium, tuba falopi, uterus, dan vagina
- External: mons pubis, labia majora & minora, clitoris, vestibular bulb, dan vestibular
gland (greater & lesser)
a. Uterus
- Posisi normal untuk rahim orang dewasa = anteverted & anteflexed
- Uterus dibagi menjadi 2 bagian utama: body dan cervix
❖ Body (and fundus)
➢ Membentuk ⅔ superior part of uterus
➢ Terletak di antara lapisan broad ligament
➢ Terdapat 2 surface: vesical (vesico-uterine) dan intestinal (recto-uterine)
➢ Terhubung ke cervix oleh isthmus of uterus
❖ Cervix
➢ Membentuk ⅓ inferior part of uterus
➢ Terbagi menjadi supravaginal (internal os) dan vaginal (external os)
❖ Wall of uterus: Perimetrium (lapisan peritoneum dengan jaringan ikat tipis),
myometrium (otot halus dengan pembuluh darah dan saraf), dan endometrium
(mucous coat dibagi menjadi lapisan fungsional dan basal)
❖ Ligament of uterus
➢ Broad ligament: mesometrium (uterus), mesosalpinx (fallopian tube),
mesovarium ovarium)
➢ Suspensory ligament of the ovary: attached ovarium to lateral pelvic wall
❖ Ligament of cervix (endopelvic ligaments and smooth muscle)
➢ Cardinal (transverse cervical) ligament: from supravaginal cervix and lateral
fornix to lateral pelvic walls
➢ Uterosacral ligament: pass superiorly and slightly posteriorly from the sides of
cervix to middle of sacrum
❖ Arterial and venous drainage
➢ Mainly from uterine artery (branches of internal iliac artery) and collateral
supply from the ovarian artery (branches of abdominal artery)
➢ Veins drainage pass through broad ligament and form uterine venous plexus
and then drain into internal iliac veins
b. Vagina
❖ Distendable musculo membranous tube from the external os. of the cervix to the
vaginal orifice (vaginal introitus)
❖ Berfungsi sebagai kanal untuk cairan menstruasi, persalinan & hubungan seksual, dan
communicate superiorly with vaginal part of cervix & inferiorly with vaginal
vestibules
❖ Vaginal fornix: reses di sekitar serviks, memiliki bagian anterior, superior, dan lateral.
Bagian posterior erat kaitannya dengan recto-uterine pouch
❖ Memiliki 4 otot: pubovaginalis, external urethral sphincter, urethrovaginal sphincter,
dan bulbospongiosus
❖ Topografi
➢ Anterior: fundus of urinary bladder and urethra
➢ Lateral: levator ani, visceral pelvic fascia, and ureters
➢ Posterior: anal canal, rectum, and recto-uterine pouch
❖ Arterial and venous drainage
➢ ⅓ upper vagina supplied by uterine arteries. ⅔ lower vagina supplied by
vaginal and internal pudendal arteries
➢ Vaginal veins form vaginal venous plexus which will merge with uterine
venous plexus forming uterovaginal venous plexus and drain to internal iliac
veins. These plexuses will communicate with vesical and rectal venous
plexuses
2. Embryology of female reproductive system
a. Genital ducts
➢ Dari intermediate mesoderm → mesospheric (wolffian) duct &
paramesonephric (Mullerian) ducts
➢ Wolffian duct → Epididymis, vas deferens, seminal vesical (Male)
➢ Mullerian duct → Uterus, fallopian tubes, cervix, ⅓ upper vagina (Female)
➢ Pada wanita, Leydig and Sertoli (-) → testosterone and anti-mullerian
hormone (-) → Wolfian duct regresi and Mullerian duct berkembang
➢ Mullerian duct akan tumbuh mendekat satu sama lain dan menyatu secara
caudal: uterus, cervix. and ⅓ upper vagina; Cranially & horizontally: fallopian
tube (4 weeks)
➢ Urogenital sinus + Mullerian duct → sinovaginal bulb (12 weeks)
➢ Sinovaginal bulb berproliferasi → vaginal plate
➢ Vaginal plate berproliferasi membentuk vaginal canal (20 weeks)
b. External genitalia
➢ Genital tubercle → glans clitoris
➢ Urethral fold → labia minora
➢ Urogenital membrane → urethral orifice, hymen, vaginal orifice
➢ Labioscrotal swelling → labia minora
3. Menstrual Cycle
a. Follicular Phase
- Proliferasi sel granulosa akibat FSH & Estrogen
- Pembentukan zona pellucida, menyelimuti primary oocyte
- CT ovarium akan berdiferensiasi menjadi thecal cells
- Granulosa + theca cells → follicular cells, sekresi estrogen
 -Formasi dari antrum → follicular size meningkat
-Pembentukan mature follicles (hanya dominant follicles, FSH reseptornya
banyak)
b. Ovulation
- Terjadi 14 hari setelah initial onset of menstruation (normally)
- Estrogen↑ → Feedback (+) → LH↑ (6-8x) and FSH↑ (2-3x)
- LH & FSH → rapid swelling of follicle
- LH → granulosa & theca cells convert to progesterone secreting cells
c. Luteal phase (secretory phase)
- Setelah expulsion, granulosa & theca cells → Corpus luteum using LH
(luteinization)
- Granulosa cells sekresi progesterone & estrogen
- Theca cells secrete androgen which are converted by aromatase enzyme into
estrogen
- Estrogen & progesterone → feedback (-) → FSH & LH ↓ → degeneration of
corpus luteum
- In pregnancy, hCG produced → prolonged corpus luteum life
d. Menstruation
- Corpus luteum degenerate → progesterone & estrogen ↓ → desquamation
of functional endometrium
4. Menstrual Disorder
★ Menstrual disorder: abnormal condition in a woman’s menstrual cycle
★ The average adult’s menstrual cycle = 28 days (range: 24-35 days)
★ The median blood loss during each cycle = 30-80 ml
★ Classification (based on cycle length)
➔ Polymenorrhea: Intervals between cycle = 21 days or fewer
➔ Irregular menstruation: variation of cycle length for more than 8 days
❏ Metrorrhagia: Irregular intervals of bleeding between cycle
❏ Menorrhagia: regular intervals with excessive blood flow (>80ml) or
menstruation lasting >7 days
❏ Menometrorrhagia: irregular intervals with excessive blood flow
(>80ml) or duration (>7 days)
➔ Oligomenorrhea: infrequent, light menstrual period (intervals between cycle
>35 days)
➔ Amenorrhea: Kondisi dimana wanita tidak mengalami haid/menstruasi, dapat
diklasifikasikan menjadi primary dan secondary amenorrhea.
- Primary amenorrhea: Kondisi ketika seorang wanita berusia 16 tahun
belum pernah mengalami menstruasi.
 -
Secondary amenorrhea: Kondisi ketika seorang wanita yang sudah
pernah mengalami mens tidak mengalami mens selama 6 bulan atau 3
periode berturut-turut.
5. Hematometrocolpos due to imperforate hymen
★ Definition: Retensi darah haid di uterus dan vagina sehingga menimbulkan
penonjolan baru pada introitus vagina
★ Etiology: Perkembangan embriologi yang abnormal atau inkomplit
★ Epidemiology:
- Insidensi: 1 per 1.000-2000 wanita
- Biasanya sporadik, tapi bisa juga multiple family members
★ Faktor risiko: Keturunan/familial inheritance
★ Tipe hymen abnormal:
- Imperforata
- Microperforate
- Cribriform
- Septate
★ Diagnosis:
- HT: Nyeri siklik, amenore, nyeri perut bawah/nyeri pelvis, sulit
urinasi/defekasi
- PE: Pelvic/rectal examination
- SE: Transabdominal, pelvic, or rectal USG; endocervical and endometrial
biopsy, and MRI
★ Komplikasi:
- Infeksi
- Subfertility
- Endometriosis
- Hidronefrosis & gagal ginjal.
★ Management:
- Operasi (hymenectomy atau hymenotomy)
- Antibiotik profilaksis
- NSAID pereda nyeri
BHP:
- Informed consent untuk treatment
- Meluruskan persepsi tentang keperawanan bukanlah dilihat dari hymen. Darah yang
keluar ketika pertama kali berhubungan berasal dari vagina. Hymen tidak memiliki
blood vessel yang memvaskularisasi nya
PHOP:
- Promotive: edukasi mengenai hymen (to correct myth in social) & normal menarche
- Curative: surgical treatment (hymenotomy or hymenectomy)
CRP: insidensi: 0,05-0,1% or 1 per 1000-10.000 population