Case presentation

DR.MOHAMED ABDELGALIL

UNDER SUPERVISION

PROF: DR MOHAMED HESHAM

20/1/2024
A 1 4 -y e a ra d o l e s c e n t g i r l p r e s e n t e d to gynaec OPD with complaints of
cyclical lower abdominal pain for past 4 months with dysuria and mass
per abdomen. There was no history of vomiting or bowel disturbances. She had
not attained menarche. On examination she was normally built with normal
height and weight. Breasts, axillary hair and pubic hair showed Ta n n e r s t a g e
I V. T h y r o i d was normal and no features of hirsutism were noted. She was
afebrile. Her pulse, blood pressure and systemic examination were
normal On abdominal examination, mild s u p ra p u b i c t e n d e r n e s s w a s n o t e d
w i t h a p a l p a b l e m a s s o f a b o u t 1 6 w e e k ’s s i z e . G e n i t a l examination showed a
bluish bulged h y m e n p o s t e r i o r t o t h e u r e t h ra . Pe r r e c t a l e x a m i n a t i o n
c o n fi r m e d t h e m a s s a n t e r i o r t o r e c t u m . w h a t i s y o u r m a n a g e m e n t ?
Case presentation

Summary )
A 1 4 -y e a r s o l d ( age of puberty )

presented to gynaec OPD ( patient started t o s e e k m e d i c a l a d v i s e a t fi r s t

time

complaints of cyclical lower abdominal pain ( every month at same time )

past 4 m o n t h s ( t h e p a t i e n t wa s f r e e b e f o r e s t a r t i n g c o m p l a i n 4 m o n t h s a g o

dysuria and mass per abdomen. ( pain accompanied with another symptoms )

no history of vomiting or bowel disturbances.( GIT causes excluded also

severity of complain not acute abdomen )
She had not attained menarche. ( primary amenorrhea )

examination she was normally built with normal height and

weight. ( to exclude other causes of primary amenorrhea )

Breasts, axillary hair and pubic hair showed Tanner stage

IV.( secondary sexual characters presents )

Thyroid was normal and no features of hirsutism were noted. (

exclude thyroid and hyper androgenism causes
She was afebrile. ( not complicated by infection )

Her pulse, blood pressure and systemic examination were

norm al ( indicate severity of the complain)

O n abdominal examination, mild suprapubic tenderness was noted

with a palpable mass of about 16 week’s size. ( pelvi abdominal mass )

Genital examination showed a bluish bulged hymen posterior to

the ureth ra. (examination show normal external genitalia except mass

rectal examination confi rmed the mass anterior to rectum. ( patients

is virgin no histor y of operation and to assess site size of mass
fundamental
What is the most likely diagnosis ?

clinical Qs
What is the most likely diagnosis ?

primary amenorrhea for D.D

1-imperforate hymen

2-transeverse vaginal septum

3-vaginal , cervical atresia

4- labial adhesion

5- suturing ant in post wall

What is the most likely diagnosis ?

primary amenorrhea for D.D

1-imperforate hymen

Primary amenorrhea .. Cyclic pain.. secondary sexual character

present … normal tall ..normal vital signs … mass ant to the
uterus .. Normal thyroid.. Pelvi abdominal mass .. bluish
bulged hymen posterior to the urethra..
What is the most likely diagnosis ?

2-transeverse vaginal septum

Primary amenorrhea .. Cyclic pain.. secondary sexual character

present … normal tall ..normal vital signs … mass ant to the
uterus .. Normal thyroid.. Pelvi abdominal mass .. No bluish
bulged hymen posterior to the urethra..
What is the most likely diagnosis ?

3-vaginal , cervical atresia

Primary amenorrhea .. Cyclic pain.. secondary sexual character

present … normal tall ..normal vital signs … mass ant to the
uterus .. Normal thyroid.. Pelvi abdominal mass .. No bluish
bulged hymen posterior to the urethra.. Small vagina
What is the most likely diagnosis ?

4- labial adhesion

Primary amenorrhea .. Cyclic pain.. secondary sexual character

present … normal tall ..normal vital signs … mass ant to the
uterus .. Normal thyroid.. Examination show labial adhesion
What is the most likely diagnosis ?

5- suturing ant in post wall

No history of any operation

fundamental What should be your
next step ?
clinical Qs
What should be your next step ?

1. Pregnancy test ( to check pregnancy )

2. Ultrasound ( to make assessment uterus to content of the

mass to exclude other causes )

3. MRI to diff erentiate between imperforate hymen and other

causes of uterine anomalies

4. IVP to see there another renal anomalies

fundamental What is the most likely
mechanism for the process ?
clinical Qs
What is the most likely mechanism for the process ?

Complete closure of the vagina due to imperfect canalization

leading to retained blood of menstruation in vagina or uterus
af ter puberty
fundamental What is the risk factor
for this condition? ?
clinical Qs
What is the risk factor for this condition? ?

variations in hymenal anatomy commonly escape diagnosis until

the time of menarche so possibality of complication will be
increased
fundamental What is the complications
associated with this disease/

clinical Qs process ?
What is the complications associated with this
disease / process ?

Hematocoplpos and hematometria and hematosalpinx will lead

to blood spillage to peritoneal cavity then adhesion infertility

Complication of ttt
fundamental What is the best
therapy / treatment?
clinical Qs
What is the best therapy / treatment?

H y menecto my

 Pre p arat i o n

 An e st he si a

 Co nse nt

 I nve st i gat i o n

 Pro ce d u re

 Po st o p e rat i ve

 Ce r t i fi cat e

 Fol l o w up
What is the best therapy / treatment?

Hymenectomy

 G e n e ra l a n e s t h e s i a + c a t h e t e r i za ti o n .

 H y m e n e c t o my → C r u c i a te i n c i s i o n + exc i s i o n o f e d g e s O R

 O p e n i n g a h o l e i n t h e hy m e n a ft e r t ra c ti o n f ro m i t s c e nt e r.

 L e av e b l o o d to d ra i n s l o w l y ( n e v e r to p r e s s o n t h e m a s s

 o t h e r w i s e a i r w i l l e n t e r t h e g e n i ta l t ra c t a l l o w i n g t h e r e t a i n e d

 b l o o d to e n te r t h e p e r i t o n e a l c av i t y ) + a nti b i o ti c s c o v e ra g e .

 N o d o u c h i n g o r d ra i n l e ft .

 V i r g i n i t y c e r ti fi c a te .
fundamental How would you
confirm the diagnosis?
clinical Qs
How would you confi rm the diagnosis?

History

General examination

Abdominal examination

Local examination

Investigation
Follow up

Pain

Complication

Reepithalization

Any new complain

Infection
Summary

this is a case of primary amenorrhea most likely imperforate hymen

need surgical management (hymenectomy )
Thank you