Case Report An 11 year old pre-menarchal girl with recent diagnosis of functional constipation presented to the ER with worsening abdominal pain and acute urinary retention. She had no medical problems until 3 months prior to presentation when she initially developed abdominal pain and was hospitalized with diagnosis of acute viral gastroenteritis and dehydration. Pt had total of 5 ER visits and 2 hospitalizations. In addition to her intermittent lower abdominal pain, she developed symptoms of dysuria, urinary hesitancy, and decreased stool frequency. Urinalysis (x4) results were normal. She was placed on scheduled miralax by her PCP following diagnosis of functional constipation. Symptoms persisted and resulted in school absences. Pt’s diet was healthy and rich in fiber with no recent changes in diet or activity and no stressors. No concerns expressed for sexual abuse. On exam, pt was uncomfortable with distended abdomen, positive bowel sounds, bilateral lower quadrant tenderness, voluntary guarding, no rebound and palpable stool on abdominal and rectal exams. Abdominal film confirmed stool retention. Pt had large stool following an enema but urinary retention continued. Bladder scan confirmed a distended bladder with resulting catheterization of ∼1.5L of urine. She was admitted with diagnoses of functional constipation, failure of outpatient therapy and resulting urinary retention. Pt was able to void following GI cleanout with Golytely, however hesitancy and abdominal pain continued. A pelvic ultrasound (Figure 1, 2) on hospital day 5 showed markedly distended vagina with fluid extending to the cervix and normal uterus and ovaries confirming diagnosis of imperforate hymen with hematocolpos. Pelvic exam revealed a tense membrane tender to light palpation encompassing the introitus. Gynecology was consulted and pt underwent a hymenectomy with complete resolution of abdominal pain ∼3 months following initial symptom development. Discussion Imperforate hymen is a rare diagnosis occurring in approximately 1 in 2000 girls. Hematocolpos is the vaginal distention with menstrual blood which induces pressure on bladder, urethra and bowel resulting in constipation and urinary retention. This diagnosis can be missed on initial presentation and recurrent visits in the face of the widespread prevalence of functional constipation in children where hospitalization due to failed outpatient therapy is common. Omittance of pelvic exam in physical exam also results in incomplete differential diagnosis. Conclusion A diagnosis of imperforate hymen and hematocolpos should be considered in pre-menarchal girls presenting with cyclical lower abdominal pain, chronic constipation, and urinary retention. A complete physical exam, including pelvic exam, and reassessment of the differential diagnosis are essential in avoiding delay in diagnosis and management.

Figure 1

Representative presentation of hematocolpos on pelvis U/S (transverse view)

Figure 1

Representative presentation of hematocolpos on pelvis U/S (transverse view)

Close modal
Figure 2

Representative presentation of hematocolpos on pelvis U/S (sagittal view)

Figure 2

Representative presentation of hematocolpos on pelvis U/S (sagittal view)

Close modal