Hematocolpos is a pathological condition characterized by the accumulation of menstrual blood in the vagina due to the closure of its lumen. It is accompanied by vaginal itching, amenorrhea, pain in the lower abdomen, sometimes a violation of urination and defecation, soreness of sexual intercourse, its difficulty or complete impossibility. Diagnostic measures include gynecological examination, vaginal probing, ultrasound and MRI of the pelvic organs. Surgical treatment is aimed at evacuation of the vaginal contents and ensuring the normal outflow of menstrual blood.
Hematocolpos – accumulation of blood in the vaginal tube. The volume of the contents of the stretched vagina in some cases can reach up to a liter or more. This is a rare condition in gynecology, occurring in less than 0.5% of patients who have sought medical help. Pathology is registered in women in the age range from menarche (12-16 years) before menopause (45-55 years) and is most often observed in puberty girls. Hematocolpos, as a rule, is a consequence of congenital malformations, postnatal injuries lead to complete obstruction much less often. Hematocolpos, developed due to congenital anomalies of the genital apparatus, is combined with defects of the urinary system in almost 55% of cases (agenesis and doubling of the kidney, absence of a ureter).
The reason for the formation of hematocolpos is complete obstruction of the vagina at any level. The source of the problem may be abnormalities that developed in utero from the fifth to the twentieth week of pregnancy, or damage to the vagina that occurred both in childhood and in adulthood.
- Congenital anomalies. Anatomical defects of the female genitals leading to hematocolpos include hymen atresia (complete overgrowth of the hymen), transverse and longitudinal vaginal septa, partial vaginal aplasia with a normally functioning uterus. The cause of developmental abnormalities is the effect of teratogenic factors. External factors include infections (especially viral), medications (primarily hormonal), chemical teratogens (gasoline, alcohols, phenols, formaldehyde), hypo- or hypervitaminosis, ionizing radiation. The internal ones include endocrine-metabolic pathologies and hereditary mutations.
- Acquired vices. In the pre-pubertal period, due to age-related features (narrowness of the lumen of the vaginal tube, physiological hypoestrogenism, immaturity of the immune system), atresia of the vagina and hymen is most often caused by inflammation – vulvovaginitis, due to insufficient hygiene of the external genitals, as well as caused by an allergic reaction, infections (herpes virus, chlamydia, urea- and mycoplasma, measles, rubella). In adult women, acquired atresia in most cases is associated with birth injuries and surgical interventions.
Acquired abnormalities of the vagina are caused by the adhesion of its walls as a result of inflammation or gross scar deformities due to injuries and surgical operations. Congenital malformations are caused by disorders of the development of the Muller system and its fusion with the urogenital sinus. In a female embryo, the fallopian tubes, uterus and vagina are formed from paramesonephric (Muller) ducts, initially having the appearance of two continuous strands. In the future, these ducts merge, while in the middle and lower part a channel is formed, closed from below by the vaginal plate and forming a single-cavity uterus and the upper part of the one-arm vagina. The vaginal tube is formed during the fusion of the Muller system, the vaginal plate and the urogenital sinus.
Underdevelopment of the lower part of the Muller ducts leads to aplasia of the vagina. With complete non-fusion of the Muller ducts, two separate uterus and two separate vaginas are formed, and one of the tubes is often “blind”, not communicating with the external environment. The result of partial non-effusion are longitudinal vaginal septa. Violations of the fusion of the vaginal plate with the Muller system and with the genitourinary sinus lead to the formation of transverse vaginal septa and hymen atresia.
Clinical manifestations of congenital and acquired vaginal defects in childhood develop in adolescence with the onset of menstruation. In adults, hematocolpos is formed after several months after traumatic exposure. The smaller the volume of the “blind” part of the vaginal tube, the earlier the pain syndrome occurs and becomes more intense. Emptying the hematocolpos leads to an instant improvement in the condition.
In girls with hymen overgrowth, the leading symptom is false amenorrhea, itching and pain syndrome joins later, after a few months, when the hematocolpos reaches a certain size. Aching pains in the lower abdomen first appear during menstruation, later they become permanent and more intense. The growth of education is accompanied by a violation of urination (first increased frequency, then delay) and constipation. With this form of anatomical anomaly, the vagina can reach significant sizes and be felt by the patient herself in the form of an internal “tumor” extending beyond the pelvis and bulging into the genital slit.
In the case of atresia and aplasia of the vagina, false amenorrhea is also observed, accompanied by severe pain and itching already in the first months from the onset of menstrual function, the pain syndrome quickly becomes permanent. Urination and defecation in these forms, as a rule, are not disturbed, but the accumulation of blood in the hollow organs located above begins much earlier. In the presence of an additional uterus with a blind “vagina”, the symptoms are similar to those of hymen atresia, with the difference that there are scanty periods, and periodic pains accompanying the development of hematocolpos in the additional vagina may not correspond to the menstrual cycle of a fully functioning sexual apparatus. In the later stages, bloody-purulent discharge may join due to perforation of the blind vagina in the area of the adjacent wall.
Sexual life can be relatively normal only with the defeat of an additional closed vagina. In this case, full-fledged sexual contact is possible (may be accompanied by discomfort and pain), conception, pregnancy and vaginal delivery. Hematocolpos caused by other anatomical defects leads to the impossibility of natural fertilization. Sexual intercourse is significantly difficult and accompanied by a pronounced pain syndrome in the case of a sufficiently high obstruction and is impossible with hymenal atresia and vaginal aplasia.
Prolonged violation of the outflow of urine due to compression of the urethra and bladder by volumetric hematocolpos can lead to inflammatory diseases of the urinary system and the development of renal failure. Due to an untreated hematocolpos, blood gradually begins to accumulate in the uterus (hematometer), and later in the fallopian tubes (hamatosalpinx), which is accompanied by constant, poorly relieved by analgesics, intense, cramping pain. 70% of patients develop endometriosis, which aggravates pain. Stagnation of bloody contents creates favorable conditions for the development of purulent infections in the uterus and appendages, leading to adhesive disease and persistent infertility. A formidable complication is necrosis of the vaginal wall or fallopian tube, followed by rupture and the development of acute pelvioperitonitis (peritonitis).
Hematocolpos caused by atresia of the hymen and aplasia of a part of the vagina can be easily suspected already at the stage of clinical examination. Difficulties are caused by the diagnosis of hematocolpos in the case of atresia and doubling of the vagina, as well as differential diagnosis mainly with oncological diseases: sarcoma and uterine fibroids, ovarian neoplasms, Wilms tumor. The diagnosis is established with the participation of an obstetrician-gynecologist and oncogynecologist. The diagnostic program includes:
- Gynecological examination. Hematocolpos can be assumed according to the anamnesis, the results of examination on the chair – palpation and visual assessment. So, when the hymen is overgrown, there is a protrusion of a cyanotic tumor formation from the genital slit or swelling of the entire perineum, aplasia is easy to establish by a small cup-shaped depression in the place of the vagina. Regardless of the origin, hematocolpos is characterized by a tight-elastic mobile formation located in the pelvic region, sometimes spreading into the abdominal cavity.
- Instrumental research. Probing the vagina allows you to identify atresia and determine its level. With the help of a vaginal puncture, it is possible to obtain bloody contents indicating hematocolpos. According to the results of MRI and ultrasound of the retroperitoneal space and pelvis, it is possible to detect an additional uterus and vagina, anatomical defects of the vagina, tumors emanating from the genitals and kidneys.
- Bacteriological examination. With the help of bacterioscopic and cultural methods, pathogens of the attached infection are identified and an effective drug is selected for its treatment.
Treatment is aimed not only at eliminating interference that prevents the outflow of menstrual blood, but also at restoring reproductive function. The volume of surgical intervention depends on the pathology that led to hematocolpos: in some cases it is a “flow”, routine operation, in others it is complex, requiring high qualification of the operating gynecologist. All operations include a mandatory stage – emptying and sanitation of the hematocolpos.
- Dissection of the hymen. Hymenotomy is performed with hematocolpos associated with hymenal atresia. The hymen is dissected by a cruciform incision, after which stitches are applied to the edges to avoid repeated fusion.
- Excision of the vaginal septum. It is shown in the presence of thin transverse membranes. The operation consists in dissecting them, followed by vaginal augmentation.
- Excision of the wall of the “blind” vagina. It is prescribed with doubling of the vagina – the presence of a longitudinal septum forming a closed cavity, or with an additional uterus with an aplasized vagina. The maximum resection of the adjacent wall is performed and the formation of a closed vagina with a normally functioning one is formed.
- Plastic surgery of the vagina. Vaginoplasty is indicated for partial aplasia, gross scarring, significant thickness of the transverse septum. Missing or damaged vaginal walls are formed from flaps of the perineum.
Prognosis and prevention
The prognosis of uncomplicated hematocolpos is favorable, an adequate surgical operation allows you to get rid of excruciating suffering forever and successfully realize reproductive function. Primary prevention of pathology consists in the prevention and timely treatment of infections in girls and women, the fight against injuries during childbirth, a healthy lifestyle, proper nutrition and the exclusion of factors that cause teratogenic effects in the first half of gestation. Secondary prevention includes ultrasound of the fetus in the last trimester of pregnancy (some anomalies that subsequently lead to hematocolpos can be detected already in this period), preventive examinations by a pediatric gynecologist of young girls and in the puberty period.