A 12-year-old girl is brought to the office for evaluation of increasing lower abdominal pain. The pain began last week, was initially colicky, and was relieved with ibuprofen. Now the pain is constant and the patient has pain with defecation and a sense of incomplete bowel evacuation. She has had decreased appetite for the last 3 days due to the pain but has had no fever, vomiting, diarrhea, or bloody stool. The patient has had intermittent lower abdominal pain for the last 6 months, but the pain usually resolves after a few days without intervention. She has no medical conditions or prior surgeries. She has not reached menarche. BMI is 19 kg/m². There is a tender, symmetric suprapubic mass to the level of the umbilicus. External genitalia are normal and breast and pubic hair development is Tanner stage 2. There is a blue-tinged bulge between the labia. Rectal examination reveals an anterior tender, central mass. Which of the following is the best next step in management of this patient?

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11ec25c8_d99f_37a5_bc81_85585bfd65fa_MD0003_00 This patient's cyclic lower abdominal pain and blue-tinged bulge between the labia are consistent with an imperforate hymen, an isolated genital outflow tract defect. Girls with a complete imperforate hymen are typically asymptomatic until menarche, when they begin to have cyclic lower abdominal pain due to uterine cramping and obstructed menstruation. As blood volume in the vagina increases (ie, hematocolpos), the vagina (and sometimes uterus) becomes markedly distended (eg, enlarged suprapubic mass), causing bulk symptoms that include constant lower abdominal pain. Posterior expansion of the hematocolpos causes increased rectal pressure, and patients can present with defecatory pain, sense of incomplete evacuation, and a tender anterior rectal mass. Treatment is with hymenal incision and drainage of the entrapped material. As the uterus and hematocolpos empty, the abdominal pain resolves and the vagina and uterus (suprapubic mass) return to normal size. blue-tinged bulge hematocolpos (Choices A and B) This patient's suprapubic mass is due to hematocolpos and uterine enlargement and will resolve with hymenal incision and drainage. CA-125 and CEA levels can be elevated in benign gynecologic conditions and are nondiagnostic. If the pelvic mass and chronic pelvic pain do not resolve with incision and drainage, a diagnostic laparoscopy may be performed to evaluate for other pathologies (eg, endometriosis). (Choice D) Patients with an imperforate hymen cannot undergo a hysterosalpingogram as the hymen prevents access to the cervix and uterine cavity. A hysterosalpingogram can be used to evaluate for uterine anomalies (eg, unicornuate uterus); uterine anomalies are not associated with imperforate hymen. (Choice E) Karyotype analysis may be performed in patients with primary amenorrhea and either no uterus (eg, androgen insensitivity syndrome [46,XY]) or lack of secondary sexual characteristics (eg, Turner syndrome [45,XO]). This patient has a uterus and normal secondary sexual characteristics. (Choice F) A uterine myomectomy is performed in patients with uterine fibroids (ie, leiomyomas). Patients with fibroids may have bulk symptoms (eg, abdominal pain, bowel symptoms); however, fibroids are typically irregularly shaped pelvic masses with no associated blue-tinged vaginal bulge. Educational objective: Imperforate hymen is a defect in the female genital outflow tract resulting in hematocolpos. The accumulated material causes pain and sometimes difficulty with defecation. Treatment is with hymenal incision and drainage. References: Imperforate hymen: cause of lower abdominal pain in teenage girls. (http://www.ncbi.nlm.nih.gov/pubmed/19960149) Obstructive reproductive tract anomalies. (http://www.ncbi.nlm.nih.gov/pubmed/25438708) Abdominal tumor in a 14-year-old adolescent: imperforate hymen, resulting in hematocolpos-a case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/25737786)

A 12-Year-Old Girl Is Brought to the Office for Evaluation