A 14-year-old girl is brought to the office for evaluation of lower abdominal pain. The pain began a year ago and was intermittent, was relieved with ibuprofen, and typically resolved in 3-4 days. However, the patient now has constant, dull, lower abdominal pain that is exacerbated for a few days each month. Over the last 2 months, she has had no appetite and has lost 4 kg (8.8 lb). The patient has had no fever, chills, or diarrhea but does have chronic constipation. She does not use tobacco, alcohol, or illicit drugs. She is not sexually active and has not had a menstrual period. The patient is in high school, where she is an honor roll student and a member of the track team. Blood pressure is 100/60 mm Hg and pulse is 62/min. Height is at the 27th percentile and weight is at the 32nd percentile for age. Breast development is Tanner stage 3. Abdominal examination reveals a tender suprapubic mass; there is no rebound or guarding. Examination of the genitalia shows Tanner stage 3 pubic hair development and a smooth, blue mass protruding from between the labia majora. Which of the following is the most likely diagnosis in this patient?

Question

A 14-year-old girl is brought to the office for evaluation of lower abdominal pain.  The pain began a year ago and was intermittent, was relieved with ibuprofen, and typically resolved in 3-4 days.  However, the patient now has constant, dull, lower abdominal pain that is exacerbated for a few days each month.  Over the last 2 months, she has had no appetite and has lost 4 kg (8.8 lb).  The patient has had no fever, chills, or diarrhea but does have chronic constipation.  She does not use tobacco, alcohol, or illicit drugs.  She is not sexually active and has not had a menstrual period.  The patient is in high school, where she is an honor roll student and a member of the track team.  Blood pressure is 100/60 mm Hg and pulse is 62/min.  Height is at the 27th percentile and weight is at the 32nd percentile for age.  Breast development is Tanner stage 3.  Abdominal examination reveals a tender suprapubic mass; there is no rebound or guarding.  Examination of the genitalia shows Tanner stage 3 pubic hair development and a smooth, blue mass protruding from between the labia majora.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c13e_ee82_8f63_a969f09797c2_MD0005_00 This patient has an imperforate hymen, a genital tract obstruction that results from failure of the lower third of the vaginal plate to canalize during development. Imperforate hymens can be diagnosed in the neonatal period; newborns have elevated estrogen levels that result in an accumulation of vaginal discharge behind the hymen (eg, mucocolpos). Diagnosis can also occur after menarche as blood and vaginal discharge accumulate behind the imperforate hymen (eg, hematocolpos). Patients can initially have intermittent lower abdominal pain (eg, cyclic) and the apparent absence of menstruation (eg, primary amenorrhea). Continued distension of the vagina and uterus from accumulated blood can lead to constant lower abdominal pain exacerbated by menses. Uterine enlargement (eg, tender suprapubic mass) can lead to bulk symptoms (eg, anorexia, constipation, weight loss). Vaginal enlargement and distension of the hymen can result in the blue intralabial mass visualized on examination. An untreated imperforate hymen can cause retrograde menses through the fallopian tubes and lead to intraabdominal adhesive disease. Treatment is with a hymenectomy. hematocolpos (Choice A) Endometriosis can present with cyclic pelvic pain; however, it also presents with heavy menstrual bleeding. Patients typically have a fixed, immobile uterus; rectovaginal nodularity; or an adnexal mass (eg, endometrioma) on examination. (Choice C) Müllerian agenesis is the congenital absence of the proximal two-thirds of the vagina with either no uterus or a rudimentary uterus. This condition can present with primary amenorrhea; there is no associated lower abdominal pain or suprapubic mass. Pelvic examination reveals a blind vaginal pouch rather than a blue vaginal mass. (Choice D) Pelvic organ prolapse can present with a vaginal bulge; however, it typically presents in multiparous, elderly patients. It is not associated with primary amenorrhea or cyclic pelvic pain. Pelvic organ prolapse (Choice E) Sarcoma botryoides (eg, embryonal rhabdomyosarcoma) typically presents in infancy and early childhood as nonfriable nodules that have a cluster-of-grapes appearance and protrude from the vagina. Educational objective: Imperforate hymen presents with cyclic pelvic pain, bulk symptoms (eg, constipation), primary amenorrhea, and hematocolpos (accumulation of blood and fluid behind the intact hymen). Treatment is via hymenectomy. References: Imperforate hymen - a rare cause of acute abdominal pain and tenesmus: case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/24009804) 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 14-Year-Old Girl Is Brought to the Office for Evaluation