The importance of a thorough clinical examination in adolescent girls presenting with acute urinary retention

We present an adolescent girl with a 1-day history of acute urinary retention and lower abdominal pain. She was admitted to the paediatric ward for ongoing treatment and investigations. Due to a myriad of factors including pain and anxiety, challenges posed included an incomplete initial abdominal and external genital examination. This case report highlights the importance of a focused history and performing an appropriate sensitive examination at the time of presentation. Furthermore, we explore the common causes of new onset urinary retention and unravel the case as it unfolds. We also highlight differential diagnoses (however, uncommon), which must be considered and not overlooked to avoid unnecessary investigations and to ensure timely management.

paediatrics, obstetrics and gynaecology

A thorough history taking and full physical examination is the basics of medicine. These basic skills remain the most important tests that can be performed on patients in spite of varied investigations which are currently available. Furthermore, a repeat history-taking and examination can help clinicians in reaching the diagnosis. Imperforate hymen is the most common yet rare congenital abnormality of the female genital tract. Although haematocolpos as a result of imperforate hymen commonly present with compressive symptoms in adolescent girls, the suspicion and prompt diagnosis are often missed due to confoundment, such as presenting as a surgical abdomen and an inadequate physical examination. This case report emphasises the consideration of imperforate hymen in an adolescent girl without menarche who presents with a history of new-onset acute urinary retention with abdominal pain. In addition, we highlight the need for a complete physical examination, including a genitourinary examination in such cases. Case presentation An adolescent girl presented to the hospital with a 1-day history of lower abdominal pain and acute onset urinary retention. Her medical history included previous urinary tract infections (UTIs) and two episodes of pyelonephritis with follow-up investigations revealing no underlying abnormalities. She was not on regular medications at the time of presentation. On examination, she was in pain with normal vitals. Her chest and cardiovascular examination were normal. Her abdomen was soft, but tender on light palpation and mainly localised to the right iliac fossa. There was also evidence of a suprapubic mass suggestive of palpable bladder. A pelvic examination was not performed on admission. She was commenced on antibiotics with presumed diagnosis of UTI. In view of her urinary retention, it was planned to catheterise the bladder, but initial attempts at catheterisation were unsuccessful and she was later catheterised with a small feeding tube to empty the bladder. Later, she was catheterised with a Foley catheter. On the second day of admission, there was no symptomatic improvement. History was reviewed and it was found that she had not attained menarche, but had developed appropriate secondary sexual characteristics and was not sexually active. Detailed genitourinary examination was not performed, but the possibility of haematocolpos as a differential was kept with a plan for further investigations. Additionally, she had not opened bowels for a few days and throughout admission, the patient’s pain frequently increased—this posed a challenge to the team in light of her constipation and the use of opioids potentially exacerbating the issue. Furthermore, the patient’s compliance was affected by pain and associated anxiety meaning difficulties in performing a detailed examination. Investigations Initial investigations included urinalysis which revealed traces of blood but microscopy was normal and culture was sterile. A urine pregnancy test was also performed in view of amenorrhoea with a negative result. Blood tests performed on admission were also unremarkable with white blood cell count of 10.4 x 109/L, C reactive protein (CRP) of 1 and normal renal function. On day 3 of admission, further blood tests, including amylase and calcium, were within normal limits; however, CRP had risen to 91. A transabdominal ultrasound was performed; however, the first scan views were limited due to the patient not being able to tolerate the probe due to pain. A second pelvic ultrasound was performed due to persistent abdominal pain and in light of the restricted views from the last scan. On this occasion, the scan revealed a massively distended vagina with fluid suggestive of imperforate hymen (figure 1). MRI confirmed the presence of haematometrocolpos, suggestive of genital outflow tract obstruction (figure 2). The vagina was distended down to the level of the introitus and measured approximately 15 cm in length and 9 cm transversely. Evidence of bladder and bowel compression was also noted. Differential diagnosis This patient presented with a painful abdomen and acute urinary retention. With a medical history of several UTIs and pyelonephritis, the patient was commenced on antibiotics. However, since the severity of the pain was disproportionate to what would be expected in this patient, it was paramount that other differentials like appendicitis, ectopic pregnancy, ovarian torsion, gastroenteritis, constipation and renal stones were considered. In view of primary amenorrhoea with the presence of secondary sexual characteristics and urinary retention, possibility of imperforate hymen was considered, which was confirmed on imaging. Treatment This patient was initially managed as UTI with antibiotic in view of an acute history of abdominal pain and urinary retention. She was also started on laxatives and analgesics. Urinary catheterisation was done to relieve urinary retention. Following confirmation of imperforate hymen, she was referred to the gynaecology team. She consented for external genital examination under anaesthesia and underwent hymen incision and drainage of haematocolpos. A circumferential incision was performed, releasing a large quantity of the old blood. There were no complications postoperatively. Outcome and follow-up After the operation, the patient was discharged once she was able to successfully pass urine. She was also advised to keep a record of her periods. The patient has since confirmed that she is now menstruating regularly although noted they are currently heavy. Her bladder and bowel functions have resumed normality. The patient has also been advised to consider commencing contraceptive pill to regulate menses if menorrhagia persists.

Acute urinary retention is a rare entity in children and is a genitourinary emergency. Aetiology range from neurological, congenital abnormalities, infectious, obstructive and psychogenic.1 An imperforate hymen is overall rare, but also the most common female genital tract anomaly with incidence ranging from 0.05% to 0.1%.2 3 An imperforate hymen results from failure of canalisation of uterogenital sinus resulting into obstruction of the outflow for vaginal and endometrial secretion.3 4 With time, accumulation of these secretions can give rise to mucocolpos, haematocolpos or haematometrocolpos.4 5 The reported frequency of haematocolpos for imperforate hymen is around 0.17% in the literature.6 Imperforate hymen is often diagnosed in adolescent girls.7 In a systematic review done by Lee et al, the mean age was found to be 10.7±4.7 years.8 In the same review, only 11% of cases were found to be diagnosed in perineonatal period, the diagnosis was missed in other cases.9 However, imperforate hymen tends to remain asymptomatic until puberty when the menarche commences. In a study done by Posner and Spandorfer, it was found that girls diagnosed at older age were all symptomatic and needed ancillary tests before diagnosis compared with those who were diagnosed in prepubertal age.3 The most common presentation in imperforate hymen is abdominal pain—with almost half cases presenting with it,8 mostly as protracted cyclical pain, but sometimes presenting as acute abdomen.8 9 The incidence of acute urinary retention is approximately 48% and that of constipation is 20.3%.8 9 All these occur as a result of the mass effect on surrounding structures like rectum, urethra and bladder by haematocolpos.4 A number of complications, namely recurrent UTIs,10 hydronephrosis,11 chronic back or sciatica,12 13 pyosalpinx,14 rupture of fallopian tube,15 pelvic inflammatory disease16 and endometriosis,3 16 can also manifest, specially if diagnosis is delayed. In absence of classical cyclical abdominal pain and presence of non-gynaecological symptoms the diagnosis can be obscured—there is paucity of data on average duration to reach a diagnosis and hospital stay for imperforate hymen. A study done by Lui et al, showed admission length of 1.9 days in those diagnosed in the emergency department and 4.2 days for those diagnosed later.9 The duration from presentation of this patient to surgery was 15 days. Certain challenges like difficult examination and imaging contributed to confirming the diagnosis promptly. In study by Posner and Spandorfer, they found that the delay in diagnosis was attributed to delay in seeking medical attention by patient, but also due to lack of genital examination in one-third of the cases, leading to different preliminary diagnosis.3 Hence, a high index of suspicion for imperforate hymen in adolescent girls with such presentation and targeted genitourinary examination should be considered for early diagnosis. Ultimately, an imperforate hymen is a clinical diagnosis—which is made based on the history and identification of a bluish bulge in the introitus on examination.3 Ultrasound can be a diagnostic tool to confirm the clinical suspicion in most cases, but MRI may also be used in complicated cases and for better assessment of the anatomy preoperatively.17 In conclusion, an imperforate hymen should always be considered as one of the differentials in adolescent girls presenting with abdominal pain and obstructive urogenital or gastrointestinal symptoms and a thorough genitourinary examination should be performed. A thorough examination, including external genital examination, during newborn examination can identify this condition in the neonatal period—although it can be challenging in view of the small size of the external genitalia and the effect of maternal oestrogen on hymen resulting in thickened, elastic and fimbriated hymen. Learning points. In the appropriate paediatric age group, a comprehensive gynaecological history is crucial. Coupled with a thorough examination, this can help identify early any serious causes. Any adolescent girl presenting with acute urinary retention, constipation or perineal pain should undergo a pelvic examination, including inspection of the external genitalia, in the presence of a chaperone after taking consent. Haematocolpos typically present in prepubertal girls; a clinician must approach such patients in a holistic manner and ensure other issues, such as anxiety are also addressed as this can impact patient compliance to examination and management. An opportunity to pick up genitourinary abnormalities by thorough examination of the external genitalia during newborn examination can avoid diagnosis late in the adolescent period. Acknowledgments We would like to acknowledge the patient and her family for their consent and extend our thanks to both the gynaecology and paediatrics team who were involved in the patients care. Footnotes Contributors: OR and SL jointly decided to write a case report on the patient from the ward. Both shared the workload by allocating headings of the case report, this was done equally. Both were involved in repeatedly proofreading the whole case report and making rolling improvements. SWP, as consultant, provided overall supervisory support, including proofreading the report and making suggestions and edits. All authors read and discussed the final manuscript before agreeing to submit. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests: None declared. Patient consent for publication: Obtained. Provenance and peer review: Not commissioned; externally peer-reviewed.

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