46. Management of Hematocolpos in Lower Vaginal Atresia by Image-Guided Drainage with Interventional Radiology: A Case Series

Abstract

<h3>Background</h3> Obstructive uterovaginal anomalies such as lower vaginal atresia (LVA), can lead to hematocolpos (HC) and subsequent pain at presentation. Definitive management of long LVA requires vaginoplasty with diligent postoperative dilation to prevent vaginal stenosis. However, many adolescents are not emotionally mature enough to adhere to this. Menstrual suppression and delayed vaginoplasty is recommended, however pain symptoms may require drainage of HC. We present a novel approach to management of symptomatic HC via image-guided percutaneous drainage by Interventional Radiology (IR). <h3>Case</h3> Case 1: 14 yo with small bladder and stress urinary incontinence presented with pelvic pain and was found to have a solitary uterus, 6 cm LVA, and a large HC on MRI. She declined vaginoplasty and opted for IR drainage. Ultrasound (US)-guided transabdominal percutaneous uterine access was obtained and tissue plasminogen activator (tPA) was infused through a drain to thin the HC fluid to allow complete aspiration. Norethindrone acetate (NAT) was initiated for menstrual suppression. Cases 2 and 3: 10 yo presented with abdominal pain and found to have a solitary uterus, 5.3 cm LVA, and a large HC on MRI. Menstrual suppression with NAT failed to control her pain; after counseling, she declined vaginoplasty and opted for IR drainage. US-guided percutaneous access was obtained, tPA infused to thin the HC, and pigtail drain placed to assist with further decompression. Cone beam CT verified the patient's anatomy and confirmed drain position. Drain was removed post-operative day 1. Symptomatic re-accumulation of HC occurred after 15 months of menstrual suppression and a repeat US-guided drainage was performed with complete decompression; GnRH agonist arm implant was placed for long-term menstrual suppression. Case 4: 15 yo with complex history including urogenital sinus, renal transplant, and urinary diversion was admitted to the hospital with pelvic pain. MRI suggested a dilated bicornuate uterus with HC and 6 cm LVA. She was counseled on management options, and elected IR drainage. US-guided, percutaneous drainage of the uterine cavity was performed with complete decompression of HC. Cone beam CT confirmed uterine anatomy after drainage. NAT was initiated for long-term menstrual suppression. Table 1 provides a detailed summary of each case. <h3>Comments</h3> We present a novel approach to management of symptomatic HC from LVA via image-guided percutaneous drainage of HC by IR. This simple outpatient procedure can successfully relieve symptoms and allow for menstrual suppression to serve as a temporizing measure until patients are mature enough to undergo definitive surgery for various obstructive uterovaginal anomalies.