Spasticity of the pelvic floor mimicking an obstructive anomaly

Abstract

BACKGROUND: Hematocolpos or hydrocolpos diagnosed in post-pubertal menstruating women raises the suspicion of a partial obstruction of a uterus didelphis or a hemi-vagina. This diagnosis requires immediate treatment to relieve pain and prevent the possible formation of endometriosis. This case report describes two patients who were evaluated at the Gynecology Clinic for Women with Mental Disabilities with the diagnosis of hematocolpos.METHODS: Two patients were evaluated at the Gynecology Clinic for Women with Mental Disabilities for a diagnosis of a hemato/ hydrocolpos based on USN and MRI findings. Both cases were evaluated and all ultrasound, IVP and MRI reports were reviewed.RESULTS: Patient A is a 13-year-old girl with cerebral palsy and mental disabilities, who presented to our clinic for irregular menses and an enlargement of the left labia. On examination her left labia appeared enlarged with a varicosity and an ultrasound was ordered to rule out a pelvic mass. The ultrasound report revealed a fluid filled distended vagina with normal uterus and ovaries. MRI confirmed the distended vagina and normal uterine configuration. Since it was not possible to examine this patient in the clinic, an exam under anesthesia was performed. This revealed a normal vagina, cervix and uterus. An intraoperative ultrasound was normal. Her IVP revealed normal ureteral implantation. Patient B is a 34-year-old gravida 0 with a medical history significant for cerebral palsy and mental disabilities. Her history reveals regular cycles until 4 months prior to presentation when they became more irregular and lighter. In addition, she was experiencing abdominal pain and night sweats. As part of her evaluation she underwent an ultrasound that revealed a markedly distended vagina, filled with fluid and a slightly enlarged uterus. Pelvic examination demonstrated a normal vagina and cervix. An MRI was performed which confirmed a distended vagina and revealed adenomyosis in the uterus, but no distension of the endometrial canal. Since the pelvic examination and the MRI were not compatible, an ultrasound was performed simultaneously with a pelvic exam. On abdominal ultrasound view prior to the pelvic examination the vagina was distended, similar to an obstructive picture. A pelvic exam under abdominal ultrasound guidance revealed a vagina filled with urine. The ultrasound clearly demonstrated resolution of the distended vagina, when the urine leaked out through the speculum. After the patient remained supine for 30 minutes an abdominal ultrasound redemonstrated the distended vagina. Her IVP was normal.CONCLUSIONS: These cases demonstrate that a spastic pelvic floor can mimic an outflow tract obstruction in a patient with urinary incontinence. If the history, pelvic examination and the images are not consistent, performing an exam under ultrasound guidance may assist in the diagnosis.