Hematocolpos on imperforated hymen and acute urinary retention A rare disease About seven observations and literature reviews

13 year old patient, admitted for management of an acute abdominal picture with the notion of cyclic pain for fi ve months. She has not had her menarche, but has developed sexual characteristics (breasts at S4 and pubic hair at P5). Examination showed a slight bulging of the hymen and the recto-vaginal septum. Ultrasound showed hematocolpos. Surgical incision of the Y-shaped hymen allowed 600 milliliters of black blood to be drained. The evolution is favourable at the follow-up examination of the patient after three weeks. A forensic certifi cate of medical loss of virginity is given to the family. Abstract


Introduction
Hymenal imperforation is a relatively rare but the most common congenital malformation of the female genital tract (1). It is often isolated but sometimes associated with malformations of the urogenital tract (2).
Painful cryptomenorrhea by parapubertal hymenorrhoea is the most classic telltale picture (3). Non-gynecologic symptoms sometimes mislead the diagnosis.
Hymenal imperforation is easily diagnosed by inspection of the external genitalia. Ultrasonography has simplifi ed the analysis of this rare pathology, and is the best method for early diagnosis thanks to in utero ultrasound.
Hymenotomy is the treatment of hematocolpos by hymenal imperforation. For hematocolpos revealing malformations, the treatment of the causal malformation is more complex.
Early diagnosis and treatment of hymeal imperforation is important in order to improve the prognosis and avoid any tubal sequelae.
In our work, we report a series of seven Hymenal imperforations.

Case reports
a) Case 1 13 year old patient, admitted for management of an acute abdominal picture with the notion of cyclic pain for fi ve months. She has not had her menarche, but has developed sexual characteristics (breasts at S4 and pubic hair at P5). Examination showed a slight bulging of the hymen and the recto-vaginal septum. Ultrasound showed hematocolpos. Surgical incision of the Y-shaped hymen allowed 600 milliliters of black blood to be drained. The evolution is favourable at the follow-up examination of the patient after three weeks. A forensic certifi cate of medical loss of virginity is given to the family. b) Case 2 15- year-old patient admitted to pediatric emergency   department for cyclical pelvic pain for 9 months with   exacerbation of pain for 7 days without urinary signs with   pelvic mass of 12cm, at ultrasound the uterus is in place  measuring

f) Case 6
Thirteen-year-old patient admitted to the pediatric emergency department for pelvic pain dating back 4 days before her admission with complicated acute urine retention since 12 hours. On abdominal and pelvic examination, there

Results and discussion
The hymen is a remnant of the mesodermal leafl et that normally perforates during the later stages of embryonic development [4]. Hymenal imperforation is a rare event estimated at 1 in 2000 female births, but the most common congenital malformation of the female genital tract [1,4,5]. The incidence reported in the literature is widely variable, depending on whether it is assessed globally, according to age or according to the type of anatomical lesion [6]. In typical cases, the age of discovery of hematocolpos is between 12 and 15 years (the age of menarche) [7,8]. In our series of 7 hematocolpos cases, the age of our patients varies between 13 and 15 years (the pubertal period). The majority of cases reported in the literature are sporadic, however, a few familial cases have been described suggesting a probable genetic predisposition [5,9]. Only one patient among the cases we have presented has a family history of hymenal imperforation.
The diagnosis of hymenal imperforation is possible in utero when a hydrometrocolpos is found on ultrasound [10,11]. The in utero diagnosis also has the added advantage of looking for associated renal malformations. This diagnosis can be made by systematic screening at birth but also in front of a hydrometrocolpos of the newborn female baby [12]. Most often, this malformation is discovered at puberty. The diagnosis should be suspected in a girl with primary amenorrhea with normally developed secondary sexual characteristics. Patients usually consult for recurrent pelvic pain secondary to blood    [13]. The cyclical nature of the painful attacks may be missed because of the usual irregularity of the menstrual cycle in the peripubertal period [14]. Pain may be misleading, pseudoppendicular and may induce 'overdoing' procedures on suspicion of acute appendicitis [15]. Haematocolpos can compress the urethra and cause dysuria, complete bladder retention and even bilateral ureterohydronephrosis [13,[16][17][18][19]20]. Einsenberg [21] reported 7 cases of bladder retention in a series of 44 haematocoplos observations [13,[16][17][18][19]20]. Constipation is due to the same compressive mechanism [22]. In our series all the patients were not yet menarche. All patients have good development of external genitalia and secondary sexual characteristics.  Attempt to preserve future fertility.
It must be undertaken in all cases, never rely on spontaneous regression of retentions. Abstention, even in mild forms, could lead to the development of genital and urinary tract infections, which are more frequently encountered in late-onset forms. In many cases, treatment is limited to simple drainage of the retained pouch. Total circumferential excision of the hymen may lead to sclerosis and orifi ce dyspareunia [28,29]. It should therefore be avoided. Hymenotomy must allow normal menstrual fl ow, trying to respect the virginity of these young patients as much as possible, especially in our social context, and to ensure a normal sexual life later on by avoiding restenosis. To do this, it is necessary to respect the orifi ces of the Bartholin glands at 5 o'clock and 7 o'clock and to make an incision at 11 o'clock in the gynaecological position in order to free the lower bank of the urinary meatus and to ensure meatohymenal dissociation. Several surgical techniques are proposed in the literature. Salvat [30], recommends the technique of radial star-shaped hymeal incisions, which is simple but does not guarantee virginity. Another technique has been described by Ali, et al. [31]. It consists of excising a small central collar of the hymen through which a Foley probe is inserted. The balloon of the catheter is infl ated to 10 cm3 and the catheter is then removed after 2 weeks. We found this technique interesting because it is simple, less invasive than other methods and preserves the normal architecture of the hymen. The only disadvantage of this technique is the secondary discomfort of wearing the catheter for 2 weeks. This technique is practiced in 3 of our patients. The results of this technique are rather encouraging: only 2 patients out of 65 have presented secondary hymenal stenosis in the Acar series [31]. In all cases, a postoperative clinical check-up must be systematic to verify the absence of secondary stenosis. This said, the best treatment remains preventive, based on early diagnosis of the malformation and on surgery undertaken after development of the genital organs but before the appearance of haematocolpos [32].
In our series, the 7 patients with hematocolpos on a hymeneal imperforation benefi ted from a Y and O incision of the hymen, evacuation of the hematic collection, and drainage by a catheter left in place for 7-10 days for the Y incision, and 15 days for the O incision. All patients were put under a biantibiotherapy, local care several times a day, and dilatation sessions according to the evolution.
The evolution in the 7 cases of hymeneal imperforation was satisfactory without postoperative stenosis.

Conclusion
Hymenal imperforations are a group of genital malformations. It is an often benign condition, with a favourable evolution, if diagnosed and treated early. On the other hand, its lack of knowledge exposes it to serious complications, threatening its vital prognosis and seriously Citation: Lahfaoui  compromising its obstetrical future. Ultrasonography remains the examination of choice to confi rm the diagnosis, and makes it possible to identify possible upstream repercussions and possible associated urogenital anomalies. Systematic screening at birth and early treatment are the best guarantee of preventing complications of this pathology. We observed 7 hematocolpos cases secondary to a lack of knowledge of an imperforate hymen. As delivery rooms in our country cannot be accompanied by paediatricians, the training of midwives, insisting on the systematic examination of newborns, will make it possible to recognize malformations at birth, including imperforation of the hymen. This would avoid emergency situations that sometimes lead to inappropriate treatment. The treatment is exclusively surgical and the routes of access are different. Most often, it remains remarkably simple and leads to a defi nitive cure.