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Severe Dysmenorrhea Due to Obstructive Anomaly

2002; Elsevier BV; Volume: 15; Issue: 3 Linguagem: Inglês

10.1016/s1083-3188(02)00139-0

1873-4332

Elisabeth H. Quint,

Endometriosis Research and Treatment

The patient is a 13-yr-old girl, who presented to a local hospital with severe abdominal pain. Menarche had been 6 months ago and she had three periods, each lasting about 5 days. She had pain with her periods initially, but after her last period it persisted. She denied nausea or vomiting or changed bowel habits. She went to her local doctor, who ordered a CT scan, which revealed a large pelvic mass and enlarged right kidney. Pelvic exam was not possible, because the patient was too uncomfortable. Otherwise she was a healthy teenager, with no prior admissions or medical problems.Dr. Mulchahey's comments:At the initial presentation of this adolescent, the first priority is to rule out an acute surgical abdomen by physical exam and an ectopic pregnancy by lab studies. Once this is accomplished, the next step is to determine the location of the mass. If this adolescent had not yet menstruated, patency of the hymen should be assessed quite simply by physical exam, without the need for a "complete" pelvic exam. While this seems almost too obvious to mention, adolescents still undergo laparotomies (or laparoscopies) only to find an imperforate hymen and hematocolpos.At this point in the work-up, the most appropriate next step would be an MRI to assist in determining the location of the mass. Multiple studies have described the superiority of MRI in defining pelvic anatomy, especially if an obstructed anomaly is suspected. This tool will usually differentiate between an intra-abdominal and vaginal mass. If the MRI identifies an intra-abdominal mass, the source could be ovarian (e.g., neoplasm or torsion), tubal (torsion, neoplasm, hematosalpinx, or ectopic pregnancy), or possibly hematometra from an obstructed Müllerian anomaly. MRI can usually distinguish vaginal masses, although they may extend into the abdominal cavity when quite large. The signal strength from the MRI also can provide further information about the solid or cystic nature of the mass. If a vaginal mass is noted in this teen, especially with the possibility of a renal anomaly noted, suspicion would be raised about an obstructed hemivagina. A vaginal mass may also arise from a large Gartner's duct cyst (which can occasionally have a communication with intra-abdominal Wolffian remnants) as well as a vaginal neoplasm.In areas where MRI may not be readily available, transrectal ultrasound has also been helpful in differentiating between intra-abdominal and vaginal masses, since transvaginal ultrasound is often not possible in a teenager. Many radiologists are experienced in transrectal ultrasound of the prostate in men. Similar imaging techniques can be used in young adolescents to produce an image very similar to transvaginal sonography. This may be especially helpful in distinguishing between solid, complex, and cystic masses.At the initial presentation, the primary goal (once life-threatening conditions have been ruled out) is to define the anatomy of the pelvis in as much detail as possible before a surgical procedure is carried out.