correct answer
b EUA with hymenectomy
This child’s presentation is consistent with imperforate hymen, the most frequent obstructive anomaly of the female reproductive tract. The incidence of imperforate hymen is relatively low, with reports of a frequency between 0.05-0.1% of female infants. The symptoms of primary amenorrhea, cyclic abdominal pain and a bluish bulge at the vaginal outlet are classic for this entity. Ultrasound should be the first line of imaging and will demonstrate hematocolpos.
The average age of menarche in the US is 12 years in white girls, 11 in Black and Hispanic girls, but may be as early as 9-10 years. The majority of patients with imperforate hymen present between 12-18 years of age. Large volume hematometrocolpos may lead to chronic constipation, fecal incontinence, or urinary retention.
The treatment for imperforate hymen is surgical. An examination under anesthesia to confirm the diagnosis should identify a definite bulge at the introitus with a paper thin membrane. A thick membrane or lack of an apparent bulge could be indicative of a vaginal septum which should not be simply excised and requires further evaluation. A circular hymenotomy is not usually recommended because of the high incidence of cicatrix formation, recurrence and potential need for future dilations. A hymenectomy with approximation of the excised edges is the treatment of choice. There may be cultural preferences to preserve the hymen. In those cases, an incision with placement of a foley catheter to drain the fluid and application of an estrogen cream for two weeks may be an alternative.
If physical examination does not reveal a bulge at the introitus, further imaging with MRI should be obtained to evaluate the reproductive tract for other anomalies such as cervicovaginal atresia, vaginal septum, obstructed uterine horns or vaginal agenesis.
