Imperforate hymen and leaking hematosalpinx mimicking acute appendicitis: A report of a rare case and a review of literature

Foster Amponsah-Manu; Paddy Ssentongo; Temitope Arkorful; Richard Ofosu-Akromah; Anna E Ssentongo; Seth Hansen-Garshong; John S Oh

doi:10.1016/j.ijscr.2019.09.003

Imperforate hymen and leaking hematosalpinx mimicking acute appendicitis: A report of a rare case and a review of literature

Int J Surg Case Rep. 2019:63:69-74. doi: 10.1016/j.ijscr.2019.09.003. Epub 2019 Sep 18.

Authors

Foster Amponsah-Manu¹, Paddy Ssentongo², Temitope Arkorful³, Richard Ofosu-Akromah³, Anna E Ssentongo⁴, Seth Hansen-Garshong³, John S Oh⁵

Affiliations

¹ Department of Surgery, Eastern Regional Hospital, P.O. Box 201, Koforidua, Ghana; Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA.
² Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA; Department of Public Health Sciences, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA; Center for Neural Engineering, Department of Engineering, Science and Mechanics, Pennsylvania State University, University Park, PA, USA. Electronic address: pssentongo@pennstatehealth.psu.edu.
³ Department of Surgery, Eastern Regional Hospital, P.O. Box 201, Koforidua, Ghana.
⁴ Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA; Department of Public Health Sciences, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA.
⁵ Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA.

Abstract

Introduction: Cases of imperforate hymen with leaking hematosalpinx into the peritoneum are rare. We present a case of imperforate hymen mimicking acute appendicitis creating diagnostic challenges with a near miss diagnosis.

Case: A 12-year-old premenarchal female presented with severe pain that migrated from the epigastrium to the right lower quadrant. Physical examination revealed an ill-defined non-tender mass in the right lower quadrant on deep palpation, without signs of peritonitis. We made a diagnosis of an appendiceal mass and the patient underwent an appendectomy. We found approximately 200 mL of dark blood in the peritoneum and an inflamed appendix. After the appendectomy we noticed an engorged right fallopian tube leaking into the peritoneum and a bulky pelvic mass in the lower segment of the uterus. Perineal examination revealed a slightly bulging imperforate hymen. Hymenectomy was performed and 500 mL of viscous old blood was drained. On follow-up, the hymen was still open.

Discussion: Imperforate hymen commonly presents with cyclic abdominal pain and enlarging mass in premenarchal females, it is rare to present with hemoperitoneum and mimicking acute appendicitis.

Conclusion: Although rare, imperforate hymen with retrograde menstruation that causes dilatation of the vagina and uterus (i.e., hematocolpometra) is an important consideration in the differential diagnosis of abdominal pain in premenarchal females with abdominal pain. It is easily diagnosed by physical examination. However, if patient or parents refuse genital exam evaluation, imaging studies can greatly help with diagnosis. Ultrasound will show an echogenic fluid accumulation in the vagina that can extend to uterus.

Keywords: Acute appendicitis; Case report; Hematocolpometra; Imperforate hymen.