Case Report

Transvaginal Sonography of Hematotrachelos and Hematometra Causing Acute Urinary Retention After Previous Repair of Intrapartum Cervical Lacerations
David M. Sherer, MD, Fady Khoury-Collado, MD, Mira Hellmann, MD, Ehab Abdelmalek, MD, Mila Kheyman, RDMS, Ovadia Abulafia, MD

bstruction of the lower female genital tract leading to proximal dilatation and development of hematocolpos, hematotrachelos, and hematometra is most commonly a result of congenital abnormalities.13 These conditions include an imperforate hymen, a complete transverse vaginal septum, and vaginal and, rarely, cervical atresia.13 Rarely these abnormalities may be unilateral, associated with lateral fusion defects of the mllerian duct and concurrent ipsilateral renal agenesis.4 Symptoms noted in adolescents in conjunction with congenital obstruction of the lower female genital tract usually consist of primary amenorrhea and dsymenorrhea,13 although acute urinary retention has also been rarely reported.57 We present an unusual case in which transvaginal sonographic findings of marked hematotrachelos and hematometra were depicted in a multiparous patient with acute urinary retention 2 years after repair of cervical lacerations sustained during vaginal delivery.

Case Report
A 36-year-old woman, para 3, came the emergency department at State University of New York, Downstate Medical Center, after acute urinary retention. Her medical history was unremarkable. Her obstetric history included 3 spontaneous vaginal deliveries at term. During her last delivery at a different institution, 2 years before coming to the emergency department, she had surgical repair of a cervical laceration. After this delivery she received repeated 400-mg/mL intramuscular injections of medroxyprogesterone acetate (Depo-Provera; Pharmacia & Upjohn, Kalamazoo, MI), for contraception. Eight months before this admission, she underwent laparoscopic tubal ligation. No intra-abdominal or pelvic congential abnormalities or uterine leiomyomata were noted at this procedure, after which she began to have cyclic lower abdominal and pelvic pain approximately every 28 days. Of note, she had had amenorrhea ever since her recent delivery, which had been attributed to

Received August 17, 2005, from the Divisions of Maternal-Fetal Medicine and Gynecologic Oncology, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York USA. Revision requested September 19, 2005. Revised manuscript accepted for publication September 21, 2005. Address correspondence to David M. Sherer, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, 445 Lenox Rd, Box 24, Brooklyn, NY 11203-2098 USA. E-mail: dmsherer@aol.com

2006 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2006; 25:269271 0278-4297/06/$3.50

Transvaginal Sonography of Hematotrachelos and Hematometra

the Depo-Provera. Her amenorrhea continued despite cessation of the Depo-Provera after the tubal ligation. One week before this admission, she had been seen at another hospital for urinary retention, which was attributed to large uterine leiomyomata. A Foley catheter was placed, and she was instructed to return to her gynecologist for continued care. Physical examination disclosed a healthy individual. She was afebrile with blood pressure of 120/80 mm Hg and pulse of 68 beats/min. Her abdomen was soft yet with marked tenderness of the lower abdomen. A mass was palpated slightly superior to the symphysis pubis. On speculum examination, a normal cervix could not be appreciated, and a large round structure measuring 10 cm in diameter was visualized completely filling the upper vaginal vault. Because of extreme tenderness, bimanual examination was not informative other than palpation of the lower pole of the previously mentioned mass in the upper vagina and fullness in the cul-de-sac. Laboratory results revealed a hemoglobin level of 11.6 g/dL, hematocrit value of 33.8%, white blood cell count of 5.5 109 cells/L, and platelet count of 123 109 platelets/L. Serum creatinine, blood urea nitrogen, and electrolyte levels, prothrombin time, and partial thromboplastin time were normal. Transabdominal sonography depicted the Foley catheter balloon in the urinary bladder and a markedly thinned and distended uterine cervix measuring 8.5 cm in diameter filled with fluid and debris. The uterus appeared acutely retroverted, yet visualization was suboptimal because of the relative distance from the transducer (Figure 1). Transvaginal sonography (Figure 2) clearly depicted an hourglass structure consisting of a dilated cervix communicating with a similarly dilated uterus. The myometrium appeared thicker than the effaced cervix, and the internal cervical os was dilated to 2 to 3 cm (Figure 2). Fluid containing debris distended both the uterus and cervix and appeared consistent with menstrual debris. The fluid was noted moving freely between the uterine and cervical cavities. These sonographic findings were considered consistent with an acquired obstruction of the lower female genital tract, specifically hematotrachelos and hematometra. Detailed examination and planned dilation of the endocervical canal to allow egress of the depicted fluid and subsequent menstruation were attempted under general anesthesia, yet no
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Figure 1. Transabdominal sonography: midline sagittal suprapubic view. Note the relationship of the urinary bladder containing the Foley catheter balloon (F), the catheter placed in the elongated urethra anterior to the markedly dilated cervix (cx, arrow) and the distally located uterus (ut). Note the suboptimal resolution of the acutely retroverted uterine structure, located at a considerable distance from the suprapubic transabdominal transducer.

dimple indicating the external cervical os could be visualized or palpated. At counseling, the patient was informed of the above and requested total abdominal hysterectomy. At laparotomy

Figure 2. Transvaginal sonography: midline sagittal view definitively depicting the markedly distended hematotrachelos (cx) and the less distended (and acutely retroverted) hematometra (ut). Note the internal cervical os, dilated approximately to 2 to 3 cm (curved arrows), and clear hematometra with a relatively thicker myometrial wall in comparison with the thinner, effaced cervix. In real time, free movement of the debris containing fluid was observed between the cervical and uterine cavities. The anechoic area proximal to the transducer represents free fluid in the anterior cul-de-sac.

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under general anesthesia, the dilated cervix was confirmed in association with an acutely retroverted uterus, which was essentially impacted in the pelvis. The urinary bladder was drawn superiorly by the mass, resulting in an elongation of the urethra. To assist in mobilization, surgical exposure, and ultimate removal of the markedly dilated and effaced uterus, removal of approximately 800 mL of menstrual debris was performed by suction through an incision in the anterior uterine wall, which was closed by a purse string suture. After the above decompression drainage, the total abdominal hysterectomy was uneventful. Pathologic assessment of the surgical specimen showed the recently evacuated dilated uterine cervix and uterus with distended cervical and myometrial tissues, respectively.

los and hematometra, with the latter acutely retroverted and impacted deep in the pelvis. To our knowledge, acquired hematotrachelos and hematometra associated with acute urinary retention has not been reported previously. In our case, although transabdominal sonography was suggestive of this acquired lesion (Figure 1) because of the acutely retroverted uterus, clear transabdominal depiction of the uterus definitively confirming this distorted anatomy was not possible. Transvaginal sonography therefore was essential in the diagnosis of this unusual occurrence, enabling definitive depiction of the effaced cervix and distended acutely retroverted and impacted uterine cavity.

References
1. Pretorious DH, Denis MA, Manco-Johnson ML, Gottesfeld KR. Ultrasound diagnosis of hematotrachelos: a case report. Am J Obstet Gynecol 1985; 15:10801082. Sherer DM, Beyth Y. Ultrasonographic diagnosis and assisted surgical management of hematotrachelos and hematometra due to cervical atresia with associated vaginal agenesis. J Ultrasound Med 1989; 8:321323. Sanders RM, Nakajima ST. An unusual late presentation of imperforate hymen. Obstet Gynecol 1994; 83:896898. Sherer DM, Rib DM, Nowell RM, Peillo AM, Phipps WR. Sonographic-guided drainage of unilateral hematometrocolpos due to uterus didelphys and obstructed hemivagina associated with ipsilateral renal agenesis. J Clin Ultrasound 1994; 22:454456. Hall DJ. An unusual case of urinary retention due to imperforate hymen. J Accid Emerg Med 1999; 16:232233. Nisanian AC. Hematocolpometra presenting as urinary retention: a case report. J Reprod Med 1999; 38:5760. Chircop R. A case of urinary retention and hematocolpometra. Eur J Emerg Med 2003; 10:244245. Witt BR. Treatment of hematotrachelos after dilatation and curettage. J Reprod Med 1999; 44:6870. Giannacopoulos K, Troukis E, Constandinou P, Rozis I, Kokonakis C, Giannikos L. Hematometra and extended vaginal haematoma after laser conization: a case report. Eur J Gynaecol Oncol 1998; 19:569570. Scheerer LJ, Bartolucci L. Transvaginal sonography in the evaluation of hematometra: a report of two cases. J Reprod Med 1996; 41:205206. Pschera H, Kjaeldgaard A. Haematocervix after conization diagnosed by ultrasonography. Gynecol Obstet Invest 1990; 29:309310. Yang JM, Huang WC. Sonographic findings of acute urinary retention secondary to an impacted pelvic mass. J Ultrasound Med 2002; 21:11651169.

Discussion
Acquired obstruction of the lower female genital tract is rare. Etiologies of such acquired lesions include iatrogenic trauma to the uterine cervix such as cone biopsies, loop electrosurgical excision procedures, and dilation and curettage, cervical or endometrial carcinoma, and radiation therapy.811 Cessation of endometrial suppression (after discontinuation of the Depo-Provera) in conjunction with the relatively recent tubal ligation (negating retrograde menstruation) contributed to the accumulation of menstrual debris in our patient with acquired cervical obstruction. A systematic English language literature search (PubMed and MEDLINE) between 1966 and 2005 using the search terms vaginal delivery, trauma, ultrasound, dysmenorrhea, amenorrhea, hematotrachelos, and hematometra indicated that acquired obstruction of the lower female genital tract after repair of cervical lacerations sustained during vaginal delivery has not been reported previously. Yang and Huang12 described 6 patients with acute urinary retention secondary to an impacted pelvic mass as depicted by transabdominal and transvaginal sonography. Three of their patients has impacted uterine leiomyomata, and 3 had a retroverted gravid uterus.12 In these 6 cases, the impacted pelvic mass displaced the cervix superiorly and anteriorly, compressing the lower bladder, leading to obstruction of the internal urethral orifice.12 It appears that a similar mechanism was present in our case in which the pelvic mass consisted of the hematotracheJ Ultrasound Med 2006; 25:269271

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