title: Unique Presentation of Hematometrocolpos Mimicking Cauda Equina Syndrome: Severe Back Pain and Urinary Incontinence in an Adolescent Girl.
abstract: BACKGROUND
  Imperforate hymen with hematometrocolpos in adolescent females is a rare pediatric condition. Classical presentation includes abdominal pain or a pelvic mass in female patients with primary amenorrhea. Atypical complaints and reluctance among emergency physicians to perform genital examination in the emergency department or the pediatric emergency department (PED) may delay correct diagnosis.
  
  
  METHODS
  We report a unique, cauda equina syndrome-like presentation of hematometrocolpos secondary to imperforate hymen in a 13-year old, previously healthy girl with primary amenorrhea. In the PED, the unusual clinical presentation of severe back pain and urinary incontinence initially mimicked cauda equina syndrome and led to delayed correct diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The novelty of this case is a cauda equina-like presentation of imperforate hymen secondary to hematocolpos. This report illustrates the highly variable clinical presentation of this rare gynecological pediatric entity. It underlines the importance of considering this rare condition in the differential diagnosis of severe upper or lower back pain alongside voiding abnormalities including urinary retention and incontinence in adolescent females with primary amenorrhea. Above all, the importance of performing a thorough history and genital examination in this subgroup early in the investigation process in the PED emerges from this case. Essentially, excellent clinical judgment and genital examination by the emergency physician may minimize unnecessary radiological investigations and ultimately, accelerate correct diagnosis and expedite appropriate surgical treatment. However, not only pediatric and adult emergency physicians, but also pediatricians and general practitioners should be aware of this entity and its diverse clinical presentation.
authors.affiliation: Pediatric Emergency Department, University Hospital Inselspital, Bern, Switzerland.
authors.forename: Ruth Mari
authors.initials: RM
authors.lastname: Löllgen
authors.affiliation: Department of Pediatric Surgery, University Hospital Inselspital, Bern, Switzerland.
authors.forename: Jan
authors.initials: J
authors.lastname: Sabo
authors.affiliation: Department of Pediatric Surgery, University Hospital Inselspital, Bern, Switzerland.
authors.forename: Anja
authors.initials: A
authors.lastname: Mettler
authors.affiliation: Department of Pediatric Surgery, University Hospital Inselspital, Bern, Switzerland.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Liniger
authors.affiliation: Department of Pediatric Surgery, University Hospital Inselspital, Bern, Switzerland.
authors.forename: Steffen
authors.initials: S
authors.lastname: Berger
mesh_terms: D000293:Adolescent; D001416:Back Pain / Q000209:etiology*; D000013:Congenital Abnormalities; D003937:Diagnosis, Differential; D005260:Female; D006409:Hematometra / Q000150:complications* / Q000175:diagnosis; D006801:Humans; D006924:Hymen / Q000002:abnormalities; D008599:Menstruation Disturbances / Q000150:complications; D011128:Polyradiculopathy / Q000209:etiology*; D014549:Urinary Incontinence / Q000209:etiology*
keywords: cauda equina syndrome; genital examination; hematometrocolpos; pediatric emergency department