Hematometra and Hematocolpos
Synonyms/Description
Hydrometra and hydrocolpos
Pyometra and pyocolpos
Etiology
The most common etiology is cervical or vaginal obstruction, resulting in a collection of blood, pus, or fluid that distends the uterus or vagina.
Hematometra/Hydrometra
Cervical stenosis can develop for multiple reasons (treatment for cervical dysplasia, prior ablation, postmenopausal effect), blocking the cervical canal and resulting in accumulation of fluid/blood in the uterine cavity. Advanced endometrial cancer can either block the canal or produce copious amounts of fluid/blood filling the uterine cavity. Many years ago, fluid in the endometrial cavity was considered a sonographic sign of cancer. More recently, Dr. Steven Goldstein showed that it is not the intracavitary fluid that conveys the risk of cancer, rather the appearance of the wall around the fluid. If the endometrium surrounding the fluid is smooth and thin, endometrial cancer is unlikely, whereas an irregular wall or mass protruding into the fluid indicates the presence of a tumor.
Benign causes of hematometra include an intracavitary fibroid or polyp in the cervix or lower uterine segment, and adhesions such as those encountered after an incomplete endometrial ablation. If the ablation seals the lower uterine segment but leaves intact endometrium at the fundus, cyclical hematometra with bilateral hematosalpinges may result. Patients with Müllerian duct anomalies who have a uterine duplication may have an obliterated horn, which will fill with blood and cause cyclical pain, typically presenting at puberty. This may pose a diagnostic dilemma if the uterine anomaly is not known, because these patients will present with a painful cystic mass in the pelvis often mistaken for a degenerating fibroid or adnexal mass. If the Müllerian duct anomaly is severe, the hematometra/hydrometra may even be visible prenatally as an intra-abdominal cystic mass in the fetus.
Hematocolpos/Hydrocolpos
Obstruction within the distal vagina is usually responsible for the development of a hematocolpos. If there is a backup of blood or fluid in the vagina, this may extend into the uterine cavity and result in an associated hematometra. Obstructions of the distal vagina are commonly owing to congenital Müllerian duct anomalies such as a transverse vaginal septum or an imperforate hymen. Patients with congenital anomalies of the vagina often have associated anomalies of the uterus; however, patients with vaginal obstruction may not become symptomatic until menarche.
Ultrasound Findings
The sonographic appearance of a hematometra/hydrometra is the presence of fluid distending the uterine cavity. Similarly hematocolpos/hydrocolpos is the presence of fluid in an obstructed vagina. The fluid often contains low-level echoes much like the texture of an endometrioma, indicating the presence of unclotted blood. The presence of more than a sliver of fluid in the uterus and/or vagina needs to be further investigated sonographically. Consider the patient’s history: Has the patient had an ablation, and does she have cyclical symptoms? Is there a known Müllerian duct anomaly? Did the patient become symptomatic at menarche or is she asymptomatic? The ultrasound exam should include a 3-D evaluation of the uterine shape looking for Müllerian uterine anomalies (see Müllerian Duct Abnormalities
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