Although included under the head of Vulvar Atresia, this will be considered chiefly in connection with atresia of the vagina. This is a congenital condition of more frequent occurrence than the other forms of vulvar atresia.
SYMPTOMS.—If the age of puberty has been attained and the subject has all the symptoms of menstruation excepting the characteristic sanguineous flow, an imperforate condition of the genital canal is suspected. Monthly pain of a bearing-down character in the hypogastric region, and pain in the back and thighs or uterine colic, are among the symptoms. At such times the abdomen may become tender and tympanitic, the pulse more frequent, and slight febrile reaction with nausea and vomiting may occur.
These symptoms closely resemble those of an attack of peritonitis, but usually, after a few days of great distress, they gradually disappear. After a lapse of three or four weeks they again return with increased severity. The girl's general health is impaired, the appetite is poor, there is constant nausea and sometimes vomiting, the bowels are constipated, the eyes lose their brilliancy, the skin presents a dirty appearance and is often covered with an eruption. Headache is almost constant. The abdomen is often very prominent from intestinal tympanitis. Later the lower extremities become oedematous, and there are indications of septicæmia, and great constitutional disturbance. The gradual accumulation of menstrual fluid, first filling and then distending the uterus and vagina, causes a gradual enlargement of the abdomen, often giving rise to a suspicion of pregnancy.
| FIG. 26. |
| Hæmatometra.—Imperforate Hymen, causing distension of uterus and vagina: H. Hymen; V, Vagina; U, Uterus; B, Bladder; R, Rectum. |
DIAGNOSIS.—If there is an accumulation of menstrual fluid in consequence of an imperforate hymen; the latter can be observed as an elastic tumor of a red color protruding outwardly between the labia. A rectal examination is necessary in order to complete the diagnosis, as by this means the presence of menstrual fluid is determined, for if it be present in sufficient quantity to distend the hymen a finger in the rectum can detect fluctuation in the vagina.
If there is no escape of the menstrual fluid beyond the vulva on account of an imperforate hymen, the vagina first becomes gradually distended, then the uterus, and finally the Fallopian tubes. As this distension increases, fluid may be forced beyond the fimbriæ of the tubes into the peritoneal cavity, or, instead, one of the tubes may rupture from the pressure within. In other instances the uterus itself ruptures from over-distension and thinning of its walls. Cases are on record where, the accumulation increasing for years, the uterus has become distended to the size attained in the latter months of pregnancy; under such circumstances its walls as well as the walls of the Fallopian tubes become thinned.
PROGNOSIS.—The physician should be careful and guarded in his prognosis. The health may become much impaired, and sometimes this is the case prior to the cause being ascertained. The chief dangers are in connection with the accumulation of menstrual fluid, such as its discharge at the fimbriated extremity of the tubes, or rupture of the tubes or uterus, and consequent escape of the fluid into the peritoneal cavity. There is also great danger in incising the hymen to permit the exit of the fluid, as will be shown under the head of Treatment. Therefore the longer has been the retention, the greater is the liability of rupture and danger in treatment.
TREATMENT.—As this is of necessity surgical, but brief allusion will be made to it. A simple incision of the hymen will permit the escape of the fluid, but the admission of air by this means is liable to cause sudden contraction of the uterus and a reflex escape of the fluid at the fimbriated extremity of the Fallopian tubes, with all the severe consequences of an intra-peritoneal hemorrhage.