Why the adolescent cannot urinate - a puzzling patient

The adolescent has had urinary tract infections several times and even two kidney infections. When she presented herself to the emergency room at William Harvey Hospital in Ashford, UK, she complained of abdominal pain and reported being unable to urinate. The doctors initially suspect that she is plagued by cystitis again.

Her stomach is soft when palpating, but she has defensive tension in the right pelvic area. Her bladder can also be felt. An ultrasound of the abdomen does not provide helpful images because the patient cannot stand the examination because of the severe pain. Because she cannot empty the bladder, the adolescent is placed in a catheter. The team of doctors gives her antibiotics to fight the suspected infection, and she is also given painkillers.

But the next day, she is no better, report Oman Rai and his colleagues in the journal “BMJ Case Reports”. There are traces of blood in the patient’s urine. But microscopically there are no abnormalities and a culture is sterile – which speaks against a cystitis caused by bacteria. A blood test is normal, a pregnancy test is negative, and the kidneys are working as they should.

The doctors take a closer look at the case. Not only was the girl having trouble urinating, she hadn’t had a bowel movement for days. In addition, the adolescent has not yet had a menstrual period and has not yet been sexually active, as they experience. Your secondary sexual characteristics are “adequately developed”, it says in the report. It seems unusual to the doctors that their menstrual period has not yet started. The patient’s exact age is not mentioned in the case report.

A large amount of liquid

Because the young person is still in severe pain, the doctors decide to do another ultrasound, and they also look at the abdomen using magnetic resonance imaging. They discover that the patient’s vagina has expanded significantly because it is bulging with fluid. In this state, the vagina also presses on the bladder and bowel.

How did liquid collect there? The patient has a so-called hymen atresia, the hymen is completely closed. The adolescent already had menstrual bleeding, but the fluid could not flow away and has accumulated due to the malformation in the body and thus increasingly caused discomfort. About one to two out of 2,000 girls are born with this malformation, the report says. It can already be recognized by an examination in newborns and can then be remedied by an operation.

Because the malformation can be remedied by a simple surgical procedure in which the hymen is opened. This also happens with the patient in Ashford. During the operation, “a large amount of old blood” flows off, the doctors write in their case report.

For the patient, the complaints are over. When she can urinate normally again, she is discharged from the hospital.

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