KEY FACTS
Terminology
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Hematometrocolpos: Distension of uterus and vagina by accumulated blood secondary to obstruction
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Hematometra: Distension of uterine cavity by blood products
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Hematocolpos: Distension of vagina by blood products
Imaging
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US best for initial evaluation of pelvic mass or primary amenorrhea
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Distended uterine &/or vaginal cavities
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Hematometrocolpos appears thick-walled superiorly due to surrounding myometrium with thinner wall where surrounded by vagina
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Mixed echogenicity material within uterine &/or vaginal cavities: Blood products of varying age
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No color flow
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Presence of flow should raise concern for mass
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3D US allows better evaluation of uterine fundal contour
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MR best to confirm blood products, absence of solid mass
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MR best to clarify anatomy, relationship of pelvic organs
Top Differential Diagnoses
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Pyometra
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Endometritis
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Muco-/hydrometrocolpos
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Gestational trophoblastic disease
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Retained products of conception
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Complex adnexal mass
Pathology
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Congenital causes present earlier than acquired obstruction
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Congenital: Imperforate hymen (most frequent cause), müllerian duct anomaly, cloacal malformation
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Acquired cervical/vaginal stenosis: Cancer, post surgery or radiation
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Associated with renal anomalies and endometriosis
Clinical Issues
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Cyclical pelvic pain/pressure, low back pain
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Primary amenorrhea at puberty from imperforate hymen
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Urinary retention, constipation
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Presents later if associated with cervical cancer
Diagnostic Checklist
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Distended uterine &/or vaginal cavities with heterogeneous avascular material
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Hematometra/hematocolpos should be considered in young female patients with lower abdominal symptoms or back pain
Scanning Tips
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Use combination of transabdominal, transvaginal, and transperineal approaches
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Evaluate renal fossae for associated renal abnormality
containing blood, consistent with hematocolpos. There is less severe distension of the uterine cavity 
where there is a thicker wall made of myometrium.
containing blood 
, consistent with hematocolpos. Note the thicker walls of the distended uterine cavity 
.
and cervical 
cavities with blood 
, consistent with hematometros in this patient who had amenorrhea from cervical stenosis post cone biopsy.
secondary to cervical stenosis post cone biopsy.
