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Urinary Symptoms Associated with Imperforate Hymen
URINARY SY:\IPT0;\18 ASSOCIATED WITH e\JPE:JLFORATE I-IYI\lEN NIORRIS M. CANDIN
'fhe urologist must at lea~t be aware of imhymen as 11 cause of urinary symptoms of an obstructive 1mture. This congenital malformation is sufficic,ntly rnrc that gynecologists H<'e only a few cases in their professional lives. Calvin and Nichitrnin, in I collected 40 cases from the literature, nnd in 1939 Tompkins 118 cases including fin, of his own. The produced by hymen with ,,,,,,.,.,,n,;c, is seldom diagnosed by thn physician who first secs tlw The symptoms appear after puberty due to rnenstrual blood retained in the ntgina :md Inter also in the utenrn. The retained fluid is typicall_v of a thick ~yrupy chocolate character which rna_v amount to several liters in \'olurne. The exµanding presses the mcthra against the pubis and al8o lifts the hlaclder into the ,,bdomen, which additional!~· stretches and narrows tlw urcthrn (fig 1).
cornbination of these conditions. The vulva will show protrusion of an imperforate hymen wlticli is usually dark, clue to old retained blood bc!tmd it (fig. . The digital rectal examination wil: disclose a large, palpable, stnrnagc-~h:1ped mass arising from tho vagina and filling tht- hollow of the sacrum. Cystoscopic examination will reYcal markcc, trig;onc and elevation of the urethra, vesical floor of the bladder, The mucosa of the may be edematous. The floor of the lilG,clder presents itself :1s an cl<~Ynted, rounckcl dorne due to the distended vagina beneath it. Tntravcuon? urograms may be normal but hydrouroter aud hyclronephrosis have been rl'ported. The medimn in the bladder wiJI demonstrate the rounded. elerntion of the floor of the hlacldcr, but 1f Lr
SYMPTOl\lt'; AND SIGNS
,\. group of syrnptorns and signs develops as the menNtrual blood is dammed consisting princiyrnliy of abdomiual abdominal swelling, and urinary disturbances. Pains occur i11 the lower abdomen and back. Discomfort or crnmplike are noted in the suprapubic and lower abdominal regions. Pressure on the urethra may make urination ,hfficnlt, The cornmm1est unnary symptoms etre frc,qneney, urgenc.\'. incontimmce, noctnria, feeling of in<:mptying and t,\'Cll retention. retention may be tho symptom. The duration of urinary retention may vary from 12 hours to a week, and may require rathetcrization. Calvin ancl ~iclmmin sx1 incidence of 68 per cent of patients witli urinary eornplaints. FIJSDJNGS
A rm1s;:; is palpable in the lower abclorncn arising from the pekis. This is due to the dis-
tended uterus, fa1Jopian
or bladder, or a
Accepted for publieation 21, 19Gl. Read at mmunl meeting of Section of American l.Jrological Association. Inc., Las Vegas, Xevarfa, February (l-9, HJG].
The diagnosi~ is rcu,dily ,~stabliRhed IY1 thorough histor_v and physical examination. history of sbsence of menstruation with abclorni.-nal pains, and urinary rn girl puberty should immecliatel:v lead the examiner to search for the significant signs: imperforate hymen, an abdominal rnnss, :ind rectal nu1ss. Cystoscopic findingH will eorTohmatr; the presence of n mass extrinsic to the floor of thn bladder. The treatment is excisio11 of the '2,B). lt may be very thick and fibn111,,.
patient is placed in Iithotom:· "'' m1.de1 general anesthesia. A catheter is pla<:ed in tlw bladder. A. recommended technique is a cruc:iate incision followed by excision of the four of the hyrnnn. My own technique lS a cision as follows (fig. : A large needle membrane syringe is inserted into the midway between the urethra and tbe rectum. A. few cubic centimeters of the contents aspirated for verification, followed or circular incision, beginning at, the ncedl1\ puncture in the center of the nnd 0 "'""'
c,
666
MORRIS M. GANDIN
tending peripherally at the outer border of the hymen at its junction with the vaginal wall. The abdominal and rectal masses will disappear as the large quantity of thick, syrupy, old blood is extruded. The edges of the circular incision are sutured with continuous locked or interrupted catgut for hemostasis. Suprapubic pressure should not be applied, in order to avoid suction of unsterile discharge on release of pressure. Vaginal examination is also avoided for the same reason. Antibiotics are advisable. PROGNOSIS
The prognosis regarding uterine function is good. Normal menstruation follows and repro-
Fm. 1. Hematocolpos shows compression of urethra and elevation of bladder floor.
duction occurs even in cases in which treatment has been delayed. Searle's patient complained of amenorrhea at 17, had the hymen excised at 32, and at 36 years of age was delivered of a healthy child. The urinary difficulties disappear after hymenotomy. CASE REPORTS
Case 1. A 10-year-old Mexican girl was seen by the family physician when she fell, striking the right buttock on a chair. She was referred to a surgeon because of a rectal mass. He, in turn, requested urological consultation on February 20, 1960 because of urinary symptoms. She noted slight pain with urination, particularly at termination. For the past 2 years she had arisen to void every 5 minutes, about 4 times in succession before falling asleep when retiring at night. Diuria occured 8 times and she experienced frequent low abdominal cramps. Examination showed a tall, well developed girl appearing 2 or 3 years older than her stated age. Blood pressure was 98/60. Heart and lungs were normal. Abdominal examination revealed right lower quadrant tenderness and fullness; slight tenderness in the left costovertebral angle; liver, spleen and kidneys not palpable. Slight tenderness was present over the right ischial tuberosity. External genitalia presented an imperforate hymen. A lubricated applicator could not be passed through the vaginal orifice. On rectal examination, a large, smooth, symmetrical, ovoid, soft mass in the anterior wall of the rectum was palpated. Urinalysis was negative. Hemoglobin 13.4 gm., white blood cells 13,700, polymorphonuclears 79 per cent, lymphocytes 21 per cent, blood urea
Fm. 2. A, imperforate hymen. B, cruciate incision. C, spiral incision
URINARY SYlvIP'l'OMS ASS0CIA1'l~D \VITI-I J:V[PJ,cRF'ORATE HYMEN
nitrogen 11.0. Intravenous urogrnphr on Febru.. ary 25 (fig. :3) revealed a nonrrnl upper urinary tract. There was a smooth defect at the miclline of the base of the bladder, believed to be due to pressure on the bladder from a distended vagin:i. to tlw imperfomtc hymen. was performed Febn1ary 25. 'J'he in the lithotomy position. ~ize 22 ~traight sheath panendoscope \1as transurethrnll? into the bladder and t»arnination nrnde with the forobhque and This was removed and
nt·eclk was inserted through the imperforate diaphragm and with a syringe old blood. Leaving the neeclle in place, rnc1s1on was tlwn made into the vaginal dia· phragm of the hymen ,rnd the r:xtcnckcl incision crossed with a transverse incision. Portions of the diaphragn1 were excised and submitted to the laboratory for tissue identification. Th,, ,,v,:tr,,,,nn,1° was then into the opened 1·agina and inspr:ction nmde with the This was rernovcd and a size :cio cc bag Foley cathc:ter in~erted into the vagina. The mcthrn was distorted upwarc[ the subnmss. The hlaclckr nn1cosa \HlS normal <"»cept in the: region of tbe trigone where them was considerable edema and convex elevation ,,.nd distortion of the interu.retcric and floor of the bladder a mass. The ureteraI orific,~s thernsdn.:s to be nonnal alconsiclerably elcevatecl. On digital rectal tlwre was felt a largE, globular mass which, after incision of the Yaginal hymen, collapsed. 260 cc of old blood w:1s c,\·acuated. 'The hymen was extreme!? thick and dc:nse and coYered the vaginal orifice. 011 wern but because of continued oozing of old bloud from the cervix was not identified.
The
c.onrne w,1s nnevrmtful. startc:d 1\farch 7 and de,c:loped. The: on reclining
Case ?. A. -"'""'-""" white was seen HJGO, because she could. not urinate for 24 hours and hall complained of baekache of months' duration. She h,td beeu referred by her to a.rt because of
Fw. :3. Intravenous urogra.m reveals normai upper urinary tra.ct. Smooth defect at midline base of blndder wns believed to be due lo pres.sun; on bladder from distended vagina secundarv imperfomte bymen. .,
in the back. A. back hmce was mude for her but die! not help much. She had been aeti \ e iu sports, but had given thc:m up. th(-: 1ms1 we(~k she had nocturia ::l times, and bilateral low::J abdominal pains and pains in tlw thighs. Slk had difficulty sleeping because: of the backacl11' She had not passed any urine for houn, a I.· though she felt urgency to Yoid. I\ o en hernaturia was found. Examination presented a girl of 12 bent forward with abdominal cli~com fort and complaining also of badrnche Blood pressure 150/90; the lwart a.nd normaJ. The abdomen cliselnsecl tt clistendecl mass extending from the pubis t,wo thirds of the distance to the tunhilirns. OUw.r organs were not palpable. Bilateral ,·oston,rk-· bral angle tenderness was elicited and also bilateral lower quadrant ,mcl ness. The external genitalia ing, rubbery, com pIT·ssible dark st1bjacent fluid. Ou rectal
668
MORRIS M. GANDIN
a large, rubbery, smooth, symmetrical mass arising anteriorly filled most of the rectum. Intravenous urograms were normal except for a large, distended bladder. The patient was able to void spontaneously after hospital admission. The urine was negative except for the presence of many erythrocytes. The blood count showed hemoglobin 12.0 gm., white blood cells 8,500, polymorphonuclears 68 per cent, lymphocytes 31 per cent, monocytes 1 per cent. Surgery was performed May 19, consisting of cystoscopy and excision of the imperforate hymen. After lithotomy position, the size 22 straight sheath McCarthy panendoscope was passed transurethrally into the bladder and examination made with the foroblique and retrospective telescopes. The panendoscope was removed and replaced with a size 18, 30 cc bag Foley catheter. A 10 cc syringe attached to a size 18 needle was then utilized to puncture the imperforate hymen, and aspiration made to reveal a thick, syrupy, chocolate-colored fluid. Using the needle as a guide, an incision was made through the vaginal diaphragm, the edges of the incision being grasped with Allis clamps, following which a circular piece of tissue was excised leaving an adequate vaginal orifice. After a tremendous flow of the syrupy material had been evacuated, aided by compression on the lower abdomen, the inner and outer mucosal edges were approximated with a continuous chromic size 00 catgut in a running lock stitch. The catheter was then removed from the bladder. Perineal dressings were applied. The tissue was sent to the laboratory for identification. The patient was returned to the ward in good condition. The postoperative course was excellent. Blood pressure 100/70. Urinary disturbances disappeared. A regular menstrual cycle was established and the cervix became palpable. The patient returned to active sport activities.
SUMMARY
Two cases are reported of imperforate hymen presenting with urinary symptoms. A history of amenorrhea with abdominal pains and urinary symptoms in a girl at puberty should produce a strong suspicion of the condition. The physical examination will divulge the imperforate hymen and the mass palpable abdominally and rectally. Pyelography may demonstrate a rounded, smooth defect at the middle of the base of the bladder. The ureters and pelvis may show hydroureter and hydronephrosis. Cystoscopy will disclose marked elevation of the urethra and the floor of the bladder. Surgical excision of the hymen is the corrective procedure. A spiral or circular excision is recommended. Antibiotics are advisable. Drains are not recommended.
440 North A St., Oxnard, Cal. REFERENCES BERNSTEIN, P. AND BERNSTEIN, W.: Hematometra. Am. J. Obst. & Gynec., 37: 126, 1939. CALVIN, J. K. AND NICHAMIN, S. J.: Hematocolpos due to imperforate hymen. Am. J. Dis. Child., 51: 832, 1936. GREENHILL, J. P.: Surgical Gynecology, 2nd ed. Chicago: The Year Book Publishers, Inc., 1957, pp. 104-105. NETTER, F. H.: Reproductive System. Summit, N. J.: Ciba, 1954, p. 140. ROSENTHAL, A. H.: Symptomatic genital anomalies in childhood. Clin. Obst. & Gynec., 3: 146, 1960. ROSENTHAL, A.H., BLOCK, R. E. AND LAPIN, A.: The imperforate hymen as a cause of "abdominal tumor." Am. J. Surg., 95: 487, 1958. ScARLE, W. N.: J. Obst. & Gynec. Brit. Emp., 44: 729-730, 1937; Lancet, 1: 961-962, 1933. TE LINDE, R. W.: Operative Gynecology, 2nd ed. Philadelphia: J. B. Lippincott Co., 1953, pp. 759-763. TOMPKINS, P.: Treatment of imperforate hymen with hematocolpos: Review of 113 cases in literature and report of 5 additional cases. J.A.M.A., 113: 913, 1939. TRAFTON, H. AND EWERT, E. E.: Hematocolpometra: Report of a case with urologic complications. Lahey Clin. Bull., 3: 216, 1944. WARNER, R. E. AND MANN, R. M.: Hematocolpos with imperforate hymen. Obst. & Gynec., 6: 405, 1955. WILSON, J. W.: Diagnosis of abdominal cysts in infants and children. Radiology, 64: 178-190, 1955.
'fhe urologist must at lea~t be aware of imhymen as 11 cause of urinary symptoms of an obstructive 1mture. This congenital malformation is sufficic,ntly rnrc that gynecologists H<'e only a few cases in their professional lives. Calvin and Nichitrnin, in I collected 40 cases from the literature, nnd in 1939 Tompkins 118 cases including fin, of his own. The produced by hymen with ,,,,,,.,.,,n,;c, is seldom diagnosed by thn physician who first secs tlw The symptoms appear after puberty due to rnenstrual blood retained in the ntgina :md Inter also in the utenrn. The retained fluid is typicall_v of a thick ~yrupy chocolate character which rna_v amount to several liters in \'olurne. The exµanding presses the mcthra against the pubis and al8o lifts the hlaclder into the ,,bdomen, which additional!~· stretches and narrows tlw urcthrn (fig 1).
cornbination of these conditions. The vulva will show protrusion of an imperforate hymen wlticli is usually dark, clue to old retained blood bc!tmd it (fig. . The digital rectal examination wil: disclose a large, palpable, stnrnagc-~h:1ped mass arising from tho vagina and filling tht- hollow of the sacrum. Cystoscopic examination will reYcal markcc, trig;onc and elevation of the urethra, vesical floor of the bladder, The mucosa of the may be edematous. The floor of the lilG,clder presents itself :1s an cl<~Ynted, rounckcl dorne due to the distended vagina beneath it. Tntravcuon? urograms may be normal but hydrouroter aud hyclronephrosis have been rl'ported. The medimn in the bladder wiJI demonstrate the rounded. elerntion of the floor of the hlacldcr, but 1f Lr
SYMPTOl\lt'; AND SIGNS
,\. group of syrnptorns and signs develops as the menNtrual blood is dammed consisting princiyrnliy of abdomiual abdominal swelling, and urinary disturbances. Pains occur i11 the lower abdomen and back. Discomfort or crnmplike are noted in the suprapubic and lower abdominal regions. Pressure on the urethra may make urination ,hfficnlt, The cornmm1est unnary symptoms etre frc,qneney, urgenc.\'. incontimmce, noctnria, feeling of in<:mptying and t,\'Cll retention. retention may be tho symptom. The duration of urinary retention may vary from 12 hours to a week, and may require rathetcrization. Calvin ancl ~iclmmin sx1 incidence of 68 per cent of patients witli urinary eornplaints. FIJSDJNGS
A rm1s;:; is palpable in the lower abclorncn arising from the pekis. This is due to the dis-
tended uterus, fa1Jopian
or bladder, or a
Accepted for publieation 21, 19Gl. Read at mmunl meeting of Section of American l.Jrological Association. Inc., Las Vegas, Xevarfa, February (l-9, HJG].
The diagnosi~ is rcu,dily ,~stabliRhed IY1 thorough histor_v and physical examination. history of sbsence of menstruation with abclorni.-nal pains, and urinary rn girl puberty should immecliatel:v lead the examiner to search for the significant signs: imperforate hymen, an abdominal rnnss, :ind rectal nu1ss. Cystoscopic findingH will eorTohmatr; the presence of n mass extrinsic to the floor of thn bladder. The treatment is excisio11 of the '2,B). lt may be very thick and fibn111,,.
patient is placed in Iithotom:· "'' m1.de1 general anesthesia. A catheter is pla<:ed in tlw bladder. A. recommended technique is a cruc:iate incision followed by excision of the four of the hyrnnn. My own technique lS a cision as follows (fig. : A large needle membrane syringe is inserted into the midway between the urethra and tbe rectum. A. few cubic centimeters of the contents aspirated for verification, followed or circular incision, beginning at, the ncedl1\ puncture in the center of the nnd 0 "'""'
c,
666
MORRIS M. GANDIN
tending peripherally at the outer border of the hymen at its junction with the vaginal wall. The abdominal and rectal masses will disappear as the large quantity of thick, syrupy, old blood is extruded. The edges of the circular incision are sutured with continuous locked or interrupted catgut for hemostasis. Suprapubic pressure should not be applied, in order to avoid suction of unsterile discharge on release of pressure. Vaginal examination is also avoided for the same reason. Antibiotics are advisable. PROGNOSIS
The prognosis regarding uterine function is good. Normal menstruation follows and repro-
Fm. 1. Hematocolpos shows compression of urethra and elevation of bladder floor.
duction occurs even in cases in which treatment has been delayed. Searle's patient complained of amenorrhea at 17, had the hymen excised at 32, and at 36 years of age was delivered of a healthy child. The urinary difficulties disappear after hymenotomy. CASE REPORTS
Case 1. A 10-year-old Mexican girl was seen by the family physician when she fell, striking the right buttock on a chair. She was referred to a surgeon because of a rectal mass. He, in turn, requested urological consultation on February 20, 1960 because of urinary symptoms. She noted slight pain with urination, particularly at termination. For the past 2 years she had arisen to void every 5 minutes, about 4 times in succession before falling asleep when retiring at night. Diuria occured 8 times and she experienced frequent low abdominal cramps. Examination showed a tall, well developed girl appearing 2 or 3 years older than her stated age. Blood pressure was 98/60. Heart and lungs were normal. Abdominal examination revealed right lower quadrant tenderness and fullness; slight tenderness in the left costovertebral angle; liver, spleen and kidneys not palpable. Slight tenderness was present over the right ischial tuberosity. External genitalia presented an imperforate hymen. A lubricated applicator could not be passed through the vaginal orifice. On rectal examination, a large, smooth, symmetrical, ovoid, soft mass in the anterior wall of the rectum was palpated. Urinalysis was negative. Hemoglobin 13.4 gm., white blood cells 13,700, polymorphonuclears 79 per cent, lymphocytes 21 per cent, blood urea
Fm. 2. A, imperforate hymen. B, cruciate incision. C, spiral incision
URINARY SYlvIP'l'OMS ASS0CIA1'l~D \VITI-I J:V[PJ,cRF'ORATE HYMEN
nitrogen 11.0. Intravenous urogrnphr on Febru.. ary 25 (fig. :3) revealed a nonrrnl upper urinary tract. There was a smooth defect at the miclline of the base of the bladder, believed to be due to pressure on the bladder from a distended vagin:i. to tlw imperfomtc hymen. was performed Febn1ary 25. 'J'he in the lithotomy position. ~ize 22 ~traight sheath panendoscope \1as transurethrnll? into the bladder and t»arnination nrnde with the forobhque and This was removed and
nt·eclk was inserted through the imperforate diaphragm and with a syringe old blood. Leaving the neeclle in place, rnc1s1on was tlwn made into the vaginal dia· phragm of the hymen ,rnd the r:xtcnckcl incision crossed with a transverse incision. Portions of the diaphragn1 were excised and submitted to the laboratory for tissue identification. Th,, ,,v,:tr,,,,nn,1° was then into the opened 1·agina and inspr:ction nmde with the This was rernovcd and a size :cio cc bag Foley cathc:ter in~erted into the vagina. The mcthrn was distorted upwarc[ the subnmss. The hlaclckr nn1cosa \HlS normal <"»cept in the: region of tbe trigone where them was considerable edema and convex elevation ,,.nd distortion of the interu.retcric and floor of the bladder a mass. The ureteraI orific,~s thernsdn.:s to be nonnal alconsiclerably elcevatecl. On digital rectal tlwre was felt a largE, globular mass which, after incision of the Yaginal hymen, collapsed. 260 cc of old blood w:1s c,\·acuated. 'The hymen was extreme!? thick and dc:nse and coYered the vaginal orifice. 011 wern but because of continued oozing of old bloud from the cervix was not identified.
The
c.onrne w,1s nnevrmtful. startc:d 1\farch 7 and de,c:loped. The: on reclining
Case ?. A. -"'""'-""" white was seen HJGO, because she could. not urinate for 24 hours and hall complained of baekache of months' duration. She h,td beeu referred by her to a.rt because of
Fw. :3. Intravenous urogra.m reveals normai upper urinary tra.ct. Smooth defect at midline base of blndder wns believed to be due lo pres.sun; on bladder from distended vagina secundarv imperfomte bymen. .,
in the back. A. back hmce was mude for her but die! not help much. She had been aeti \ e iu sports, but had given thc:m up. th(-: 1ms1 we(~k she had nocturia ::l times, and bilateral low::J abdominal pains and pains in tlw thighs. Slk had difficulty sleeping because: of the backacl11' She had not passed any urine for houn, a I.· though she felt urgency to Yoid. I\ o en hernaturia was found. Examination presented a girl of 12 bent forward with abdominal cli~com fort and complaining also of badrnche Blood pressure 150/90; the lwart a.nd normaJ. The abdomen cliselnsecl tt clistendecl mass extending from the pubis t,wo thirds of the distance to the tunhilirns. OUw.r organs were not palpable. Bilateral ,·oston,rk-· bral angle tenderness was elicited and also bilateral lower quadrant ,mcl ness. The external genitalia ing, rubbery, com pIT·ssible dark st1bjacent fluid. Ou rectal
668
MORRIS M. GANDIN
a large, rubbery, smooth, symmetrical mass arising anteriorly filled most of the rectum. Intravenous urograms were normal except for a large, distended bladder. The patient was able to void spontaneously after hospital admission. The urine was negative except for the presence of many erythrocytes. The blood count showed hemoglobin 12.0 gm., white blood cells 8,500, polymorphonuclears 68 per cent, lymphocytes 31 per cent, monocytes 1 per cent. Surgery was performed May 19, consisting of cystoscopy and excision of the imperforate hymen. After lithotomy position, the size 22 straight sheath McCarthy panendoscope was passed transurethrally into the bladder and examination made with the foroblique and retrospective telescopes. The panendoscope was removed and replaced with a size 18, 30 cc bag Foley catheter. A 10 cc syringe attached to a size 18 needle was then utilized to puncture the imperforate hymen, and aspiration made to reveal a thick, syrupy, chocolate-colored fluid. Using the needle as a guide, an incision was made through the vaginal diaphragm, the edges of the incision being grasped with Allis clamps, following which a circular piece of tissue was excised leaving an adequate vaginal orifice. After a tremendous flow of the syrupy material had been evacuated, aided by compression on the lower abdomen, the inner and outer mucosal edges were approximated with a continuous chromic size 00 catgut in a running lock stitch. The catheter was then removed from the bladder. Perineal dressings were applied. The tissue was sent to the laboratory for identification. The patient was returned to the ward in good condition. The postoperative course was excellent. Blood pressure 100/70. Urinary disturbances disappeared. A regular menstrual cycle was established and the cervix became palpable. The patient returned to active sport activities.
SUMMARY
Two cases are reported of imperforate hymen presenting with urinary symptoms. A history of amenorrhea with abdominal pains and urinary symptoms in a girl at puberty should produce a strong suspicion of the condition. The physical examination will divulge the imperforate hymen and the mass palpable abdominally and rectally. Pyelography may demonstrate a rounded, smooth defect at the middle of the base of the bladder. The ureters and pelvis may show hydroureter and hydronephrosis. Cystoscopy will disclose marked elevation of the urethra and the floor of the bladder. Surgical excision of the hymen is the corrective procedure. A spiral or circular excision is recommended. Antibiotics are advisable. Drains are not recommended.
440 North A St., Oxnard, Cal. REFERENCES BERNSTEIN, P. AND BERNSTEIN, W.: Hematometra. Am. J. Obst. & Gynec., 37: 126, 1939. CALVIN, J. K. AND NICHAMIN, S. J.: Hematocolpos due to imperforate hymen. Am. J. Dis. Child., 51: 832, 1936. GREENHILL, J. P.: Surgical Gynecology, 2nd ed. Chicago: The Year Book Publishers, Inc., 1957, pp. 104-105. NETTER, F. H.: Reproductive System. Summit, N. J.: Ciba, 1954, p. 140. ROSENTHAL, A. H.: Symptomatic genital anomalies in childhood. Clin. Obst. & Gynec., 3: 146, 1960. ROSENTHAL, A.H., BLOCK, R. E. AND LAPIN, A.: The imperforate hymen as a cause of "abdominal tumor." Am. J. Surg., 95: 487, 1958. ScARLE, W. N.: J. Obst. & Gynec. Brit. Emp., 44: 729-730, 1937; Lancet, 1: 961-962, 1933. TE LINDE, R. W.: Operative Gynecology, 2nd ed. Philadelphia: J. B. Lippincott Co., 1953, pp. 759-763. TOMPKINS, P.: Treatment of imperforate hymen with hematocolpos: Review of 113 cases in literature and report of 5 additional cases. J.A.M.A., 113: 913, 1939. TRAFTON, H. AND EWERT, E. E.: Hematocolpometra: Report of a case with urologic complications. Lahey Clin. Bull., 3: 216, 1944. WARNER, R. E. AND MANN, R. M.: Hematocolpos with imperforate hymen. Obst. & Gynec., 6: 405, 1955. WILSON, J. W.: Diagnosis of abdominal cysts in infants and children. Radiology, 64: 178-190, 1955.