Hematocolpos Secondary to Acquired Vaginal Scarring After Radiation Therapy for Colorectal Carcinoma

Case Report Hematocolpos Secondary to Acquired Vaginal Scarring After Radiation Therapy for Colorectal Carcinoma Sachit K. Verma, MD, Oksana H. Baltarowich, MD, Anna S. Lev-Toaff, MD, Donald. G. Mitchell, MD, Manisha Verma, MD, Frances Batzer, MD Hematocolpos in a postmenopausal woman is uncommon because most cases are due to a congenital anomaly and present during the neonatal or perimenarchal period. In older women, hematocolpos results from near or complete vaginal occlusion secondary to radiation therapy for cervical carcinoma or from scarring after surgical procedures such as cone biopsy. Rarely, vaginal obstruction may be due to postmenopausal atrophy, endometriosis, or vaginitis, leading to scarring or adhesions. 1 6 Hematocolpos after radiation therapy for colorectal carcinoma is a rare clinical entity. We report an unusual case of hematocolpos secondary to acquired vaginal scarring after radiation therapy for colorectal carcinoma in a postmenopausal woman who had dyspareunia and pelvic and lower back pain. Characteristics on 3-dimensional (3D) transvaginal sonography (TVS) and magnetic resonance imaging (MRI), as well as intraoperative sonographic guidance, are described, together with current management and a review of the literature. The diagnosis of vaginal scarring and associated hematocolpos was suggested by TVS and confirmed by intraoperative sonography. Case Report Abbreviations MRI, magnetic resonance imaging; 3D, 3-dimensional; TVS, transvaginal sonography Received February 3, 2009, from the Departments of Radiology (S.K.V., O.H.B., A.S.L.-T., D.G.M.), Medicine (M.V.), and Obstetrics and Gynecology (F.B.), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania USA. Dr Lev-Toaff is currently with the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania USA. Revision requested March 5, 2009. Revised manuscript accepted for publication March 9, 2009. Address correspondence to Sachit K. Verma, MD, Department of Radiology, Thomas Jefferson University, 132 S 10th St, Main Building, Philadelphia, PA 19107 USA. E-mail: medskv@yahoo.com A 53-year-old woman, gravida 1, para 1, with a surgical history of resection for colorectal cancer followed by chemotherapy and radiation treatment underwent an evaluation for dyspareunia and pelvic and lower back pain 8 years after her cancer treatment. After treatment for cancer, she received hormone replacement therapy in the form of continuous combined oral conjugated estrogen and progestin for acute menopausal symptoms as well as for bone protection. Her gynecologic history included regular periods before the surgery and an uncomplicated pregnancy with a vaginal delivery. Her family history was notable for ovarian cancer in her mother. The physical examination revealed a healthyappearing woman in no apparent distress (height, 5 ft 6 in; weight, 116 lb; blood pressure, 110/70 mm Hg). A 2009 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2009; 28:949 953 0278-4297/09/$3.50

Hematocolpos After Radiation Therapy for Colorectal Carcinoma bimanual examination confirmed the presence of a soft midline mass possibly felt to be her uterus. The adnexa were not palpable, and the cervix could not be visualized on a speculum examination. No appreciable discharge was noted, and wet smear results were negative. Laboratory test results revealed a hemoglobin level of 12.4 g/dl, a hematocrit value of 0.38, a white blood cell count of 5.7 10 9 /L, and a platelet count of 291 10 9 /L. Serum creatinine, blood urea nitrogen, electrolyte, prothrombin time, and partial thromboplastin time values were normal. Magnetic resonance imaging performed 6 years after her cancer treatment to assess for signs of malignancy recurrence showed a large rounded encapsulated fluid collection measuring 8.0 7.2 7.3 cm occupying the lower pelvis with high signal intensity on T1-weighted images (Figure 1A) and intermediate to slightly high signal intensity on T2-weighted images. The mass was surrounded by several T2-hyperintense foci and showed concentric rings at the periphery, indicating the presence of blood in various stages of evolution (Figure 1B) in the cervix and proximal vagina with an associated mass effect on the bladder. There was no enhancement after gadolinium contrast agent administration (Figure 1C). In the midsagittal plane (Figure 1B), MRI showed that the cervical canal was also distended and contiguous with the endometrial cavity, which mea- A Figure 1. A, Axial T1-weighted MRI. B, Fat-suppressed sagittal fast spin echo T2-weighted MRI. C, Fat-suppressed gadoliniumenhanced axial T1-weighted MRI. The images show a large hyperintense nonenhancing well-encapsulated hemorrhagic collection distending the upper vagina and extending into the cervical canal, consistent with hematocolpos (asterisks). Fluid in the distended part of the vagina is surrounded by several T2- hyperintense foci (B, center and right arrows) and a concentric ring (B, left arrow) at the periphery, consistent with the presence of blood in various stages of evolution. B C 950 J Ultrasound Med 2009; 28:949 953

Verma et al sured 15 mm and contained hemorrhagic material. Vaginal stenosis secondary to prior radiation treatment was suggested as a cause of the accumulated blood. No further follow-up was performed at the time. The patient became symptomatic, and pelvic sonography was advised. A 3D TVS examination depicted a distended upper vagina containing diffuse low-level echoes measuring 4.9 3.3 5.4 cm, consistent with blood known as hematocolpos (Figure 2). A thin hypoechoic diaphragm-like soft tissue structure measuring about 3 mm in thickness was seen crossing the vagina, consistent with an obstructing vaginal scar between the patent lower vagina and the hematocolpos (Figure 3). The lower vagina had a normal appearance with a length of approximately 3 cm; the appearance of the cervix was unremarkable. The uterus was normal with an endometrial thickness of 3 mm. Both ovaries were visualized as small with no cystic components. In contrast to the MRI, sonography showed that the uterus and cervical canal were not distended because this patient was no longer menstruating. In the operating room, under laryngeal mask anesthesia, successful intraoperative real-time transabdominal sonographic guidance was used to facilitate access to the hematocolpos via a blunt dilator, which resulted in the release of dark blood with complete evacuation of the fluid. The vaginal scarring was resected, with restoration of her normal vaginal length. Placement of a vaginal stent to prevent immediate closure was performed under continued sonographic guidance. The patient tolerated the procedure well. Endometrial biopsy confirmed an atrophic endometrium with chronic inflammation and old hemorrhage. Postoperatively, the patient continued to receive combined hormone replacement therapy with good resolution of her menopausal symptoms. Maintenance of an adequate vagina allowing for cervical visualization necessitated the continuous use of the vaginal stent, placed 3 nights per week with estrogen cream. A minimal constrictive ring at the site of previous scarring was still visible. The patient was advised that if she resumed vaginal intercourse, continued use of the vaginal stent may become unnecessary. Figure 2. Transperineal 3D multiplanar sonography shows sagittal (top left), axial (top right), and coronal (bottom left) views of a distended upper vagina filled with complex fluid containing diffuse low-level echoes most consistent with the hemorrhagic contents of the hematocolpos (asterisks). The lower vaginal walls are opposed to each other, creating the white line in the top left image. Discussion This report describes an unusual case of a midvaginal transverse scar acquired after radiation therapy that led to formation of hematocolpos due to obstruction of vaginal outflow. Hematocolpos is the term derived from the Greek words hematos, meaning blood, and kolpos, meaning vagina. 4 The obstruction may be primary (congenital), such as a müllerian defect of the lower female genital tract (eg, imperforate hymen, transverse vaginal septum, and partial vaginal agenesis), 7,8 or it may be acquired. 1 6 Acquired vaginal stenosis commonly occurs as a result of radiation treatment for gynecologic malignancies such as cervical, endometrial, vulvar, and vaginal carcinomas. 1,4,5 Rarely, it may also follow pelvic irradiation in patients with colorectal carcinoma. 5 Vaginal stenosis occurs after completion of radiation therapy as a result of denudation of the vaginal epithelium, leading to perivaginal fibrosis of the areas that were denuded. 1 Thinning of the vaginal mucosa and scarring result in shortening and narrowing of J Ultrasound Med 2009; 28:949 953 951

Hematocolpos After Radiation Therapy for Colorectal Carcinoma A B Figure 3. A, Midsagittal 3D TVS shows a hypoechoic band of tissue (between arrows) that represents the scar between the patent lower vagina and the upper vaginal collection of blood constituting the hematocolpos (asterisk). B, Sagittal 3D TVS shows a 3-mm vaginal scar measured between the calipers and the hematocolpos (asterisk). the vagina. It is exaggerated by the frequent simultaneous onset of menopause and precipitated by radiation therapy with a resultant local estrogen deficiency. Clinical awareness of vaginal obstruction as a postradiotherapy complication is important because it impairs the quality of life and may lead to problems with sexual function, potential infection of the pelvic organs, and even sepsis. The diagnosis is usually made at the onset of symptoms. As with this patient, modes of presentation are commonly dyspareunia, pelvic pain, and back pain. 3,9 Obstructive symptoms such as urinary retention, dysuria, and constipation due to mechanical pressure on the bladder, urethra, and rectum by the accumulated menstrual blood are also common. 10,11 Management of hematocolpos and vaginal stenosis depends on the extent of the pelvic obstruction and the location. A definitive preoperative diagnosis is crucial for defining the best treatment strategy. In addition, other etiologies for a pelvic mass, including malignancy recurrence and a possible second malignancy, must be considered. To our knowledge, a case with sonographic and MRI findings of hematocolpos secondary to acquired vaginal scarring after radiation therapy for colorectal carcinoma has not been reported previously in the literature. Transperineal sonography and TVS have been used for diagnosing an obstructed vagina and consequent hematocolpos and for defining the anatomic defect. 12,13 These conventional methods may not allow for adequate angulation of a TVS probe to properly visualize the anatomic details of pelvic organs in the coronal plane. With the 3D TVS technique, it is possible to determine whether the obstruction is due to a vaginal septum or adhesion, its measurements, and its configuration, whether incomplete or complete, and define its relationship with adjacent pelvic structures. In this case, 3D TVS was performed because of increasing pelvic cramps, a persistent pelvic mass, a shortened vagina with nonvisualization of the cervix on the physical examination, and lack of an appreciable explanation on MRI. On sonography, hematocolpos manifests as a distended vagina containing fluid with low-level echoes, solid debris, or both. This case showed the classic appearance of old blood. The transversely oriented vaginal scar was seen as a thin hypoechoic band between the lower vagina and hematocolpos. Sonography is a simple, flexible, inexpensive, and noninvasive imaging modality that has an added advantage for guiding an invasive procedure for diagnostic and therapeutic purposes. In this case, 3D sonography confirmed the presence of hematocolpos, determined the 952 J Ultrasound Med 2009; 28:949 953

Verma et al cause and level of the vaginal obstruction, and ruled out a urologic or gastrointestinal abnormality. Intraoperative sonographic guidance was essential for appropriate entry into the hematocolpos and subsequent evacuation. Correct placement of the vaginal stent was confirmed. Magnetic resonance imaging is highly sensitive in characterizing the components of large collections or masses with variable signal intensities on T1- and T2-weighted sequences and their enhancement patterns. 14 In this case, MRI revealed the large hyperintense fluid collection within the grossly distended vagina to be hemorrhagic contents with no solid components. Furthermore, MRI helped in excluding other possible etiologies, including a Nabothian cyst, a Gartner duct cyst, and a malignant lesion. Early diagnosis and management of hematocolpos are essential to relieve pressure and prevent hematometrium (accumulation of blood in the endometrial cavity), hematosalpinx (accumulation of blood in fallopian tube), and urinary tract obstruction. The mainstay of treatment is drainage and evacuation. 15 Vaginal dilation with the use of dilators and placement of a mechanical removable stent should be attempted for vaginal stenosis before surgical reconstruction is considered. 2,16 In this case, intraoperative sonography allowed complete evacuation of the hematocolpos and proper placement of a vaginal stent as a means of preventing restenosis. Because many of these patients become acutely menopausal after cancer treatment, local or systemic estrogen therapy to provide adequate epithelialization and perhaps prevent adhesion recurrence should be initiated simultaneously. In conclusion, pelvic 3D TVS was effective in confirming the diagnosis of hematocolpos and identifying the underlying cause. Intraoperative sonographic guidance during procedures is essential for safely approaching a vaginal collection and finding the point of stenosis. Both are important for an accurate preoperative diagnosis and effective surgical management. 2. Decruze SB, Guthrie D, Magnani R. Prevention of vaginal stenosis in patients following vaginal brachytherapy. Clin Oncol (R Coll Radiol) 1999; 11:46 48. 3. Speas CK, Gallup DC, Gallup DG. Hematocolpos in elderly women. South Med J 1998; 6:815 818. 4. Bruner DW, Lanciano R, Keegan M, Corn B, Martin E, Hanks GE. Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma. Int J Radiat Oncol Biol Phys 1993; 27:825 830. 5. Greven KM, Paunesku T. Radiation complications of the pelvis. Cancer Treat Res 2006; 128:125 153. 6. Parmley TH, Woodruff JD. Complete vaginal occlusion in postmenopausal women. Obstet Gynecol 1975; 46:235 238. 7. Yu TJ, Lin MC. Acute urinary retention in two patients with imperforate hymen. Scand J Urol Nephrol 1993; 27:543 544. 8. Dickson CA, Saad S, Tesar JD. Imperforate hymen with hematocolpos. Ann Emerg Med 1985; 14:467 469. 9. Harrison CS. Hematocolpos as a cause of low-back pain: a case report. Spine 1991; 16:985 986. 10. Soloway MS, Rao MK, Kest L. Hematocolpos with urinary tract obstruction in an adult. J Urol 1977; 117:811 812. 11. Ward A, Maher P. Haematocolpos: an unusual presentation. Br J Clin Pract 1979; 33:83 84. 12. Meyer WR, McCoy MC, Fritz MA. Combined abdominalperineal sonography to assist in diagnosis of transverse vaginal septum. Obstet Gynecol 1995; 85:882 884. 13. Sailer JF. Hematometra and hematocolpos: ultrasound findings AJR Am J Roentgenol 1979; 132:1010 1011. 14. Griffin N, Grant LA, Sala E. Magnetic resonance imaging of vaginal and vulval pathology. Eur Radiol 2008; 18:1269 1280. 15. Schneider K, Hong J, Fong J, Sanders CG. Hematocolpos as an easily overlooked diagnosis. Curr Opin Pediatr 1999; 11:249 252. 16. Morley GW, DeLancey JO. Full-thickness skin graft vaginoplasty for treatment of the stenotic or foreshortened vagina. Obstet Gynecol 1991; 77:485 489. References 1. Hartman P, Diddle AW. Vaginal stenosis following irradiation therapy for carcinoma of the cervix uteri. Cancer 1972; 30:426 429. J Ultrasound Med 2009; 28:949 953 953