(P92) A Unique Case of Lower Abdominal Pain in the Emergency Room

Chief Complaint: Right lower quadrant abdominal pain and difficulty urinating for ten days.
History of Present Illness: Patient was a 29 year old G2P2 female with a past surgical history of two C-sections and tubal ligation who presented with ten days of right lower quadrant abdominal pain associated with dysuria, difficulty urinating, intermittent hematuria and vaginal spotting. The pain radiated to her right flank and back and was associated with nausea but no vomiting, fevers, or chills. Patient denied vaginal discharge, dyspareunia, diarrhea, chest pain, shortness of breath, headache or dizziness.Patient denied any previous history of nephrolithiasis.

Pertinent Physical Exam: Patient was a young female noted to be in no acute distress. Cardiovascular exam with regular rate and rhythm no murmurs, rubs, or gallops,and lungs clear to auscultation bilaterally. Abdomen was flat and soft with right greater than left lower abdominal and suprapubic tenderness with voluntary guarding and no rebound. Pelvic exam was notable for right adnexal tenderness without palpable masses or lesions, no cervical motion tenderness, closed os, and no blood or discharge in the vaginal vault. Capillary refill was less than 2 seconds and the patient was ambulatory in the ED.

Pertinent Laboratory Data: Blood work noted a negative HCG, a hemoglobin/hematocrit of 11.9/ 34.9, a white blood cell count of 10.6, a urinalysis with trace leukocyte esterase and white blood cells but no bacteria, and a negative vaginitis panel. The patient underwent a transvaginal ultrasound which showed a didelphys uterus with trace free fluid and fluid distension of the right endometrial cavity. Patient underwent a CT Abdomen and Pelvis, showing a normal appendix, a solitary left kidney, and an ill defined right adnexa, with recommendation for MRI. MR Pelvis demonstrated obstruction of the right hemivagina with hematometrocolpos and hematosalpinx; consistent with Herlyn-Werner-Wunderlich(HWW) Syndrome.

Case

Discussion: This case demonstrates a unique cause of lower abdominal pain. Lower abdominal pain is an incredibly common Emergency Room (ER) complaint representing 5-10% of annual ER visits [1]. The differential for this pain is broad and can include GYN pathology such as ectopic pregnancy, fibroids, ovarian masses, and ovarian torsion, GU pathology such as kidney stones and pyelonephritis, and GI pathology such as appendicitis, colitis, and diverticulitis [2]. In this patient’s case, her lower abdominal pain was found to be due to hematocolpos secondary to Herlyn-Werner-Wunderlich (HWW) Syndrome. HHW is a rare congenital condition characterized by uterus didelphys with blind hemivagina and ipsilateral renal agenesis, affecting up to 3.8% of the population. Patients typically present a few years post menarche with a variety of symptoms including recurrent urinary tract infections, urinary retention, and pelvic pain with hematocolpos, which is how our patient presented. Management includes surgical repair to allow for outflow of uterine lining during menstruation [3]. This case is particularly unique given the patient had a history of multiple obstetric and gynecological procedures including two C-sections and a tubal ligation before her ultimate diagnosis of HWW was discovered. This patient was evaluated by gynecology and cleared for close outpatient follow up for surgical repair.

References and Acknowledgements : 1. Brewer BJ, Golden GT, Hitch DC, Rudolf LE, Wangensteen SL. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg. 1976 Feb;131(2):219-23. doi: 10.1016/0002-9610(76)90101-x. PMID: 1251963.
2. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8. PMID: 18441863.
3. Wdowiarz K, Skrajna A, Reinholz-Jaskólska M. Diagnosis and treatment of Herlyn-Werner-Wunderlich syndrome: a case report. Prz Menopauzalny. 2021 Apr;20(1):52-56. doi: 10.5114/pm.2021.104034. Epub 2021 Mar 1. PMID: 33935621; PMCID: PMC8077801.