Hematometra is the collection of blood within the uterine cavity. This retention occurs because a physical obstruction prevents the normal outflow of menstrual or postpartum blood through the cervix and vagina. Understanding the factors that determine the severity of this condition is necessary to guide timely and appropriate medical intervention.
Defining Hematometra and Its Symptoms
The mechanism behind hematometra involves a blockage in the lower reproductive tract that seals off the natural exit for uterine contents. When the cervical canal is occluded, blood that would normally be shed remains trapped, causing the uterus to distend and building pressure within its walls.
The most common symptoms include severe, cyclic abdominal or pelvic pain, often correlating with a missed menstrual period. This trapped blood leads to an enlarged uterus, which may be felt as a firm, tender mass in the lower abdomen. Other associated symptoms include primary amenorrhea or, if the obstruction is partial, abnormal bleeding patterns. The pressure exerted by the distended uterus can compress nearby organs, leading to secondary signs like difficulty with urination or acute urinary retention.
Assessing the Urgency When Hematometra Becomes an Emergency
While chronic hematometra can be managed electively, acute presentations require emergency medical attention. The most significant indicator of an emergency is the development of an infection, known as pyometra, where the stagnant blood becomes infected. Signs of systemic infection, such as high fever, chills, rapid heart rate, or other indicators of sepsis, necessitate immediate hospital care.
Sudden, unmanageable pain suggests rapid uterine expansion or potential uterine wall compromise. Although rare, extreme distension carries a risk of uterine rupture, which requires emergency surgery. Furthermore, the enlarged uterus can lead to acute kidney injury if it exerts significant pressure on the ureters, blocking urine flow.
The distinction between urgency and immediate danger lies in the presence of systemic symptoms beyond pain. Stable patients with moderate pain and no signs of infection may undergo elective management. Patients presenting with signs of shock or an acute abdomen due to suspected infection or impending rupture must be stabilized and treated without delay. Prompt diagnosis and drainage are necessary to alleviate pressure and mitigate the risk of severe complications.
Underlying Causes of Uterine Blood Accumulation
Blood retention results from a physical barrier at the cervix or vagina. In adolescents, the cause is often a congenital anomaly, such as an imperforate hymen or a transverse vaginal septum, which prevents menstrual blood from exiting the body. Less commonly, congenital cervical agenesis, the failure of the cervix to fully form, can be the source of the obstruction.
Acquired mechanical causes frequently lead to cervical stenosis, a narrowing or closure of the cervical canal. This scarring often occurs following surgical procedures on the cervix, such as a Loop Electrosurgical Excision Procedure (LEEP), cone biopsy, or endometrial ablation. Radiation therapy to the pelvis or chronic cervical infections can also result in scar tissue that closes the canal.
The third category involves space-occupying lesions. Benign growths like cervical polyps or fibroids growing into the cervical canal can create a physical plug, leading to blood retention. Malignant tumors of the cervix or endometrium may also be the cause, as the growth itself obstructs the canal, sometimes presenting as an initial symptom of the underlying cancer.
Diagnosis and Treatment Options
Diagnosis involves a pelvic examination, which may reveal an enlarged, globular, and tender uterus. The primary diagnostic tool is imaging, with a pelvic ultrasound used to visualize the condition. Ultrasound provides clear images of a distended uterine cavity filled with fluid, confirming blood accumulation and often helping to pinpoint the level of the obstruction.
Treatment involves relieving the obstruction to drain the blood and then addressing the underlying cause to prevent recurrence. The most frequent procedure for drainage is a cervical dilation and evacuation (D&E), where the cervical canal is gently widened to allow the trapped blood to flow out. This procedure is often performed under ultrasound guidance to minimize the risk of uterine wall injury.
If the obstruction is internal, such as from scar tissue or a polyp, a hysteroscopy may be necessary. This procedure involves inserting a thin, lighted telescope through the cervix into the uterus to visualize the cavity. This allows the physician to identify and remove the specific blockage. For long-term resolution, subsequent treatment focuses on the root cause, such as surgical correction of a congenital defect or management of a tumor.