Antenatal diagnosis and successful management of fetal mucocolpometra in a resource-limited setting: a case report from Ethiopia

Abstract

Introduction

Imperforate hymen is the most common congenital anomaly of the female genital tract, usually diagnosed at puberty. Neonatal presentation is rare, and antenatal diagnosis is even less common but increasingly recognized with advances in prenatal ultrasonography. Fetal mucocolpometra results from distal vaginal obstruction and may present as a cystic pelvic mass, with potential for postnatal complications such as urinary obstruction.

Case Presentation

We report a 17-year-old primigravida from rural North-western Ethiopia whose fetus was found on late antenatal ultrasound to have a large cystic pelvic mass suggestive of mucocolpometra. At 37 weeks and 6 days of gestation, she underwent emergency cesarean section for obstetric indications. A live female neonate was delivered with good APGAR scores but developed marked abdominal distension and acute urinary retention shortly after birth. Examination revealed a bulging, bluish vaginal introitus. The diagnosis of mucocolpometra secondary to imperforate hymen was made. Hymenectomy was performed under sterile conditions, draining approximately 300 mL of milky fluid, with immediate clinical improvement.

Discussion

Antenatal detection of mucocolpometra remains uncommon, particularly in resource-limited settings. Early recognition is important to prevent complications such as urinary obstruction and abdominal distension. This case demonstrates that antenatal ultrasound alone can provide sufficient diagnostic suspicion to guide timely intervention, even where advanced imaging is unavailable.

Conclusion

Fetal mucocolpometra should be considered in cases of antenatally detected pelvic cystic masses. Early diagnosis and prompt surgical management can result in excellent outcomes, even in resource-limited settings.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12887-026-07241-3.

Introduction

Imperforate hymen is the most common congenital anomaly of the female genital tract, resulting from failure of canalization of the vaginal plate during embryologic development [1]. Its estimated incidence ranges from 0.05% to 0.1%, and it is most commonly diagnosed at puberty, typically presenting with primary amenorrhea and cyclic pelvic pain due to retained menstrual blood [2]. Presentation in the neonatal period is uncommon, while antenatal diagnosis is rare but increasingly recognized with advances in prenatal ultrasonography [3, 4].

Fetal mucocolpometra occurs when distal vaginal obstruction leads to accumulation of secretions under the influence of maternal estrogens [3]. On antenatal ultrasound, it usually appears as a cystic pelvic mass located posterior to the bladder and anterior to the rectum, sometimes containing internal echoes [5]. Early recognition is important, as delayed diagnosis may result in complications such as urinary tract obstruction, abdominal distension, or infection [6].

In resource-limited settings, including Ethiopia, antenatal diagnosis of such conditions remains challenging due to limited access to advanced imaging modalities and specialized expertise. Consequently, many cases are identified only after birth when complications arise [6, 7]. However, recent reports suggest that improving access to obstetric ultrasound is facilitating earlier detection and better outcomes even in low-resource environments [7].

We report a rare case of antenatally diagnosed fetal mucocolpometra secondary to imperforate hymen, presenting with acute urinary retention in the neonatal period, successfully managed in a resource-limited setting.

Case presentation

A 17-year-old primigravida woman, from rural area of North-western Ethiopia, was admitted to our hospital with pushing down pain of 10 h duration. She reported amenorrhea for approximately nine months, although her last normal menstrual period was unknown. She had regular antenatal care follow-up. Her antenatal screening tests were unremarkable. Her blood group was B Rh-negative.

She was referred from Primary Hospital with a diagnosis of latent phase of first stage of labor plus third trimester pregnancy, liquor passage, Rh-negative status (unsentisized), and suspected fetal congenital malformation for further evaluation and management. There were no other reported danger signs during pregnancy.

On admission to our hospital, she was in active labor. Her vital signs were stable. Abdominal examination revealed a term-sized gravid uterus with a longitudinal lie and cephalic presentation. The fetal heart rate was 140 beats per minute. Uterine contractions were 3 in 10 min, each lasting 35–40 s. Pelvic examination showed a cervix dilated to 3 cm and 80% effaced. The membranes were ruptured with grade III meconium-stained amniotic fluid, and the presenting part was at station Zero.

Obstetric ultrasound revealed a singleton intrauterine pregnancy in cephalic presentation with positive fetal heart activity. The gestational age was estimated at 37 weeks and 6 days, with an estimated fetal weight of 3.6 kg. There was oligohydramnios, with Amniotic fluid index of 2 cm with ruptured membranes. The placenta was fundal. Additionally, a large pear-shaped cystic mass measuring approximately 90 × 70 mm was identified in the mid-pelvis, located posterior to the bladder and anterior to the rectum, with internal echoes (Fig. 1). Both kidneys appeared normal, with no evidence of hydronephrosis or upper urinary tract dilatation, and no other congenital anomalies were detected.

Fig. 1.

A large pear-shaped cystic mass measuring approximately 90 × 70 mm in the mid-pelvis, located posterior to the bladder and anterior to the rectum, with internal echoes

With the assessment of term pregnancy in active labor complicated by grade III meconium-stained amniotic fluid and oligohydramnios, concerning for possible fetal compromise, together with a suspected fetal pelvic space-occupying lesion likely mucocolpometra secondary to imperforate hymen, the patient was prepared for emergency cesarean delivery. The fetal anomaly contributed to perinatal planning but was not the sole indication for cesarean section. Given the presence of Grade III meconium-stained amniotic fluid on pelvic examination and severe oligohydramnios (amniotic fluid index of 2 cm with ruptured membranes) on ultrasound, there was significant concern for fetal compromise. These obstetric findings constituted the primary indications for emergency cesarean delivery. In addition, the antenatally detected large fetal pelvic cystic mass, suspected to represent mucocolpometra secondary to imperforate hymen, was considered during perinatal planning and neonatal management. Accordingly, the patient underwent emergency cesarean section at 37 weeks and 6 days of gestation.

An emergency cesarean section was performed. Intraoperatively, the uterus was intact and bilateral adnexa appeared normal. A live female neonate weighing 3.6 kg was delivered with APGAR scores of 8 and 9 at 1 and 5 min, respectively.

On neonatal evaluation, the newborn cried immediately after birth, requiring no resuscitation. Vital signs were within normal limits. However, abdominal examination revealed gross distension with a palpable mass extending from the pelvis up to the level midway between the xiphisternum and the umbilicus and genitourinary examination showed a distended vaginal introitus with bluish discoloration suggestive of mucocolpometra (Fig. 2). The urethral meatus was visible upon elevation of the mass, but there was no passage of urine. The anus was normally formed, and the neonate passed meconium.

Fig. 2.

Distended abdomen with a palpable mass extending from the pelvis up to the level midway between the xiphisternum and the umbilicus and distended vaginal introitus with bluish discoloration

Laboratory investigation showed a normal complete blood count (CBC). Cord blood analysis revealed blood group O Rh-negative. The neonate was diagnosed with acute urinary retention secondary to mucocolpometra likely due to imperforate hymen. An intravenous line was secured, and urinary catheterization was attempted using a size 4 nasogastric tube.

After obtaining informed consent from the mother, the neonate was taken to the operating room. Under ketamine sedation and aseptic conditions, hymenectomy was performed. Approximately 300 mL of whitish milky fluid was drained from the vagina and uterus (Fig. 3). The cavity was irrigated with normal saline, and hemostasis was secured (Video attached). The neonate tolerated the procedure well and was transferred back to the mother in stable condition with normal vital signs.

Fig. 3.

Whitish milky fluid drained from the vagina and uterus

Postoperatively, the neonate showed marked improvement. Urinary retention resolved within a few hours of hymenectomy, and spontaneous urination was observed on the day of the procedure. Abdominal distension progressively subsided thereafter. Oral feeding was tolerated well, and no signs of infection or urinary complications were observed during hospitalization. The neonate remained clinically stable and was discharged home after 5 days of hospitalization. At the 6-week follow-up visit, physical examination revealed no recurrence of vaginal distension or urinary retention, and the infant remained clinically well.

Discussion

Imperforate hymen is the most common congenital anomaly of the female genital tract, resulting from failure of canalization of the vaginal plate during embryologic development [1]. Its incidence is estimated at approximately 0.05–0.1%, and it is most frequently diagnosed at puberty with primary amenorrhea and cyclic pelvic pain [2]. Neonatal presentation is uncommon, while antenatal (intrauterine) diagnosis, as observed in our case, is exceedingly rare but increasingly reported with advances in prenatal ultrasonography and fetal imaging techniques [3].

Fetal mucocolpometra results from distal vaginal obstruction with accumulation of secretions under the influence of maternal estrogens [3]. Recent literature highlights that antenatal cases are usually detected in the third trimester as a midline retrovesical cystic pelvic mass on ultrasound, sometimes with internal echoes due to mucus or debris [4, 5, 8]. These imaging characteristics are important in distinguishing mucocolpometrafrom other fetal pelvic cystic lesions.

The differential diagnosis of a fetal pelvic cyst includes ovarian cysts, mesenteric cysts, enteric duplication cysts, and urinary tract anomalies [5].Sonographically, fetal mucocolpometra typically appears as a midline, retrovesical cystic mass located posterior to the bladder and anterior to the rectum. Internal echoes or fluid-debris levels may be present due to accumulated mucus or cellular debris. In contrast, fetal ovarian cysts are usually unilateral, thin-walled, and located laterally rather than in the midline. Enteric duplication cysts commonly demonstrate a characteristic “double-wall” or “gut signature” appearance and are closely associated with bowel loops. Mesenteric cysts are often mobile, unilocular, and not specifically related to pelvic organs. Urinary tract anomalies such as megacystis or obstructive uropathy may present with a cystic pelvic structure but are typically associated with bladder enlargement, hydronephrosis, or abnormal amniotic fluid volume. Recognition of the retrovesical location, midline configuration, internal echoes, and relationship to adjacent pelvic structures can aid in distinguishing fetal mucocolpometra from other fetal pelvic cystic lesions during antenatal ultrasound evaluation [4, 5, 8]. In high-resource settings, fetal MRI is frequently used for further characterization; however, in resource-limited settings such as Ethiopia, access to advanced imaging remains limited. Therefore, diagnosis relies primarily on skilled ultrasonography and careful clinical correlation after birth. Despite these limitations, our case demonstrates that antenatal ultrasound alone can be sufficient for early suspicion and appropriate perinatal planning.

Antenatal diagnosis remains challenging in low- and middle-income countries due to limited access to routine obstetric ultrasound and trained personnel. Studies from African settings indicate that most cases are still diagnosed postnatally, often after complications develop [6]. However, recent reports from Ethiopia and similar settings show increasing detection rates of fetal anomalies due to improved ultrasound availability and training, reflecting gradual progress in maternal-fetal care services [7]. In the present case, cesarean delivery was undertaken primarily for obstetric indications rather than the fetal anomaly itself, although antenatal recognition of the lesion facilitated immediate neonatal evaluation and intervention.

One of the most clinically significant complications of mucocolpometra is compression of adjacent pelvic structures, particularly the urinary tract. Antenatally diagnosed cases have been associated with hydronephrosis and urinary obstruction due to mass effect [9, 10]. In our case, antenatal ultrasound did not demonstrate hydronephrosis or upper urinary tract dilatation despite the large pelvic mass, although the neonate subsequently developed acute urinary retention shortly after birth.

Management of imperforate hymen with mucocolpometra is simple and definitive, consisting of hymenotomy or hymenectomy to allow drainage of retained secretions [1]. Across both high-resource and low-resource settings, outcomes are excellent when early intervention is performed. In our patient, hymenectomy resulted in drainage of approximately 300 mL of fluid, with immediate clinical improvement. Recent case reports continue to confirm that prompt surgical management leads to excellent prognosis even in neonatal or antenatal presentations [7, 11]. Similarly, our patient demonstrated excellent short-term outcome, with complete resolution of urinary obstruction and no evidence of recurrence during follow-up evaluation.

From a global health perspective, this case highlights the dual reality of congenital anomaly care in resource-limited settings: diagnostic limitations alongside increasing capacity for early detection. Barriers such as limited imaging resources, delayed referral systems, and shortage of pediatric surgical expertise may negatively influence outcomes. However, our case demonstrates that early antenatal suspicion, timely referral, and simple surgical intervention can overcome these limitations and result in excellent outcomes even in settings such as Ethiopia.

Comparison with recent literature shows that although antenatal diagnosis of mucocolpometrais increasingly reported, it remains uncommon, especially in low-resource environments. Furthermore, most antenatally diagnosed cases are uncomplicated, whereas our case is notable for the development of acute urinary retention, emphasizing the clinical relevance of close postnatal monitoring even after prenatal diagnosis (Table 1).

Table 1.

Comparison of reported cases of fetal/neonatal mucocolpometra

Author (Year)	Setting	Age at Diagnosis	Antenatal Detection	Key Prenatal Findings	Postnatal Presentation	Complication	Management	Outcome
Ogunyemi (2001) [8]	High-resource	Intrauterine (22 wks)	Yes	Pelvic cyst + urinary dilation	Urinary obstruction	Hydronephrosis	Surgery	Good
Yildirim et al. (2008) [5]	High-resource	Intrauterine	Yes	Hydrocolpos	Abdominal mass	None	Hymenectomy	Good
Tseng et al. (2008) [6]	High-resource	Intrauterine	Yes	Retrovesical cyst	Pelvic mass	Hydronephrosis	Surgery	Good
Nazir et al. (2006) [3]	LMIC	Neonatal	No	Not detected	Abdominal distension	Urinary obstruction	Surgery	Good
Idrissa et al. (2010) [4]	Africa	Neonatal	No	Not detected	Abdominal distension	Intestinal obstruction	Surgery	Good
Katorza et al. (2015) [7]	High-resource	Intrauterine	Yes	Pelvic cystic mass	Mild symptoms	None	Surgery	Good
Ethiopian case (2023) [7]	Ethiopia	Intrauterine	Yes	Retrovesical cyst	Abdominal mass	Mild urinary effect	Hymenectomy	Good
Present Case (2026)	Ethiopia (resource-limited)	Intrauterine	Yes	Large cystic mass with echoes	Severe distension + bulging introitus	Acute urinary retention	Hymenectomy (300 mL)	Excellent

Conclusion

Fetal mucocolpometra secondary to imperforate hymen is a rare but significant cause of antenatally detected pelvic cystic masses. Although typically diagnosed at puberty, increasing use of prenatal ultrasonography allows earlier detection, even in resource-limited settings. This case demonstrates that antenatal ultrasound can provide sufficient diagnostic suspicion to guide timely perinatal and postnatal management. Despite limited access to advanced imaging in settings such as Ethiopia, early recognition, appropriate referral, and prompt surgical intervention can lead to excellent outcomes. The occurrence of acute urinary retention highlights the importance of close neonatal monitoring. Hymenectomy remains a simple and definitive treatment with rapid clinical improvement, underscoring the importance of considering mucocolpometra in fetal pelvic cystic lesions.

Authors' contributions

NAA: management of the patient, wrote the original draft, and revision of the final manuscript, KTY: Writing– original draft, Conceptualization, MHS: Writing– review & editing, BAA and AAZ: Writing– review & editing, Resources, ATB: Writing– review & editing. All authors reviewed the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

Data sharing is not applicable for this article as no datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical approval was not required for this case report according to institutional policy. Written informed consent was obtained from the patient’s parent for participation of this case report.This case report was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Written informed consent was obtained from the patient parent for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.

Competing interests

The authors declare no competing interests.