Pediatric Imperforate Hymen Treatment & Management

  • Author: Martin I Herman, MD, FACEP, FAAP; Chief Editor: Andrea L Zuckerman, MD   more...
 
Updated: Oct 2, 2009
 

Medical Therapy

Medical therapy has no role in the management of imperforate hymen because the retained secretions are typically sterile. In addition, the hymen must be surgically resected to relieve the obstruction.

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Surgical Therapy

Surgical intervention for imperforate hymen should require only one definitive procedure to evacuate the retained secretions and to ensure the maintenance of patency. Simple drainage of the material confined beyond the hymen is contraindicated because it does not allow for adequate drainage of the thick fluid, is not definitive, and increases the risk of infection (pyometras).

Two techniques are most commonly advocated: simple incision and small excision of the membrane. Simple incision of the hymen may be associated with postoperative stenosis with strictures, and it is not the method generally preferred at many centers. Use of an X -shaped incision ought to be the method of choice.

An elliptical excision of the membrane is performed close to the hymenal ring, using needle-tip cautery, followed by evacuation of the obstructed material. This technique is considered to be most effective in definitive treatment. Avoid compressing the uterus and fallopian tubes to speed evacuation of the trapped contents after the hymen is incised.

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Preoperative Details

After the appropriate diagnostic studies are performed, an outpatient procedure to be performed under general anesthesia is scheduled.

Distinguishing an imperforate hymen from a transverse vaginal septum is important because the latter requires a relatively extensive procedure to reconstruct a functional vaginal tract and because it has implications in terms of reduced fertility. The clinical and radiologic distinction between the conditions is based on the presence of a thin distal membrane in an imperforate hymen versus a thick proximal septum in a transverse vaginal septum. Transverse vaginal septum cannot be treated with a cruciate incision, and imperforate hymen does not require a procedure more extensive than hymenotomy. In contrast to imperforate hymen, transverse vaginal septum poses some concern about future pregnancy outcomes.

The retained secretions are typically sterile unless previous manipulation (eg, needle aspiration) has resulted in infection. Therefore, prophylactic antibiotics are not usually required.

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Intraoperative Details

The urethra should be identified first, and a catheter can be placed if the patient has had urinary obstructive symptoms. Various ways to make the incision have been discussed. The incision on the hymenal membrane can be made with a scalpel or with an electrocautery device. After the hymenal edges are inspected, the incision is completed, and excess tissue can be resected further, if needed. To prevent recurrence, absorbable suture is used to perform formal marsupialization by anchoring the incised membrane to the vaginal wall in several locations. Local anesthetic can be injected into the edges of the hymen to achieve postoperative analgesia. As an alternative, lidocaine jelly can be applied topically.

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Postoperative Details

For postoperative analgesia, acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are usually sufficient. The patient should anticipate the continued evacuation of retained material for a week. Uterine and/or vaginal cramping should also be anticipated and treated with NSAIDs. No further radiologic or surgical evaluation is necessary after a normal menstrual cycle is established.

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Follow-up

Postoperative follow-up is deferred for 6-8 weeks to allow the patient to reestablish a menstrual cycle. Findings on evaluation of the patient's menstrual cycle determine the need for further evaluation.

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Complications

Incomplete drainage and failure of marsupialization may result in recurrent obstruction and, potentially, an ascending pelvic infection. Although prophylactic antibiotics are not recommended, postoperative fever or abdominal pain must be evaluated and treated promptly. Potential complications include endometritis, salpingitis, or tuboovarian abscess—any of which can affect subsequent fertility.

Concern for secondary endometriosis resulting from retrograde menstruation is sufficient for some authors to advocate irrigation of the peritoneal cavity by using a laparoscopic technique. No definitive information regarding the frequency of this condition is available, and most surgeons and gynecologists avoid a concomitant intra-abdominal procedure. Compared with primary endometriosis, secondary endometriosis generally does not become a chronic condition that impairs fertility. Endometriosis is not a uniformly chronic consequence of hematometrocolpos secondary to imperforate hymen. Retrograde menstruation can occur with secondary endometriosis as a result of vaginal outflow obstruction. However, this condition is believed to be self-limited after the primary condition is corrected.

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Outcome and Prognosis

Outcome after repair of imperforate hymen is excellent. If findings on an appropriate preoperative evaluation are normal, a patient can be reassured that her genital tract is otherwise normal. The incidence of dyspareunia is also low.

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Future and Controversies

Thorough genitourinary examination is essential in girls of all ages from birth through the onset of menarche. If primary amenorrhea is identified or if other structural abnormalities are noted, proper management is essential. By performing these examinations and by promptly diagnosing and treating imperforate hymen, primary care practitioners can help prevent the obstructive symptoms of imperforate hymen and its potential high-risk complications due to delayed care.[11] After appropriate evaluation is completed to exclude complicated obstruction of the vaginal tract outflow, management of imperforate hymen is straightforward, and the long-term complications are minimal.

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Contributor Information and Disclosures
Author

Martin I Herman, MD, FACEP, FAAP  Professor, Department of Pediatrics, Division of Critical Care and Emergency Medicine, University of Tennessee Health Sciences Center; President, Pediatric Emergency Services Specialists, PC; Assistant Medical Director of Emergency Services, LeBonheur Children's Medical Center

Martin I Herman, MD, FACEP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, and Tennessee Medical Association

Disclosure: Challenger COrporation Ownership interest Board membership

Coauthor(s)

Amulya K Saxena, MD, PhD  Associate Professor, Department of Pediatric and Adolescent Surgery, Medical University of Graz, Austria

Amulya K Saxena, MD, PhD is a member of the following medical societies: Austrian Society for Pediatric and Adolescent Surgery, European Pediatric Surgeons Association, German Society of Pediatric Surgery, German Society of Surgery, International Pediatric Endosurgery Group, and Tissue Engineering and Regenerative Medicine International Society (TERMIS)

Disclosure: Nothing to disclose.

Elizabeth A Paton, RN, MSN, NP  CS Nurse Practitioner, Department of Emergency Medicine, Le Bonheur Children's Medical Center

Elizabeth A Paton, RN, MSN, NP is a member of the following medical societies: American Academy of Nurse Practitioners, American Academy of Pediatrics, Emergency Nurses Association, and Sigma Theta Tau International

Disclosure: Nothing to disclose.

Specialty Editor Board

Elizabeth Alderman, MD  Director of Fellowship Training Program, Director, Adolescent Ambulatory Service, Professor, Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Merck Honoraria Speaking and teaching

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

H Biemann Othersen Jr, MD  Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Andrea L Zuckerman, MD  Assistant Professor of Obstetrics/Gynecology and Pediatrics, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center

Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Nothing to disclose.

References
  1. Wall EM, Stone B, Klein BL. Imperforate hymen: a not-so-hidden diagnosis. Am J Emerg Med. May 2003;21(3):249-50. [Medline].

  2. Goodyear-Smith FA, Laidlaw TM. What is an 'intact' hymen? A critique of the literature. Med Sci Law. Oct 1998;38(4):289-300. [Medline].

  3. Berenson AB. The prepubertal genital exam: what is normal and abnormal. Curr Opin Obstet Gynecol. Dec 1994;6(6):526-30. [Medline].

  4. Congenital abnormalities of the female reproductive tract. In: Mishell DR, Stenchever MA, Droegemueller W, et al, eds. Comprehensive Gynecology. 3rd ed. St Louis, Mo: Mosby-Year Book; 1997.

  5. Stelling JR, Gray MR, Davis AJ, et al. Dominant transmission of imperforate hymen. Fertil Steril. Dec 2000;74(6):1241-4. [Medline].

  6. Hewitt G. Examining pediatric and adolescent gynecology patients. J Pediatr Adolesc Gynecol. Aug 2003;16(4):257-8. [Medline].

  7. Nazir Z, Rizvi RM, Qureshi RN, Khan ZS, Khan Z. Congenital vaginal obstructions: varied presentation and outcome. Pediatr Surg Int. Sep 2006;22(9):749-53. [Medline].

  8. Winderl LM, Silverman RK. Prenatal diagnosis of congenital imperforate hymen. Obstet Gynecol. May 1995;85(5 Pt 2):857-60. [Medline].

  9. Ogunyemi D. Prenatal sonographic diagnosis of bladder outlet obstruction caused by a ureterocele associated with hydrocolpos and imperforate hymen. Am J Perinatol. 2001;18(1):15-21. [Medline].

  10. Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg. Oct 1999;34(10):1555-6. [Medline].

  11. Posner JC, Spandorfer PR. Early detection of imperforate hymen prevents morbidity from delays in diagnosis. Pediatrics. Apr 2005;115(4):1008-12. [Medline]. [Full Text].

  12. Buick RG, Chowdhary SK. Backache: a rare diagnosis and unusual complication. Pediatr Surg Int. 1999;15(8):586-7. [Medline].

  13. Croak A, Gebhard J. Congenital abnormalities of the female urogenital tract. J Pelvic Med Surg. 2005;11(4):165-81.

  14. El-Messidi A, Fleming NA. Congenital imperforate hymen and its life-threatening consequences in the neonatal period. J Pediatr Adolesc Gynecol. Apr 2006;19(2):99-103. [Medline].

  15. Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings. J Pediatr Adolesc Gynecol. Feb 2002;15(1):27-35. [Medline].

  16. Master-Hunter T, Heiman DL. Amenorrhea: evaluation and treatment. Am Fam Physician. Apr 15 2006;73(8):1374-82. [Medline].

  17. Rock JA, Zacur HA, Dlugi AM, et al. Pregnancy success following surgical correction of imperforate hymen and complete transverse vaginal septum. Obstet Gynecol. Apr 1982;59(4):448-51. [Medline].

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Embryologic origin of the hymenal membrane.
Neonate with a bulging perineum due to mucocolpos.
Sagittal sonogram in an adolescent with imperforate hymen shows a distended vagina and uterus.
Transverse sonogram in an adolescent with imperforate hymen shows a distended vagina immediately posterior to the bladder.
 
 
 
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