Pediatric Imperforate Hymen Treatment & Management
- Author: Amulya K Saxena, MD, PhD; Chief Editor: Andrea L Zuckerman, MD more...
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.
Surgical intervention is most often required in the adolescent who presents with symptomatic vaginal outflow obstruction. Establishing a patent hymen is necessary to eliminate pain and discomfort and to establish a functional genital tract. Avoidance of persistent obstruction preserves the patient's fertility by reducing the risk of secondary endometriosis.
In the infant with a bulging hymenal membrane due to the effects of maternal estrogen, the diagnosis is evident, and surgical therapy can be undertaken promptly.
On occasion, the diagnosis is made serendipitously in asymptomatic premenarchal girls. Intervention can justifiably be delayed until they approach menarche. This delay ensures that a previously nonvisualized orifice, such as an anterior crescentic opening, is absent. The presence of such an opening may obviate surgical intervention.
Surgical intervention is contraindicated only when the evaluating physician is unfamiliar with the condition and the differential diagnoses and when imaging modalities that help in excluding complicated anomalies of vaginal development are unavailable. Because evacuation of hematocolpos rarely requires emergency intervention, referral to a tertiary care center should be considered.
Office CO2 laser therapy has been studied as a means of treating imperforate hymen. In an observational study (N=49) assessing this approach for managing various benign pathologies and congenital malformations of the female lower genital tract, Frega et al reported rapid, excellent healing among the 13 patients with imperforate hymen, with no wound infection, scarring, stenosis, recurrence, or need for reintervention.
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.
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.
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.
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.
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.
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.
Ameh EA, Mshelbwala PM, Ameh N. Congenital vaginal obstruction in neonates and infants: recognition and management. J Pediatr Adolesc Gynecol. 2011 Apr. 24(2):74-8. [Medline].
Congenital abnormalities of the female reproductive tract. Mishell DR, Stenchever MA, Droegemueller W, et al, eds. Comprehensive Gynecology. 3rd ed. St Louis, Mo: Mosby-Year Book; 1997.
Wall EM, Stone B, Klein BL. Imperforate hymen: a not-so-hidden diagnosis. Am J Emerg Med. 2003 May. 21(3):249-50. [Medline].
Goodyear-Smith FA, Laidlaw TM. What is an 'intact' hymen? A critique of the literature. Med Sci Law. 1998 Oct. 38(4):289-300. [Medline].
Berenson AB. The prepubertal genital exam: what is normal and abnormal. Curr Opin Obstet Gynecol. 1994 Dec. 6(6):526-30. [Medline].
Stelling JR, Gray MR, Davis AJ, et al. Dominant transmission of imperforate hymen. Fertil Steril. 2000 Dec. 74(6):1241-4. [Medline].
Domany E, Gilad O, Shwarz M, Vulfsons S, Garty BZ. Imperforate hymen presenting as chronic low back pain. Pediatrics. 2013 Sep. 132(3):e768-70. [Medline].
Hewitt G. Examining pediatric and adolescent gynecology patients. J Pediatr Adolesc Gynecol. 2003 Aug. 16(4):257-8. [Medline].
Nazir Z, Rizvi RM, Qureshi RN, Khan ZS, Khan Z. Congenital vaginal obstructions: varied presentation and outcome. Pediatr Surg Int. 2006 Sep. 22(9):749-53. [Medline].
Eksioglu AS, Maden HA, Cinar G, Tasci Yildiz Y. Imperforate hymen causing bilateral hydroureteronephrosis in an infant with bicornuate uterus. Case Rep Urol. 2012. 2012:102683. [Medline]. [Full Text].
Nagai K, Murakami Y, Nagatani K, Nakahashi N, Hayashi M, Higaki T, et al. Life-threatening acute renal failure due to imperforate hymen in an infant. Pediatr Int. 2012 Apr. 54(2):280-2. [Medline].
Winderl LM, Silverman RK. Prenatal diagnosis of congenital imperforate hymen. Obstet Gynecol. 1995 May. 85(5 Pt 2):857-60. [Medline].
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].
Sak ME, Evsen MS, Soydinc HE, Sak S, Yalinkaya A. Imperforate hymen with elevated serum CA 125 and CA 19-9 levels. J Reprod Med. 2013 Jan-Feb. 58(1-2):47-50. [Medline].
Ayaz UY, Dilli A, Api A. Ultrasonographic diagnosis of congenital hydrometrocolpos in prenatal and newborn period: a case report. Med Ultrason. 2011 Sep. 13(3):234-6. [Medline].
Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg. 1999 Oct. 34(10):1555-6. [Medline].
Frega A, Verrone A, Schimberni M, Manzara F, Ralli E, Catalano A, et al. Feasibility of office CO2 laser surgery in patients affected by benign pathologies and congenital malformations of female lower genital tract. Eur Rev Med Pharmacol Sci. 2015. 19 (14):2528-36. [Medline]. [Full Text].