Pediatric Imperforate Hymen Treatment & Management

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 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.

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.

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.

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.

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.