Imperforate Hymen Treatment & Management

After initial presentation and suspected diagnosis of an obstructive anomaly in an adolescent, the use of continually administered oral contraceptive to suppress menses allows symptomatic relief and essential time needed to obtain further diagnostic studies. In addition, the use of nonsteroidal anti-inflammatory drugs can provide pain relief; narcotic analgesics may be required.

The timing of surgical therapy is based on the presence of symptoms. A symptomatic mucocele manifesting in a neonate should be treated expediently but is not considered a surgical emergency. If an asymptomatic patient is diagnosed with an imperforate hymen without a mucocele during childhood, this patient can be treated after the onset of puberty and prior to the development of a hematocolpos or hematometra. The presence of estrogen stimulation in puberty facilitates surgical repair and healing.

While expedient treatment of an imperforate hymen is appropriate when it manifests in an adolescent with hematometra and hematocolpos, the procedure should not be performed on an emergent basis without an appropriate preoperative evaluation. Surgical correction should be definitive.

Important: A diagnostic technique (eg, needle aspiration in the office setting) should not be used to confirm the diagnosis because this can allow the introduction of bacteria into what had been a sterile hematocolpos or hematometra, setting the stage for pyocolpos or pyometrium, with the potential to adversely affect fertility.

The patient and family should be prepared for the surgical procedure, which can be described as a hymenotomy (opening up the hymenal membrane). Cultural considerations regarding the importance of a certain appearance of the hymen, as an indication of virginity, and the meaning of the term virginity, may need to be discussed with this condition and its surgical repair. Surgical correction of an imperforate hymen is a medical necessity. While procedures that involve a small incision to “preserve virginity” have been described, subsequent restenosis can occur, leading to unnecessary pain and the need for a repeat procedure. Cultural views, while respected, should not preclude the performance of the medically appropriate surgery.

Some authors advocate concurrent diagnostic and possible operative laparoscopy in a young woman presenting with hematocolpos, because pelvic adhesions and intra-abdominal endometriosis may be present. The presence of endometriosis in young women with obstructing anomalies has been discussed in support of the theory of retrograde menstruation. ^[29] Anecdotal evidence suggests that endometriosis and pelvic adhesions associated with obstructive anomalies spontaneously resolve once the obstruction is treated. In one series, endometriosis was not seen among young women in whom a subsequent laparoscopy was performed. ^[30] The potential risks and benefits of this component of the surgical procedure should be explained to the young woman and her parents in an effort to facilitate informed decision-making and consent.

The objective of a hymenotomy procedure is to open the hymenal membrane in such a way as to leave a normally patent vaginal orifice that does not scar. Infiltration of the membrane prior to the incision with a long-acting local anesthetic (eg, 0.25% bupivacaine) provides preemptive analgesia.

If a large hematocolpos is present, it typically is under pressure, and the surgeon should be prepared to dodge the pressure-driven stream of thickened old blood (typically the consistency and color of chocolate syrup) and to evacuate the hematocolpos and hematometra using one or more suction cannulae. The revision of the initial incision in the hymenal membrane must await the evacuation of the hematocolpos.

The hymenal orifice is enlarged using a circular incision following the lines of the normal annular hymenal configuration. Alternatively, a cruciate incision along the diagonal diameters of the hymen, rather than anterior to posterior, avoids extension injury to the urethra and can be enlarged by removal of excess hymenal tissue. In either approach, hemostasis is required using interrupted stitches with fine absorbable suture (eg, 4-0 polyglycolic acid suture).

Recent articles address cultural concerns with a surgical modification of the classic hymenectomy/hymenotomy that the authors tout to preserve virginity.

Basaran et al reported on successful treatment of 2 cases of imperforate hymen using a simple vertical incision, with oblique sutures to prevent refusion. ^[31] The technique of making a small central incision with the placement of a Foley catheter, which is then left in place for 2 weeks, accompanied by the application of estrogen cream was described as less invasive. The adolescents’ perspective on the invasiveness of having to wear a Foley catheter in their vaginas for 2 weeks was not described. ^[32] The follow-up on this case series further describes that this technique required a repeat surgical procedure in a small number of cases.

Acar et al subsequently reported on the successful use of this technique in 65 women. ^[33] The current author of this article does not recommend this technique, as efforts to create a small hymenal opening withpersistent hymenal tissue may lead to stenosis with reaccumulation of hematocolpos and/or subsequent laceration at the time of first intercourse due to tissue rigidity from scarring. The concept that the hymen is "preserved" when a central incision is made, compared with the "destruction" of the hymen with a cruciate incision might be considered a semantic stretch by some and disingenuous by others. Nevertheless, cultural views should be addressed and considered sensitively.

The application of 2% lidocaine jelly to the vaginal introitus is suggested to provide postoperative analgesia. A running interlocking suture is discouraged to minimize circumferential scarring. Relaxing incisions (a radial incision in the hymen that is closed horizontally) may be helpful for ensuring adequate vaginal diameter and minimizing the need for a repeat procedure due to scarring.

Aspiration or puncture of the mucocolpos or hematocolpos without definitive enlargement of the vaginal orifice should be avoided because a pyocolpos or ascending infection may develop.

The surgical procedure of hymenotomy and evacuation of hematocolpos is performed in an outpatient setting. The patient and family should be instructed to expect continued drainage of dark, thick, old blood for several days to a week after the procedure. Mild cramping may occur as the hematometra resolves and evacuates.

Ibuprofen or other NSAIDs may be prescribed for the uterine cramping. Topical lidocaine jelly is recommended for the vaginal orifice. The patient is instructed to apply the jelly sparingly to the area a few minutes prior to urinating and as needed for soreness. Baths are not prohibited and, in fact, may provide some soothing comfort and help keep the area clean. The use of a hair dryer on the cool setting to dry the area avoids the abrasion of towel drying.

Topically applied estrogen cream has been shown to improve vascularity and promote healing of mucosal tissue in animal studies. Application of estrogen cream to the surgical repair site may be recommended for use on a daily basis for the first 2 weeks after the procedure is performed.

Patients and/or parents are instructed to call the physician's office if the patient experiences severe cramping unrelieved by ibuprofen or develops a fever. The family should also be informed that all sutures are absorbable and dissolve, sometimes with the observation of the ends of the suture as small threads.

Schedule a postoperative office visit 1-2 weeks after the surgical procedure. At that visit, inspect the area for signs of inflammation or infection. Topical lidocaine jelly facilitates the examination and helps relieve the patient's anxiety. A 3- to 6-month course (or longer) of menstrual suppression with continuous oral contraceptive pills may be indicated and should be discussed at the postoperative visit.

If a laparoscopic procedure was performed and demonstrated endometriosis, the potential benefits of using a gonadotropin-releasing hormone agonist and subsequent hormonal suppression must be weighed against the increased risk of scarring due to a hypoestrogenic state.

Infectious complications to the procedure are rare, and prophylactic antibiotics are not required. However, data on which to base this decision are sparse. A careful surgical technique with adequate opening of the vaginal orifice prevents stenosis and reaccumulation of the hematocolpos or mucocele, which carries a risk for pelvic inflammatory disease with pyocolpos, pyometra, endomyometritis, salpingitis, or tubo-ovarian abscess. The development of pelvic inflammatory disease clearly has implications and risks for subsequent infertility, pelvic pain, and ectopic pregnancy.

Injury to the adjacent urethra, rectum, or bladder is possible if the anatomic defect is not defined clearly and if the actual condition is vaginal agenesis or a complicated müllerian abnormality rather than a simple imperforate hymen.

Clinical outcome and prognosis generally are good; one study found pregnancy success more likely following surgical correction of an imperforate hymen than following repair of a complete transverse septum. ^[34] The retrograde menses and endometriosis associated with an obstructed outflow tract have been postulated to behave in a more benign manner than spontaneously occurring endometriosis without obstruction, although this assertion is based primarily on anecdotal clinical experience rather than specific outcome reports or evidence.

Management of an imperforate hymen has essentially remained unchanged from the initial descriptions of the procedure; thus, improvements in surgical therapy are not expected. Small variations in technique are described, such as the use of laser or electrosurgery rather than a scalpel to incise the hymenal membrane. The advantages of this technical modification have not been demonstrated.

Typically, the condition is not diagnosed until postmenarche, when the young woman presents with cyclic abdominal pain, pressure symptoms, and often with an abdominal and/or pelvic mass representing a large hematometra and hematocolpos. This morbidity can potentially be avoided if clinicians (eg, pediatricians, obstetrician, gynecologists, family physicians) are trained to examine the genitalia of newborns and young children. Timing of the surgical correction could then be planned more appropriately; while this is not a controversial recommendation, implementation is far from universal in clinical practice. The future should hold a better prognosis for young girls if their gynecologic health is more appropriately addressed in this manner.