Pediatric Imperforate Hymen Treatment & Management

Updated: Jun 23, 2020
  • Author: Amulya K Saxena, MD, PhD, DSc, FRCS(Glasg); Chief Editor: Andrea L Zuckerman, MD  more...
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Treatment

Approach Considerations

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. [23]

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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 a 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.

Procedural 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 distinctions between the conditions are 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 of making the incision have been discussed. The incision on the hymenal membrane can be made with a scalpel or with an electrocautery. After the hymenal edges are inspected, the incision is completed, and excess tissue can be resected further, if necessary. 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 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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Complications

Incomplete drainage and failure of marsupialization may result in recurrent obstruction and, potentially, an ascending pelvic infection. [24] Although prophylactic antibiotics are not recommended, postoperative fever or abdominal pain must be evaluated and treated promptly. Potential complications include endometritis, salpingitis, or tubo-ovarian 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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Long-Term Monitoring

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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