Hymen sparing surgery for imperforate hymen: case reports and review of literature

Hymen-saving hymenotomy of imperforate hymen in neonates and adolescents: tertiary medical center experience

Background

Imperforate hymen (IH) is the most common obstructive anomaly of female genital tract. Hymen saving has a great importance for both cultural and religious reasons. Conventional surgical treatment for this condition is cruciate incision hymenotomy or hymen-saving central annular hymenotomy (HSCAH). This study aimed to review presentations and management of neonate and adolescents with IH at one tertiary hospital over 12 year’s period. The aim also was to stress upon importance of hymen saving to our Muslim community and improve knowledge, enable targeted education, and reduce unnecessary tests and diagnostic delay for this condition.

Methods

Twenty-five patients with IH were diagnosed and treated in this retrospective cohort study over 12 years, from January 2010 till December 2021. Demographic characteristics of the patients, their symptoms and signs, investigations, type of operations, recurrence, and infections were recorded and analyzed.

Results

Saudi accounted for the majority of IH cases (88%). There were fifteen adolescents, and ten were neonates. Bulging imperforate hymen, pelvic/abdominopelvic mass, constipation, acute urine retention, abdominal discomfort, and lower abdominal distension were among the signs and symptoms. All 25 patients had HSCAH, 21 of whom had primary HSCAH and four of whom had secondary HSCAH due to recurrence. To avoid recurrence, HSCAH was performed with suturing of the inner vaginal mucosa to the exterior vestibular mucosa.

Conclusion

Early diagnosis of imperforate hymen for neonate and adolescent girls and prompt definitive HSCAH could have positive impact on treatment outcome and decrease complications and fulfill integrity of hymen as virginity of high importance in our Muslim community and other similar culture, where hymen-sparing procedure is preferred by most of these patients and families.

Unusual presentation of a septate hymen leading to a retained vaginal tampon in the urinary bladder

There is a wide range of hymenal variants which exist and usually become apparent to women during puberty. Our case describes a 16-year-old woman with a previously undiagnosed hymenal septum who presented with a retained tampon within the urinary bladder. This case report discusses a rare presentation of a hymenal variant and highlights the importance of understanding the difference in pelvic examinations in children and adolescents when compared with adults and awareness of the different hymenal variants.

Long-Term Results of an Imperforate Hymen Procedure that Leaves the Hymen Intact

Purpose of the Study

The aim of this study was to show the clinical results of postoperative evaluation of cases of imperforate hymen that presented at our center during a 21-year period.

Methods

A Foley's catheter was inserted in 74 patients of imperforate hymen who reported to the Department of Obstetrics and Gynecology, Meram Faculty of Medicine, Necmettin Erbakan University, between January 1, 1996, and December 31, 2016 with history of pelvic pain. In each case, the hymen was opened via a circular incision from the central of the distended. A Foley's catheter was inserted, and estrogen cream was prescribed for application on the hymenal structure for 14 days. The catheter was removed after 14 days.

Results

The mean age of the patients at the time of this study was 28.3 ± 2.6 years, and the mean age at diagnosis was 13.2 ± 2.5 years. Twenty-nine (96.6%) patients had experienced vaginal bleeding during their first sexual intercourse experience, and one patient (3.4%) had not. Fourteen out of the 30 married women had become pregnant, of whom nine had delivered vaginally and five had delivered via a cesarean section. After undergoing renal ultrasound, none of the patients had any apparent anomalies. Only one patient had a uterine anomaly, which was a bicornuate uterus.

Conclusion

A circular incision with insertion of Foley's catheter prevents many social problems by preserving the hymen's architecture and allowing vaginal bleeding to occur during the first sexual intercourse experience.

Imperforate hymen and leaking hematosalpinx mimicking acute appendicitis: A report of a rare case and a review of literature

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Cases of imperforate hymen (IH) that present with hemoperitoneum mimicking acute appendicitis are rare.

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Diagnosis and management can be a challenge especially in low-resource setting.

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Surgical management of both acute appendicitis and IH can be successful achieved during the same operative session.

Introduction

Cases of imperforate hymen with leaking hematosalpinx into the peritoneum are rare. We present a case of imperforate hymen mimicking acute appendicitis creating diagnostic challenges with a near miss diagnosis.

Case

A 12-year-old premenarchal female presented with severe pain that migrated from the epigastrium to the right lower quadrant. Physical examination revealed an ill-defined non-tender mass in the right lower quadrant on deep palpation, without signs of peritonitis. We made a diagnosis of an appendiceal mass and the patient underwent an appendectomy. We found approximately 200 mL of dark blood in the peritoneum and an inflamed appendix. After the appendectomy we noticed an engorged right fallopian tube leaking into the peritoneum and a bulky pelvic mass in the lower segment of the uterus. Perineal examination revealed a slightly bulging imperforate hymen. Hymenectomy was performed and 500 mL of viscous old blood was drained. On follow-up, the hymen was still open.

Discussion

Imperforate hymen commonly presents with cyclic abdominal pain and enlarging mass in premenarchal females, it is rare to present with hemoperitoneum and mimicking acute appendicitis.

Conclusion

Although rare, imperforate hymen with retrograde menstruation that causes dilatation of the vagina and uterus (i.e., hematocolpometra) is an important consideration in the differential diagnosis of abdominal pain in premenarchal females with abdominal pain. It is easily diagnosed by physical examination. However, if patient or parents refuse genital exam evaluation, imaging studies can greatly help with diagnosis. Ultrasound will show an echogenic fluid accumulation in the vagina that can extend to uterus.

Virginity-sparing management of hematocolpos with imperforate hymen: case report and literature review

Imperforate hymen results from failure of the endoderm of the urogenital sinus to completely canalize and has an incidence of 0.01% to 0.05%. This sometimes presents as a pelvic mass that compresses the bladder causing acute urinary retention. A 13-year-old girl was referred to our department with a history of primary amenorrhea, cyclic lower abdominal pain, abdominal–pelvic mass, constipation and acute urinary retention. She had an ultrasonography misdiagnosis of a huge ovarian mass before referral to our unit. On examination, the vagina was bulging and compressing the rectum. Repeat abdominal ultrasonography confirmed the diagnosis of hematometrocolpos. She underwent X-shaped hymenotomy with a favorable outcome. Diagnosis of imperforate hymen requires high suspicion index. Virginity-sparing surgery constitutes a good treatment option for cultural and religious reasons.

Imperforate Hymen: A Comprehensive Systematic Review

Imperforate hymen (IH) is an uncommon congenital anomaly of the female genital tract, with the hymen completely obstructing the vaginal opening. Despite the simple diagnosis and treatment of IH, missed or delayed diagnosis is often a clinical problem owing to its low incidence, nonspecific symptoms, or insufficient physical examination. The aim of this study is to identify the characteristics, clinical presentations, treatment modalities, and outcomes of imperforate hymen patients. In this study, a literature search of PubMed databases was performed for sources published up to 3 July 2018 for English-language studies with the term “imperforate hymen”. The literature review identified 251 citations and 155 articles (143 case reports, 12 case series) containing 253 patients who were finally included (two papers were not written in English). Among 236 postnatal patients, the mean age of the patients was 10.7 ± 4.7 years. Abdominal pain (54.2%), urinary retention (20.3%), abnormal menstruation (14.0%), dysuria (9.7%), increased urinary frequency (5.1%), severe presentation of renal failure (n = 5, 2.1%), and urinary tract infection (n = 1, 0.4%) were presented. Most patients diagnosed with the condition underwent surgical treatment (83.5%), most of whom were treated via a hymenotomy (35.2%) and hymenectomy (36.4%), and the use of prophylactic antibiotics were only used in 7 patients. There were no differences in outcomes between two surgical methods. In addition, 141 (59.7%) patients showed improvement and 5 deceased patients were not related to IH or the operation itself; Complications, such as vaginal adhesion, were only noted in 6.6% of patients. In addition, among 17 cases of newborns with a diagnosis of IH before birth, hymenectomy (n = 5, 29.4%) and hymenotomy (n = 9, 52.9%) were the main treatment modalities and showed improved prognosis in 52.9% of newborns. Because IH diagnosis is easy and postsurgical prognosis is good, clinicians should carefully examine every female patient at birth. IH should be considered regarding adolescent girls with abdominal pain, lower back pain, or urinary retention, and perform appropriate physical examinations of the genital introitus. In addition, accurate diagnosis as IH, not misdiagnosing as vaginal septum or agenesis, is important to prevent severe complications such as stricture and ascending infection.

Pelvic pain in young girls: not only dysmenorrhoea!

Imperforate hymen is the most frequent cause of haematocolpos, although it is a rare malformation (1:2000). We present two cases of young girls with cyclic abdominal pain and urinary symptoms. At gynaecological examination, they all presented imperforate hymen and ultrasound revealed significant vaginal distension. X-shaped hymenectomy was performed in all patients. The later the diagnosis of imperforate hymen, the higher the risk of complications like haematometra, haematosalpinx, haemoperitoneum and infections such as tubo-ovarian abscesses, peritonitis and endometriosis (retrograde menstruation theory).

Annular hymenotomy for imperforate hymen

AIM

Imperforate hymen is the most common obstructive anomaly of the female genital tract. Conventional surgical treatment for this condition is the cruciate incision made on the hymen. The aim of this study was to evaluate a novel technique that preserves virginity after hymenotomy using electrocautery.

METHODS

Patients diagnosed with imperforate hymen and treated with annular hymenotomy between 2009 and 2013 were included in this retrospective cohort study. Annular incision was done using electrocautery on the hymen whilst sparing the intact hymenal tissue circumferentially at least 5 mm from the base.

RESULTS

Fifteen patients were included in the study. Mean age of patients was 14.2 ± 2.2 years. The median operation time was 5 min (3-9 min). No complications occurred. During the follow-up examinations, none of the patients had hymenal closure and all had regular menstrual bleeding.

CONCLUSION

This novel technique showed complete success without any observed complication. This technique might be a good alternative for patients seeking to preserve virginity after surgery.

Microperforated hymen: a case of delayed diagnosis

Although the incidence of microperforated hymen (MH) is unclear, this hymenal subocclusive anomaly is considered a rare entity. Differently from imperforated hymen, MH may be asymptomatic until puberty when the women’s quality of life is jeopardized. Depending on the size of the microperforation, MH’s clinical features me be very similar to those found in imperforated hymen cases. However, MH may present infectious complications since the accumulated secretion retained in the vaginal canal has contact with the external environment and therefore represents a source of entry for infectious agents. The authors report a case of a 28-year-old woman who sought the gynecologist complaining of inability to have vaginal intercourse. She referred normal menses, but in fact, although regular, bleeding was filiform and was exteriorized only through the right side of the vagina. Physical examination and imaging disclosed a microperforation of the hymenal membrane at 10 o’clock position. Hymenotomy under general anesthesia was undertaken. Outcome was favorable and the patient could thenceforth have a normal life. We conclude that this anomaly may be overlooked, interfering on its incidence determination. The delayed onset of symptoms and psychological embarrassing aspects, which postpone gynecological consultation, may contribute for misdiagnoses. We call attention to a mandatory detailed anamnesis and thorough physical examination to diagnose this anomaly before the puberty, when complications are less frequent and treatment is advisable.

A rare non urologic cause for urinary retention; report of 2 cases

Although Imperforate hymen is a rare condition, it is the most common obstructive anomaly of the female genital tract. The early diagnosis of this condition requires a high index of suspicion in newborns and in females without a history of menarche. Hydronephrosis is a known but rare complication of an imperforate hymen. Hereby we preset 2 cases of premenstrual adolescent with urinary retention and bilateral moderate to severe hydroureteronephrosis.

Imperforate Hymen - a rare cause of acute abdominal pain and tenesmus: case report and review of the literature

Imperforate hymen is a rare condition that presents with amenorrhea, cyclical abdominal pains and urine retention among pubertal girls. A 14 year old girl with imperforate hymen underwent hymenotomy for hematocolpometra, having presented with abdominal pains and tenesmus.

Virginity sparing surgery for imperforate hymen: report of two cases and review of literature

Imperforate Hymen (IH), an obstructive congenital anomaly of the female genital tract, is seen in 1 in 2000 female births. Treatment of IH is hymenotomy or hymenectomy. Different types of incisions are mentioned in the literature. We reported two cases of IH with different clinical presentations and described a simple virginity preserving and socially acceptable procedure to protect the virginity of the patient. In cultures and religions where the destruction of the hymen is a social problem in unmarried girls, virginity sparing surgery should be chosen in gynecological practice. Here we described a simple procedure without need for prophylactic antibiotic treatment and foley catheter application to form an intact annular hymen in two cases.

Müllerian duct anomalies: successful endoscopic management of a hybrid bicornuate/septate variety

STUDY OBJECTIVE

To highlight the coexistence of uterine septum in cases diagnosed as bicornuate uterus on basis of the external shape of uterine fundus.

STUDY DESIGN

Case report with description of the technique.

SETTING

Women's Health Assiut University Hospital.

PARTICIPANTS

An adolescent female with progressive pains dating since menarche.

INTERVENTIONS

Hysteroscopic resection under laparoscopic monitoring through an intact hymen.

MAIN OUTCOME MEASURE

Operative time, complications, postoperative abdominal pain, appearance of the uterine cavity

RESULTS

A patient with a septate uterus with a fundal depression and hemiuterine obstruction underwent hysteroscopic resection under laparoscopic monitoring. Laparoscopy was beneficial in diagnosis and treatment of associated pathology and monitoring the hysteroscopic procedure. Hysteroscopic metroplasty was performed and resulted in unification of the lower two thirds of the uterus. Dysmenorrhea was dramatically improved after the procedure. Subsequent office hysteroscopy confirmed restoration of a unified lower uterine corpus anatomy mimic to the original bicornuate state.

CONCLUSIONS

External fundal depression which characterizes bicornuate uterus was associated with a septate uterus with hemi uterine obstruction. This report demonstrates the coexistence of the two anomalies. Endoscopic management of this patient was safe and successful.