Imperforate Hymen (2)

Treatment

Medical Therapy

After initial presentation and suspected diagnosis of an obstructive anomaly, the use of continually-administered oral contraceptive pills to suppress menses allows symptomatic relief and essential time needed to obtain further diagnostic studies. In addition, the use of nonsteroidal anti-inflammatories can provide pain relief.

Surgical Therapy

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. 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.

Preoperative Details

The patient and family should be prepared for the surgical procedure, which can be described as a hymenotomy (opening up the hymenal membrane). 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. Anecdotal evidence suggests that endometriosis and pelvic adhesions associated with obstructive anomalies spontaneously resolve once the obstruction is treated. Thus, other authors do not believe that laparoscopy is indicated. 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.

Intraoperative Details

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. Often, the revision of the 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 injury to the urethra and can be enlarged by removal of excess hymenal tissue. In either approach, the vaginal epithelium is then sutured to the hymenal ring using interrupted stitches with fine absorbable suture (eg, 4-0 polyglycolic acid suture). The application of 2% lidocaine jelly to the suture line 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.

Dane et al present a new technique where an oval-centralized closure around an insufflated Foley catheter (10 cm³) is left in place for 2 weeks.³ This was used to prevent hymenal architecture destruction, thus creating circumferential stenosis around the Foley catheter. The authors of this article do not recommend this technique, as efforts to create a small hymenal opening with persistent hymenal tissue could lead to stenosis with reaccumulation of hematocolpos and/or subsequent laceration at the time of first intercourse due to tissue rigidity from scarring.

Postoperative Details

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.

Follow-up

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.

Complications

Infectious complications to the procedure are rare, and prophylactic antibiotics are not required. However, data on which to base this decision are few. 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.