Imperforate Hymen in a Teenage Girl: A Case Report

Abstract

Background: Imperforate hymen is the most common congenital obstructive anomaly of the female reproductive outflow tract. The incidence of imperforate hymen is 0.01% - 0.1% of all newborn females.
Aim: The aim of the report is to present this uncommon clinical condition and create awareness on the presentation and management modalities.
Case Report: Miss GS a 14 year old secondary school student with cyclical lower abdominal pain and absence of menstruation of one year duration. Examination revealed an 18 week uterine size and an imperforate hymen. She had hymenotomy in theatre under general anaesthesia with drainage of haematometria and haematocolpos. She was discharged in good clinical state. Conclusion: Imperforate hymen is a rare clinical condition. A high index of suspicion in pubertal girls with cyclical abdominal pains with absence of menstruation should be entertained. A favourable outcome follows prompt diagnosis and effective treatment.
Keywords: Imperforate, Hymen, Cyclical, Hymenotomy, Incision

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*Corresponding Author
kokagua[at]hotmaildotcom
Receiving Date: May 25, 2020
Acceptance Date: June 07, 2020
Publication Date: June 11, 2020
Imperforate Hymen in a Teenage Girl: A Case Report
Eli S1,2, Okagua KE2*, Kalio DGB2 and Briggs NCT3
1Mother and Baby Care Global Foundation (Mother, Baby and Adolescent Care Global Foundation),
Nigeria
*2Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port
Harcourt, Rivers State, Pin code: 500241, Nigeria
3Department of Community Medicine, Rivers State University, Port Harcourt, Rivers State, Pin code:
500241, Nigeria
INTRODUCTION
Imperforate hymen is a rare congenital anomaly where a hymen without an opening completely
obstructs the vagina thereby preventing menstrual blood to flow out [1]. It is the most common
congenital obstructive anomaly of the female reproductive outflow tract [2]. The incidence of
imperforate hymen is 0.5% - 1% of all newborn female [2]. There are variations in the embryonic
development of the hymen, this may be due to fenestration, septa bands as well as
microperforations [3]. In addition, there is anterior displacement and differentiation in the rigidity
with or without elasticity of the hymenal tissue [4]. As part of physical examination the inspection of
the neonate or child’s external genitalia and anus is necessary [5]. The pediatrician should be part of
the physical examination by the obstetrician [6]. Variations of this hymenal differentiation can be
done in the delivery room by the obstetrician taking note of the relationship between the structure
caused by oestrogen [4,5]. Due to the effect of oestrogen on the neonate or child the labia majora
are plump, the hymen is elastic and fimbriated with the mucosal surfaces often pale [5]. Imperforate
hymen has been diagnosed with prenatal ultrasound scan together with bladder outlet obstruction
due to hydrocolpos and mucocolpos. Despite recommendation for the inspection of the external
genitalia during the neonatal and early childhood period, variations in hymenal anatomy are missed
until menarche [6]. Hymenotomy are often postponed to pubertal
period due to scaring in early childhood because low levels of
endogenous estrogen [5].
From the historical perspective, researchers have revealed the
dimensions of the hymenal opening to be approximately 1 mm for each
ABSTRACT
Background: Imperforate hymen is the most common congenital obstructive anomaly of the female
reproductive outflow tract. The incidence of imperforate hymen is 0.01% - 0.1% of all newborn females. Aim: The
aim of the report is to present this uncommon clinical condition and create awareness on the presentation and
management modalities. Case Report: Miss GS a 14 year old secondary school student with cyclical lower
abdominal pain and absence of menstruation of one year duration. Examination revealed an 18 week uterine size
and an imperforate hymen. She had hymenotomy in theatre under general anaesthesia with drainage of
haematometria and haematocolpos. She was discharged in good clinical state. Conclusion: Imperforate hymen is a
rare clinical condition. A high index of suspicion in pubertal girls with cyclical abdominal pains with absence of
menstruation should be entertained. A favourable outcome follows prompt diagnosis and effective treatment.
Keywords: Imperforate, Hymen, Cyclical, Hymenotomy, Incision

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International Journal of Innovative Medicine and Health Science, Volume 12, 2020, 147-150
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year of age ruling out neonatal period when maternal estrogen lead to early elasticity [4,5].
However, in prepubertal age, a remarkable widening referencing this guideline may be suggestive of
possible child sexual abuse. The draw back to this guide the type of device to be used, the degree of
child relaxation, the position of the examination and the examiner [5]. Specialist in child sexual abuse
assessors have used colposcopy and aided visual examination to examine the morphology and
integrity of the hymenal ring [4,5]. The diagnosis of imperforate hymen is seldom made in infancy.
The infant may have bulging, yellow-grey mugs at or beyond the introitus [4,5]. The presence of an
abdominal mass has been described in association with urinary obstruction [4]. Most often a
planned hymenotomy during puberty is a wise course of action in majority of cases diagnosed in
infancy or childhood; assuming there are no urinary symptoms or obstruction [6]. In the adolescent
age group, the patient may often time present with cyclical abdominal pain, urinary retention and
constipation. The diagnosis may be missed in some instances. Surgery is the presence of adequate
estrogenization avoids the scaring and potential need for a repeat surgery that can occur when
surgery is performed on the un-estrogenized hymen and vagina [4,5]. Although these adolescents
most adolescents most often than not present as an emergency with acute abdominal pain, this
condition clinically should not be managed as an acute emergency [5]. The pelvic anatomy should
clearly be defined with the use of an appropriate image technique [4]. The surgery should be
planned with the most skilled and experienced gynaecologist to perform the operation as a
scheduled rather than an emergency [4,5]. This case report discusses the clinical presentation and
management of 14 year old miss GS, who presented with cyclical abdominal pain and absence of
menstruation of one year duration physical examination, revealed imperforate abdominal mass of
14 week size and an imperforate hymen she subsequently had a planned hymenotomy done for her.
CASE REPORT
Miss GS a 14 year old secondary school student with cyclical lower abdominal pain and absence of
menstruation of one year duration. Examination revealed an 18 week uterine size and an
imperforate hymen. She had a cruciate incision in theatre under general anaesthesia with drainage
of haematometria and haematocolpos. She was discharged in good clinical state. On Physical
examination she had abdomino-pelvic mass equivalent to 18 weeks gestation. Vaginal inspection
revealed bulging blue membrane. A mass was palpated on rectal examination and her hymen was
intact. A clinical diagnosis of imperforate hymen was made. Investigations requested for were;
abdominal/pelvic ultrasound scans which revealed abdomino-pelvic mass of 14 cm by 14 cm, a full
blood count of which the haemoglobin concentration and white blood cells were within normal
range, electrolyte/urea/creatinine were also within normal range and her urine
microscopy/culture/sensitivity yielded no growth after 48 hours. Her managing team was made up
of gynaecologists, paediatricians and psychologist. Mother and child were counseled. She had
hymenotomy of the imperforate hymen in theatre under regional anaesthesia with subsequent
drainage of the haematometra and haematocolpos. She had antibiotics cover and analgesia post-
operatively which was uneventful. She was discharged on the first post-operative day in good clinical
state. She did well on her follow-up visit with subsequent regular and normal menstrual flow.
DISCUSSION
This case report highlights the presentation and management of Miss GS 14 year old adolescent who
had hymenotomy of an imperforate hymen and subsequent drainage of haematometra and
haematocolpos. She did well post-operatively and in her subsequent follow-up period. Her
management was multidisciplinary involving the gynaecologist, paediatrician, clinical psychologist
and paediatric nurses. Our patient misses GS presented with cyclical abdominal pain, haematometra
and haematocolpos. The prevalence of imperforate hymen is between 0.014 – 0.1% [1]. The
prevalence varies from region to region as revealed by myriads of authors across the globe [1,2].
Apart from the clinical features of our patient highlighted above other clinical presentations of

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imperforate hymen are hydrocolpos and mucocolpos coexisting with bladder obstruction diagnosed
with prenatal ultra sound [9,11]. Some authorities have revealed rare presentations of imperforate
hymen making diagnosis difficult or missed [1,5-8]. Some of these rare clinical features of
imperforate hymen are haematosalpinges, intra-abdominal endometriosis, hydroureter,
hydronephrosis, renal failure, acute abdominal pain and tenesmus [1,2,8].
The diagnosis of imperforate hymen is made from history, physical examination an investigations.
However, in infancy diagnosis is made prenatally by the use ultrasound scan [1,11]. In infancy and
early childhood diagnosis of imperforate hymen is often missed [8]. Our patient miss GS, who
presented in her early adolescent years with complaints of cyclical abdominal pains and absence of
menstruation. Her physical vaginal examination revealed imperforate hymen. This was confirmed
with abdominal ultrasound scan which showed the presence of haematocolpos and haematometra.
Other investigation which may help in the diagnosis of imperforate hymen are a transrectal or
transperineal ultrasound scan [1,7,8]. In addition, vaginoscopy or colposcopy may be instrumental in
the diagnosis of imperforate hymen [1,4-8]. The differential diagnosis of imperforate hymen are
cribriform hymen, vaginal cyst, acquired labial adhesions obstructing or partially obstructing vaginal
septa (longitudinal or transverse), vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser Syndrome)
with or without the presence of uterus or functional endometrium and Androgen Insensitivity
Syndrome (Testicular Feminization Syndrome) [2,5,9].
Surgery (hymenotomy) is the main treatment modality for imperforate hymen [1,2,8]. However, the
timing of the surgery may vary with majority of authorities recommending surgery at puberty when
estrognization is complete [1,2]. our patient miss GS had her hymenotomy at age 14 when she
started having cyclical abdominal pain with the presence of haematocolpos and haematometra. One
of the draw-backs of performing hymentomy at infancy and early childhood is that complications of
vaginal stenosis and re-accumulation of the haematocolpos and haematometra are uncommon due
to incomplete estrogenization at age [1,4]. Other complications that are associated with imperforate
hymen post-operatively are infections, pyocolpus, pyometra, endopyometritis, salpingitis, tubo-
ovarian abscess, Pelvic Inflammatory Disease (PID), risk of infertility, chronic pelvic pain and ectopic
pregnancy [1,2,8]. In addition, other complications that may occur as a result of hymenotomy are
injury to adjacent organs such as the urethra, rectum or bladder [3-5,8]. These iatrogenic surgical
injuries may occur if the anatomical defect is not well defined clearly especially if there were other
congenital anomaly such as vaginal agenesis or mullerian abnormality [2,3]. Our patient miss GS did
not have any post-operative complications.
CONFLICT OF INTEREST
None
ACKNOWLEDGEMENT
Mother and Baby Care GLOBAL Foundation (Now Mother, Baby and Adolescent Care Global
Foundation).
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