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New Treatments for Imperforate Hymen

The diagnosis of an imperforate hymen should be made long before adolescence, optimally during routine neonatal and pediatric examinations; however, it is not unusual to see a teenager present with the typical picture of primary amenorrhea, cyclic or acyclic pelvic pain, bulging hymen, and hematocolpos. Hematometra does not usually develop with simple imperforate hymen because the vagina has great distensibility and can accommodate a large amount of blood. It is, however, quite commonly seen with a imperforate hyman.

Most cases of imperforate hymen are congenital due to failure of degeneration of central epithelial cells of the hymenal membrane. Rarely, the condition is the result of inflammatory processes before.

If the vagina and the uterus are not distended by estrogen-induced secretions at the time of birth, the imperforate hymen may remain asymptomatic until after puberty. At that time, the accumulation of menstrual material engorges the vaginal tract, causing pelvic or abdominal pain. It is of historic interest that this condition was known to Aristotle and was mentioned in his treatise.

We know of instances of women in whom the "os uteri" was grown together and continued so until the time arrived for the menstrual discharge to begin and pain come on; in some, the passage burst open of its own accord, in others, it was separated by physicians; and in some cases, where the opening either was forcibly made or could not be made at all.

Most cases of imperforate hymen are diagnosed before the age of 15 years. A cystic mass formed by the enlargement of the vagina and displacement of the uterus can extend above the symphysis and into the abdominal cavity. Abdominal pain is a regular symptom and urinary difficulties, most commonly acute retention, may develop. Many patients who are inadequately examined undergo extensive radiologic evaluation before the correct diagnosis is finally made. Examination of the external genitalia reveals a mass protruding between the labia majora. The bulging mass varies in size, is bluish-red in color, and continuous with the pelvic mass (Fig. 11) . Constipation results in some cases because of pressure on the rectum from the distended vagina.

Treatment

The surgical therapy consists of hymenotomy.

The central part of the hymen should also be excised.

Needletip electrocautery facilitates hemostasis on the hymenal edge. This avoids the need for multiple sutures and minimizes the stricture. The use of a Yankauer suction tip inserted high into the vagina or through the dilated cervix into the uterus facilitates evacuation. At times the wall suction becomes plugged and a high speed suction evacuator is required. Infection is rare once drainage is established, and prophylactic antibody therapy.