Accepted Manuscript

Spontaneous Reformation of Imperforate Hymen after Repeated Hymenectomy

Ahmed M.E. Ossman, M.D., Yasmine I. El-Masry, M.S., Mohamed M. EL-NAmoury,

M.S., Sameh M. Sarsik, MB BCh

PII: S1083-3188(16)00160-1
DOI: 10.1016/j.jpag.2016.02.001
Reference: PEDADO 1957

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 2 January 2016

Revised Date: 23 January 2016
Accepted Date: 1 February 2016

Please cite this article as: Ossman AME, El-Masry YI, EL-NAmoury MM, Sarsik SM, Spontaneous
Reformation of Imperforate Hymen after Repeated Hymenectomy, Journal of Pediatric and Adolescent
Gynecology (2016), doi: 10.1016/j.jpag.2016.02.001.

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Title page

Authors

Ahmed M.E. Ossman, M.D., Obstetrics and Gynecology department, Tanta university hospital,

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Tanta.

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Yasmine I. El-Masry, M.S., Obstetrics and Gynecology department, Tanta university hospital,

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Tanta.

Mohamed M. EL-NAmoury, M.S., Obstetrics and Gynecology department, Tanta university

hospital, Tanta.
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Sameh M. Sarsik, MB BCh, Obstetrics and Gynecology department, Tanta university hospital,
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Tanta.
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Corresponding author

Name: Sameh Magdy Sarsik.

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House officer

Tanta university Hospital, Tanta, Egypt.

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Address: 9 Noor Al-Eman St. Manshiyat Al Bakry, Al-Mahalla Al-Kubra, Al-Gharbiya, Egypt.
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Phone: +201158541122.

E-mail: samehmagdyhassan@gmail.com.

Post code: 31962

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Spontaneous reformation of imperforate hymen after repeated

hymenectomy

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Abstract

Background: Imperforate hymen prevents menstrual blood drainage, which causes cyclic lower

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abdominal pain and amenorrhea. Untreated cases may develop serious complications as

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endometriosis and infertility. Hymenectomy represents the adequate treatment.

Case: A16 years old virgin female with recurrent lower abdominal pain, urine retention and

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secondary amenorrhea following three hymenectomy operations, examination revealed
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imperforate hymen. A fourth hymenectomy operation was performed with continuous locked

sutures all over the edges.

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Summary and conclusion: Reformed imperforate hymen after hymenectomy should be

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suspected if the symptoms recurred. Diagnosis can be achieved through meticulous clinical
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examination and appropriate imaging techniques.

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Introduction

Imperforate hymen is considered the most common obstructive congenital anomaly of the female
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reproductive tract, and has an incidence of 1 in 1,000 to 1 in 10,000(1). Such condition results in
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closure of the natural passage for menstrual blood, debris, cervical and vaginal secretions

proximal to the membrane. Most of the cases pass unnoticed, until becoming symptomatic after

menarche due to hematocolpos and hematometra secondary to the accumulated menstrual

blood(2).
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It was always simple to manage such cases once the diagnosis is achieved, by satellite surgical

incision of the hymen in order to release the tension and evacuate the blood, with a good surgical

outcome in majority of the cases(2)(3).

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Here we are reporting a case of reformed imperforate hymen for the third time after repeated

surgical incisions of the hymen, and to our knowledge this is the first reported case.

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Case presentation

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A 16 years old virgin girl was presented to Gynecology department, Tanta university hospital on

Thursday 5 November 2015, complaining of lower abdominal pain of gradual onset and

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progressive course since a month and a half after the third set of hymenectomy, she was also
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complaining of urine retention, abdominal distension, secondary amenorrhea and a severe

psychic stress. The patient denied any physical trauma or sexual abuse.
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Examination revealed that she is over weighted (BMI 29), with excessive hair growth; over the
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chin and the lateral sides of the face, V shaped area of the chest and excess pubic hair with
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pyramidal shaped distribution extending to the umbilicus (score 7 on modified Ferriman–

Gallwey system), her breasts were well developed with pale brown areolae and flat nipples
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(stage 4 on tanner scale). Palpation of the abdomen revealed; tenderness all over the abdomen

with a pelvi-abdominal mass, its upper border lies midway between the umbilicus and the
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symphysis pubis.
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Examination of the external genitalia revealed normal mons pubis, labia majora, labia minora,

normal sized clitoris and excess pubic hair. By separation of the labia a mildly bulging bluish

membrane was observed (FIG.1A& 1B).

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Reviewing her medical profile revealed that, the condition started over a year ago with monthly

abdominal pain and primary amenorrhea. She sought medical care for the first time on 9 May

2015 at a Al-Mabara governmental hospital when she experienced severe acute abdominal pain

and urine retention, her pelvi-abdominal ultrasonography showed dilated vagina measuring

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16.5*8.4*8.4 cm in dimension filled with 615 ml of echogenic fluid and a partially obstructed

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urinary bladder neck, she was diagnosed as a case of imperforate hymen with hematocolpos with

secondary urine retention, she was managed by urinary catheterization to relief her symptoms,

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then, she underwent the first set of hymenotomy by annular incision and followed by Foley’s

catheter insertion at the site of the incision, and removed after 4 days.

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During June and July 2015 the symptoms recurred, in the form of amenorrhea, cyclic pain and

abdominal enlargement; therefore, she was admitted to the Red Crescent Hospital, her MRI
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showed imperforate hymen with hematocolpos, she underwent the second hymenectomy on the

1st of August 2015 by annular incision, 750 cc of blood was drained, followed by application of
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Foley’s catheter for 4 days. On 22 August2015 she returned to the hospital for follow up,
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medical examination revealed reformation of the hymen and the MRI showed hematocolpos

formation with no other abnormal findings. So, she underwent the third hymenectomy on the
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next day with a larger incision and the edges of the incision were cauterized by diathermy,
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Foley’s catheter was placed for 3 days then removed.

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When she presented to our department, she stated that she experienced recurrence of the

symptoms during the last two months, urinary catheterization was done to relieve the urine

retention, followed by 3D ultrasonography that showed; hematocolpos (FIG.2) and imperforate

hymen (FIG.3), and she was prepared for the fourth surgery. A complete set of investigations
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were done with no remarkable findings. A written consent was obtained from her guardian to

permit the surgery.

Hymenectomy was done by 10*10mm circular incision with removal of the vascular tissue that

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was examined histopathologically, 600cc of accumulated blood was drained followed by

irrigation using 250 cc saline until the withdrawn fluid was clear, continuous locked sutures were

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done all over the edges and Foley’s catheter(16mm) was applied.

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The histopathological examination revealed hyperplastic stratified squamous epithelium

overlying dense fibro-vascular connective tissue, and her hormonal profile showed no

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abnormalities.
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The post-operative period was uneventful, she returned to the hospital for follow up and for
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psychological support sessions by a psychiatric specialist, the catheter was removed two weeks

after the surgery and she had a menstruation a week later.

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Three weeks after the operation she had a normal menstruation.

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Discussion
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During embryogenesis of female embryo, defective fusion of the uterovaginal canal with the

urogenital sinus results in formation of transverse vaginal septum, while the hymen is formed at
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the site where the uterovaginal canal meets the urogenital sinus from the proliferated sinovaginal
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bulbs, later on during the development perforation of the sinovaginal bulbs take place. If the

hymen fails to canalize with the rest of the vagina; it is called imperforate hymen which leads to

blockage of the menstrual blood natural passage. Accumulation of the menstrual debris causes

the symptoms and the possible complications.

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Mostly, symptoms of imperforate hymen occur after menarche secondary to hematocolpos

(collection of blood in the vagina) and hematometra (collection of blood in the uterus); in the

form of cyclic lower abdominal pain, distention and primary amenorrhea. Urinary retention,

constipation and lower back pain may occur through mechanical pressure on the neighboring

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pelvic structures(4). On the other hand some cases may present during infancy period with a

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bulging hymen as a sequence of mucocele formation proximal to the hymen(5). Correction of

this condition is necessary to avoid the possible complications such as infections, retrograde

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menstruation with subsequent endometriosis, infertility. Also hydronephrosis and kidney failure

were reported(4).

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Hymenectomy should be performed either by cruciate incision of the hymen or by using Co2

laser; in order to drain away the collected blood. Another alternative and more recent technique
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uses annular incision followed by the application of Foley’s catheter for 14 days; to preserve the

hymenal ring structure, which may represent a suitable surgical option in the communities where
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the intact hymen represents an important indicator of virginity(3).

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Closure of the hymen after puberty is an extremely rare event. In literature(6) two cases of
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secondary hymenal closure during pregnancy were reported, one of the cases had no history of

previous surgical involvement of the hymen, while the other had a history of hymenectomy at a
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younger age.
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Meanwhile, sexual abuse as well as genital trauma were reported by Berkowitz(7) as a possible

causes of developing acquired imperforate hymen as a sequence of excessive healing, A recent

case was reported to have secondary amenorrhea after closure of partially stenosed hymenal

orifice with neither sexual abuse nor surgical intervention of the hymen(8).
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In the current case closure of the hymnal orifice occurred spontaneously after each of the

previous hymenctomies.

Conclusion

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In case of cyclic abdominopelvic pain in pubertal girls imperforate hymen should be suspected,

especially if associated with secondary amenorrhea, even if the patient has a history of

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hymenectomy. Clinical examination of the external genitalia is a sufficient tool to confirm or

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exclude the recurrence of imperforate hymen.

Conflict of interests

The authors report no conflicts of interest.

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The authors alone are responsible for the content and writing of the paper.
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Acknowledgment
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7. Berkowitz CD, Elvik SL, Logan M. A simulated “acquired” imperforate hymen following
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