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Surgical therapy: The timing of surgical therapy is based on the
presence of symptoms. A symptomatic mucocele presenting in the
neonatal time period should be managed expediently. If an asymptomatic
imperforate hymen without mucocele is diagnosed during childhood, it
can be managed during puberty and prior to the development of a
hematometra or hematocolpos. The presence of estrogen stimulation in
puberty facilitates the surgical repair and healing.
While the treatment of an imperforate hymen is a surgical urgency when
it presents in an adolescent with hematometra and hematocolpos, the
procedure should not be performed on an emergency basis without
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: Preoperative pelvic and abdominal ultrasound (to
image the kidneys and urinary tract) should be performed, with MRI
reserved for the evaluation of questionable anatomy or the possibility
of m?lerian abnormalities.
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The patient and family should be prepared for the surgical procedure,
which can be described as a hymenotomy (opening up the hymenal
membrane). A concurrent laparoscopy also is suggested in a young woman
presenting with hematocolpos because severe pelvic adhesions and
extensive intra-abdominal endometriosis may be present. 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 (or hymenectomy)
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 old blood and to evacuate the hematocolpos and hematometra using
one or more suction tubes. 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 directly
anteriorly and can be enlarged by removal of excess hymenal tissue. In
either approach, the vaginal epithelium then is 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 to provide postoperative analgesia is suggested.
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.
Concurrent diagnostic laparoscopy may be performed in the usual manner
to allow lysis of adhesions and excision or cautery of any
endometriosis that may be encountered. Copious isotonic irrigation
should be used to lavage any retrograde blood in the pelvic and
abdominal cavity to prevent future development of adhesions or
endometriosis.
Postoperative details: The surgical procedure of hymenotomy and
evacuation of hematocolpos is performed on an outpatient basis. 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 nonsteroidal anti-inflammatory drugs (NSAIDs) may
be prescribed for the 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 to keep the area clean. The use of a hair
dryer on the cool setting to dry the area avoids the abrasion of towel
drying. Patients and/or parents are instructed to call the physician?s
office if the patient experiences severe cramping unrelieved by
ibuprofen or if a fever develops. The family also should be informed
that all sutures are absorbable and dissolve, sometimes with the
observation of the ends of the suture as small threads.
Follow-up care: Schedule a postoperative office visit 1-4 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 to relieve the patient's anxiety. A 3- to
6-month course (or longer) of menstrual suppression with oral
contraceptives may be indicated and should be discussed at the
postoperative visit.
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