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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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