Author Information
Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Abstract
Microperforate hymen is an uncommon congenital malformation of the female genital tract. It usually is an isolated anomaly, but may occur associated with other anomalies. A case of microperforate hymen, with opening juxtaposed to the external urinary meatus is presented.
Introduction
Congenital anomalies of the hymen include imperforate, microperforate, cribriform, and septate types.[1,2] A microperforate hymen allows some menstrual flow, but may cause partial obstruction and stasis. That may lead to infection ascending up the genital tract.[3] It also causes dyspareunia. The opening is usually at or near the center of the hymen. A case is presented where it was juxtaposed to external urinary meatus. This is the first case of this type in the world literature.
Case Report
A 21 year old woman, married for 2 years, presented with apreunia. She had menarche at the age of 13 years. Her past menstrual cycles were regular, painless, and with moderate flow. Her last menstrual period had been 3 weeks ago. She had apareunia. She had never been able to have penetrative sexual intercourse. Her general and systemic examination revealed no abnormality. Her breast development was of Tanner’s stage 5. Her axillary and pubic hair development was normal. Local examination showed an apparently intact hymen, normal clitoris, labia minora and majora, and external urinary meatus. Rectal examination showed a normal sized uterus, and no pelvic tenderness or mass. Since she claimed to have regular menses, she was asked to report during a menstrual flow. She presented a week later. There was flow of menstrual blood from a spot near 6 o’clock position of the external urinary meatus. Careful local examination showed a small opening outside the urinary meatus, closely related to it, from which the menstrual blood was escaping. A radiological study was done after a week, in which radiopaque dye was injected through a catheter passed through that opening into the cavity beyond and radiograph was obtained (figure 1). It showed a vagina of normal dimensions. A diagnosis of a microperforate hymen was done. She was investigated and was found to be fit for anesthesia. A week following her next menstrual period, surgical correction of the microperforate hymen was done under spinal anesthesia. the hymen was split longitudinally from its perforation site to the fourchette. Interrupted sutures of No. 2-0 polyglactin were put over the cut edges to approximate the lining epithelium on both sides of the cuts, for achieving hemostasis as well as better healing across the edges so that opposite cut edges would not approximate in the midline (figures 2 to 8). Two fingers could be easily passed into the vagina at the end of the operation. The patient made an uneventful recovery. She was advised to apply an antiseptic cream locally for one week and maintain menstrual hygiene. She was well at the first follow up after 15 days, and had successfully stated sexual intercourse 2 months after the surgery.
Figure 1. Radiograph showing normal vagina (black arrow) filled with radiopaque dye instilled through a catheter. A gauze swab (yellow arrow) is seen around the introitus, held around the microperforation of the hymen to prevent leakage of the dye during the procedure.
Figure 2. Local examination showing absence of any hymenal opening. The external urinary meatus is pointed out by yellow arrow. The position of hymen is pointed out by black arrows.
Figure 3. The microperforation is enlarged by putting it on stretch with the tip of a curved hemostat. The thinness of the hymen is made evident by its fold elevated by the hemostat.
Figure 4. The hymen is slit longitudinally from its opening towards the fourchette.
Figure 5. Approximation of epithelium on inner and outer surface of the cut hymen over the cut edges. Sutures have already been placed at 3, 6, and 9 o’clock positions. A suture is being placed between 7 and 8 o’clock positions.
Figure 6. Normal vagina and cervix are seen after insertion of a Sims’ speculum and a right angled retractor to retract the posterior and anterior vaginal walls respectively.
Figure 7. The end result. External urinary meatus is shown by yellow arrow. Sutures are seen along the rim of the new hymenal opening. Normal vagina is seen within.
Figure 8. The end result. The external urinary meatus is shown by passing the tip of a curved hemostat into it.
Discussion
A microperforate hymen is almost always an isolated finding. But an association with bifid clitoris, hypoplastic kidney with ectopic ureter, duplication of the ureter, polydactyly and vascular anomalies has been reported.[4] Familial occurrence has also been reported.[5] A microperforate hymen can cause ascending pelvic infections and recurrent urinary tract infections. Microorganisms ascend through microperforations in the hymen, infect collected discharge behind the hymen and can cause formation of a pelvic abscess.. Recurrent urinary tract infections can occur because of pooling of urine in the functional urogenital sinus and invasion into the urethra. They can then infect any accumulated material in the vagina, uterus, tubes, and abdomen.[3] In case of a married woman, if efforts at sexual intercourse are continued in presence of a microperforate hymen, urethral coitus may take place, resulting in urethral dilatation and urinary symptoms.[6] Coitus interfemora with deposition of semen over the external genitals can lead to a pregnancy, the sperm entering the vagina through the microperforation.[7]
In our case the hymenal opening was large enough to permit drainage of menstrual blood and vaginal discharge without collecting behind the hymen. So there was no occurrence of ascending pelvic infection or urinary tract infection. Fortunately there was no urethral dilataion caused by urethral coitus. The surgical treatment was satisfactory, and the patient had normal sexual activity two months after the operation.
Microperforate hymen can escape detection if the menstrual flow is not obstructed. Thus it sometimes comes to light much later than an imperforate hymen. A careful genital examination at birth can detect the condition and will prevent a number of complications reducing morbidity considerably.
Acknowledgment
I than Dr Sana Bijapur for recording operative video.
References
- DiVastaad, Grace e. Normal hymen and hymenal variations. In Practical Pediatric and Adolescent Gynecology, First Edition. Edited by Paula J. Adams Hillard. 2013 John Wiley & Sons, Ltd. New Jersey. Pp 45-48. available from: http://sci-hub.cc/10.1002/9781118538555.ch9
- Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. . J Pediatr 2002; 140(5):600–607.
- Sanfilippo AM, Mansuria SM. Microperforate Hymen Resulting in Pelvic Abscess. J Pediatr Adolesc Gynecol (2006) 19:95–98.
- Winderl L, Silverman R: Prenatal diagnosis of congenital imperforate hymen. Obstet Gynecol 1995; 85:857.
- Liang CC, Chang SD, Soong YK: Long-term follow-up of women who underwent surgical correction for imperforate hymen. Arch Gynecol Obstet 2003; 269:5.
- Di Donato V, Manci N, Palaia I, Bellati F, Perniola G, Panici PB. Urethral coitus in a patient with a microperforate hymen. J Minim Invasive Gynecol. 2008 Sep-Oct;15(5):642-3. doi: 10.1016/j.jmig.2008.05.002.
- Goto K, Yoshinari H, Tajima K, Kotsuji F. Microperforate hymen in a primigravida in active labor: a case report. J Reprod Med. 2006 Jul;51(7):584-6.
Parulekar SV. Juxtaposition Of Urethral And Microperforate Hymenal Openings. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/juxtaposition-of-urethral-and.html