"Sewed girl" pronounced "virgin": hymenoplasty and the shift in rhetoric of virginity in Iran.

In late 2018, Ayatollah Makarem Shirazi posted a fatwa approving hymenoplasty for women who had lost their virginity before marriage, arguing that the medical procedure could restore a woman's virginity and therefore her honour. Hymenoplasty, which restores a woman's hymen to its 'virgin' state, is a highly controversial procedure in Iranian society because it strikes at the heart of the purist feminine ideal promoted by the Islamic Republic. For an ayatollah with a conservative reputation to sanction such a procedure seemed antithetical to his position in the regime. On closer inspection, however, it is possible to see his comment as a rhetorical attempt to assert control. Recent social changes, including an increase in the number of educated women and the emergence of new communication technologies, have challenged the rigidity of the old order as women take advantage of emerging freedoms of action and expression. Ayatollah Makarem's fatwa endorsing hymenoplasty can be read as a response to this perceived threat. This essay draws on Kenneth Burke's rhetorical theory to argue that Ayatollah's fatwa should be seen less as a tolerant recognition of social change and more as an attempt to maintain order. Fearing that women might begin to question and reject the entire moral order of the regime, he approves of hymenoplasty to prevent what Burke calls the 'weak in virtue' from falling into 'the strong in sin'.

A 7-Year Retrospective Analysis of Hymenoplasty: Profiles From a Specialized Gynecological Cosmetic Surgery Practice.

BACKGROUND: Hymenoplasty-surgical reconstruction of the hymen-is on the rise in Turkey, reflecting the enduring importance of virginity which is rooted in sociocultural and religious beliefs. Demographic factors shape women's decisions regarding this procedure. OBJECTIVES: The aim of this investigation was to delve into the multifaceted perceptions around virginity and hymenoplasty in Turkey, examining the impact of sociocultural and religious beliefs on women's decisions. The study also explored demographic influences, offering insights into the societal and cultural backdrop of hymenoplasty. METHODS: A 7-year retrospective analysis of 4259 patient records (2015-2022) at a private clinic was conducted, and statistical tools were used to meticulously analyze data on demographics and shared decision-making dynamics. RESULTS: In the examined cohort (83.3%), the choice of permanent hymenoplasty was prevalent among individuals aged 14 to 49 years, with 58.6% being engaged and seeking the procedure a week before marriage. Notably, 91.0% were accompanied by friends during consultations, and a minority disclosed a history of childbirth or experience of forced intercourse. An increasing trend in first-time and post-assault hymenoplasty procedures was observed in 2021. Geographically, the majority of individuals resided in Istanbul, but represented all Turkish regions. Additional procedures such as vaginoplasty were common, with mostly successful postprocedural outcomes and minor complications. CONCLUSIONS: This study highlighted the enduring social importance of virginity in Turkey, emphasizing hymenoplasty as a coping strategy for psychological and societal challenges. The study calls for comprehensive patient support and societal progress in respecting women's bodily autonomy, urging a shift away from the cultural fixation on virginity.

Characteristics of fetal physiological and pathological uterine effusion observed on prenatal ultrasonography: a case report.

BACKGROUND: The prenatal detection rate of fetal uterine effusion is very low, and current case reports mainly focus on pathological hydrometrocolpos. We presented two cases of fetal physiological uterine effusion with different ultrasonic characteristics and compared them with one case of hydrometrocolpos with the hope of identifying strategies to reduce misdiagnosis of fetal uterine effusion. CASE PRESENTATION: This paper reports the cases of two female fetuses with abnormal pelvic echoes in the third trimester, referred to a tertiary center to be screened for suspected pelvic teratoma and cystic mass, respectively. Ultrasound consultation revealed fetal uterine effusion. The two fetuses were delivered at our hospital after a full term. Re-examining the uterus and adnexa of the neonates revealed that the uterine effusion had subsided naturally. Another female fetus had a large cystic mass in the pelvic cavity in the third trimester, and prenatal examination indicated fetal hydrometrocolpos. The fetus was delivered at our hospital after a full term. The hydrometrocolpos existed even after birth. After consultation with a neonatal surgeon and gynecologist, the newborn was diagnosed with congenital imperforate hymen with hydrometrocolpos. Hymen puncture and open drainage led to a good prognosis. CONCLUSIONS: Prenatal ultrasonography plays an important role in diagnosing and differentiating between physiological and pathological fetal uterine effusion. It can help reduce misdiagnoses that can lead to incorrect clinical decisions.

Hymen and virginity: What every paediatrician should know.

Paediatricians may face the notion of 'virginity' in various situations while caring for children and adolescents, but are often poorly prepared to address this sensitive topic. Virginity is a social construct. Despite medical evidence that there is no scientifically reliable way to determine virginity, misconceptions about the hymen and its supposed association with sexual history persist and lead to unethical practices like virginity testing, certificate of virginity or hymenoplasty, which can be detrimental to the health and well-being of females of all ages. The paediatrician has a crucial role in providing evidence-based information and promoting positive sexual education to children, adolescents and parents. Improving knowledge can help counter misconceptions and reduce harms to girls and women.

Imperforate Hymen: Clinical Pearls and Implications of Management.

Imperforate hymen is a common condition that with classic appearance and presentation in puberty. This may be diagnosed in a neonate when mucocolpos is noted. There are many great pretenders of this condition, but the hallmarks include a bulging hymen with blue hue at puberty. If this is not seen on external genital exam, the provider should proceed with magnetic resonance imaging to better assess the reproductive tract anatomy before engaging in surgery. For providers uncomfortable in managing conditions often confused with an imperforate hymen, referral to a Pediatric and Adolescent Gynecologist or specialist comfortable managing these conditions, is recommended.

Evaluation of knowledge and practice of hymenoplasty among Egyptian gynaecologists: a cross-sectional study.

OBJECTIVES: The aims of the study were to evaluate the knowledge and practice of hymenoplasty among gynaecologists in Egypt. METHODS: A cross-sectional study was conducted in January 2020, in which a self-administered questionnaire was completed by 120 gynaecologists at private clinics and hospitals in Ismailia, Egypt. The questionnaire consisted of 19 items relating to participants' sociodemographic characteristics, knowledge and practice of hymenoplasty. RESULTS: Eighty-eight (73.3%) participants were not able to give an accurate definition of the hymen; furthermore, 65 (54.2%) were not aware of the different types of hymen. Forty-nine (40.8%) participants were able to define hymenoplasty and 39 (32.5%) knew the different hymenoplasty procedures. Hymenoplasty had been performed by 35 (29.2%) participants. Of these, 26 (74.3%) had carried out the procedure in a private clinic; the median annual number of procedures performed was four. Only two (5.7%) participants reported the occurrence of complications during the procedure. There were no sociodemographic differences between gynaecologists who had and had not performed hymenoplasty. CONCLUSION: There is a lack of sufficient knowledge about hymenoplasty among Egyptian gynaecologists; nevertheless, it continues to be practised in private clinics.

Hymenal atresia - a rare congenital anomaly with the risk of late diagnosis.

OBJECTIVE: Comprehensive analysis of causes, clinical signs, dia-gnostic process, differential dia-gnosis and therapy of hymenal atresia. METHODS: Literature search using the Web of Science, Google Scholar and PubMed databases with keywords and analysis of articles published in high impact and reviewed journals. RESULTS: Hymenal atresia is a congenital malformation of a womans genitals, which is manifested by complete obstruction of the vaginal introitus by a closed hymen. It should be dia-gnosed in the neonatal period, but clinically it usually manifests itself only during puberty as a result of menstrual blood retention (cryptomenorrhea) with the cyclic abdominal pain at monthly intervals. The therapy is based on optimally timed surgical creation of communication in the hymen (hymenotomy, hymenectomy) enabling free evacuation of menstrual contents. The aim of this simple treatment method is immediate subjective relief from pain and a permanent solution to this congenital anomaly. CONCLUSION: Knowledge of all types of congenital malformations of the female genitalia is a basic condition for an early and effective dia-gnostic process in adolescent girls with abdominal pain. The girl who has not yet menstruated and has cyclic lower abdominal pain and a tumor behind the pubic symphysis should be examined by a specialist in pediatric and adolescent gynecology who will confirm hymenal atresia according to a bluish and closed hymen, and suggest prompt and effective therapy.

Evaluation of hymenal adhesions resection in the treatment of recurrent post-coital cystitis.

OBJECTIVE: To describe and evaluate the technique of hymenal adhesions resection in the treatment of recurrent post-coital cystitis. MATERIALS AND METHODS: Monocentric retrospective observational study including patients operated for hymenal adhesions resection between 2013 and 2020. The indication was based on the association of 4 conditions: at least 3 episodes of documented cystitis per year, a post-coital rhythm, a failure of preventing hygienic and dietary rules, a negative etiological assessment except for the existence of hymenal adhesions. RESULTS: Twenty-three patients were included. The procedures were performed on an outpatient basis. With a mean follow-up of 36.5 months (standard deviation: 22.3), 21 patients (91%) reported a correction of recurrent post-coital cystitis, 16 (70%) had 1 to 2 annual episodes of cystitis, 19 (83%) reported improvement with surgery and satisfaction was rated on average at 8.5/10 (standard deviation: 2.15). None of the 23 patients had persistent documented recurrent cystitis after surgery, 12 (52%) had 1 to 2 documented episodes annually, and 11 (48%) had no documented recurrence. Three cases of postoperative complications were observed: vulvovaginitis, delayed healing, and pyelonephritis. No cases of dyspareunia were reported during the follow-up. CONCLUSION: In case of post-coital cystitis, accompanied by hymenal adhesions, and without any other identified cause, the removal of hymenal adhesions could be an alternative to iterative antibiotic therapy.

Clinical analysis of the MyoSure hysteroscopic tissue removal system of endometrial polyps in women with an intact hymen.

BACKGROUND: To investigate the clinical efficacy of the MyoSure hysteroscopic tissue removal system in the treatment of endometrial and cervical polyps in women with an intact hymen. METHODS: Retrospective analysis was performed on the clinical data of 32 patients treated with the MyoSure hysteroscopic tissue removal system for endometrial and cervical polyps. RESULTS: All the patients successfully completed the procedure. No intraoperative complications, such as cervical trauma, uterine perforation or TURP syndrome, were reported. The surgical time ranged from 5 to 35 min, with an average time of 19.3 min, and the intraoperative blood loss ranged from 2 to 50 ml with an average blood loss of 10.8 ml. After surgery, all patients were shown to have intact hymens. No residual polyp tissues were observed under the microscope, and abnormal uterine bleeding was relieved. CONCLUSIONS: The MyoSure hysteroscopic tissue removal system can be a safe and effective treatment for endometrial and cervical polyps in women with an intact hymen.

A New Practical Surgical Technique for Hymenoplasty: Primary Repair of Hymen With Vestibulo-Introital Tightening Technique.

BACKGROUND: Hymenoplasty is distinct from other genital surgeries with its ethical and psychological issues. It is performed to narrow the vaginal opening to ensure vaginal bleeding with penetration. There are various kinds of techniques with different success rates. OBJECTIVES: The authors sought to report a new hymenal reconstruction technique with vestibulo-introital tightening with the results of 145 procedures. METHODS: The new technique included a diamond-shaped incision to the vestibulum with the base in the posterior midline and superior corner 2 to 3 cm higher above the hymen. The angles were accommodated according to the degree of tightening, and the submucosal layer was closed from the apex downwards involving the vaginal mucosa. RESULTS: The satisfaction rate of the patients was 99.3%. No adverse events were observed. CONCLUSIONS: Compared with previous techniques described, this hymenal reconstruction technique is an alternative with the advantage of low risk of loosening because the tension on the hymen alone is decreased. Additional tightening of the introitus increases the satisfaction rates in some patients.

Hymen Restoration: An Experience From a Moroccan Center.

BACKGROUND: Hymenoplasty is one of the least described vulvovaginal procedures in plastic surgery without any surgical standard that attempts to restore the hymen's ability to bleed during sexual intercourse on a couple's wedding night. OBJECTIVES: The objective of this study was to report outcomes from a Moroccan retrospective study of a series of 529 patients who underwent either a hymenorrhaphy or a hymenoplasty. METHODS: This was a retrospective study of 529 patients who underwent hymen restoration at a center in Morocco between April 2010 and April 2019. The data were collected according to the requirements of the center through preoperative and postoperative consultations and in-person or phone post-coital interviews. The procedure consisted of suturing the edges of the hymen remnants with Vicryl 5-0, leaving a small opening in the newly reconstructed hymen. Two techniques-hymenal flap hymenoplasty and vaginal flap hymenoplasty-were employed depending on the presence or absence of hymen remnants. RESULTS: A total of 529 patients underwent hymen restoration, including 42% hymenorrhaphies, 58% hymenoplasties, 39% hymenal flap hymenoplasty, and 19% vaginal flap hymenoplasty. The mean age of the patients was 32 years. Of the 227 women who underwent a hymenorrhaphy, no failure was reported, and all the patients who had sexual intercourse within 15 days of the procedure experienced vaginal bleeding. Of the 99 hymenoplasties employing vaginal flaps, only 1 failure was reported. CONCLUSIONS: The techniques utilized in our cohort are safe and the complications are minor with general satisfaction of patients.

Acute Urinary Retention due to Haematometrocolpos from Imperforate Hymen in a Pubescent Nigerian Girl.

BACKGROUND: Cryptomenorrhoea is an uncommon gynaecological condition in the adolescent age group. While cyclical abdominal pain is the usual clinical symptom, patients with atypical presentation require a high index of suspicion and meticulous evaluation. OBJECTIVE: This case report describes atypical presentation of haematometrocolpos in a pubescent Nigerian female. METHODS: A case of acute urinary retention in an adolescent girl, due to haematometrocolpos, is presented. A 13-year-old supposedly premenarcheal girl presented at the Children Emergency Unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria with acute urinary retention of twelve hours' duration. There was no preceding history of difficulty with voiding. About 1,200mls of urine was drained from the bladder with a self-retaining catheter. Examination revealed an 18-week-sized cystic abdomino-pelvic mass, and the vagina was closed with a bulging membrane at the introitus. Abdomino-pelvic ultrasonography revealed a distended uterus containing fluid with low level echo, typifying the ground-glass appearance. Trans-hymenal ultrasonography using a 2.5-7.5MHz endocavitary probe confirmed a ballooned-out vagina with similar content, with a 2mm thick hymen at the distal end. RESULTS: Hymenectomy was performed with spontaneous drainage of the menstruum. She was discharged after successful trial of voiding without catheter. CONCLUSION: Though uncommon, haematometrocolpos from lower genital obstruction should be considered as a differential diagnosis of lower urinary tract obstruction in pubescent girls. Trans-hymenal ultrasonography is accessible and accurate for assessing the level of obstruction and the thickness of the intervening tissue.

CONTEXTE: La cryptoménorrhée est une affection gynécologique rare dans le groupe d'âge des adolescents. Alors que la douleur abdominale cyclique est le symptôme clinique habituel, les patients présentant une présentation atypique nécessitent un indice de suspicion élevé et une évaluation méticuleuse. OBJECTIF: Ce rapport de cas décrit la présentation atypique de l'hématométrocolpos chez une femme nigériane pubère. MÉTHODES: Un cas de rétention urinaire aiguë chez une adolescente, due à un hématométrocolpos, est présenté. Une fillette de 13 ans prétendument prémenarchique s'est présentée à l'unité d'urgence pour enfants du complexe hospitalier universitaire Obafemi Awolowo, à Ile-Ife, au Nigéria, avec une rétention urinaire aiguë d'une durée de douze heures. Il n'y avait pas d'antécédents antérieurs de difficulté à la miction. Environ 1 200 ml d'urine ont été drainés de la vessie à l'aide d'un cathéter autobloquant. L'examen a révélé une masse kystique abdomino-pelvienne d'une taille de 18 semaines, et le vagin était fermé avec une membrane bombée à l'introït. L'échographie abdomino-pelvienne a révélé un utérus distendu contenant du liquide avec un écho de faible niveau, caractérisant l'aspect en verre dépoli. L'échographie trans-hyménale utilisant une sonde endocavitaire de 2,5 à 7,5 MHz a confirmé un vagin gonflé avec un contenu similaire, avec un hymen de 2 mm d'épaisseur à l'extrémité distale. RÉSULTATS: L'hyménectomie a été réalisée avec drainage spontané des menstrues. Elle a obtenu son congé après un essai réussi de miction sans cathéter. CONCLUSION: Bien que rare, l'hématométrocolpos d'une obstruction génitale inférieure doit être considéré comme un diagnostic différentiel de l'obstruction des voies urinaires inférieures chez les filles pubères. L'échographie trans-hyménale est accessible et précise pour évaluer le niveau d'obstruction et l'épaisseur du tissu intermédiaire. Mots clés: Rétention urinaire aiguë, cryptoménorrhée, hématométrocolpos, imperforation de l'hymen, adolescente avant la ménarche, scintigraphie trans-hyménale.

Recurrent formation of haematocolpos in a young girl with multiple congenital anomalies of the urogenital tract.

An 11-year-old girl, a known case of left crossed fused renal ectopia and sacral hypoplasia presented to the gynaecological OPD in Karachi, Pakistan, in February 2019 with complaints of abdominal pain. On examination, she was found to have a septum covering her vaginal orifice. She was subsequently diagnosed with haematocolpos secondary to imperforate hymen. Incision and drainage was done. However, despite surgical management, she continued to have recurrent formation of haematocolpos for the next two months secondary to multiple complete and partial transverse vaginal septa and post-operative formation of adhesions. Definitive management was done with ultrasound guided needle puncture and drainage, followed by post-operative tampon use to maintain patency.

Imperforate hymen: Retrospective review from a single tertiary centre of presenting symptoms and diagnostic process.

AIM: To review presentations, diagnostic processes and time to diagnosis of presentations of imperforate hymen at one tertiary paediatric hospital over a 10-year period. The aim was to improve knowledge, enable targeted education and reduce unnecessary tests and diagnostic delay for this congenital obstructive disorder of the female reproductive tract. METHODS: A pragmatic, retrospective, observational study was conducted of all female patients, aged younger than or equal to 18 years of age, presenting to the Royal Children's Hospital, Melbourne, over an 18-year period. Presenting symptom(s), time to diagnosis, investigations ordered and number of health-care professionals consulted prior to diagnosis were recorded. RESULTS: A total of 27 patients met eligibility criteria, and 85% presented with pain (23/27). Pain was frequently associated with other symptoms (15/23). Over three quarters of patients consulted more than one health-care professional prior to diagnosis (22/27). Of the 27 patients, 19 had imaging undertaken prior to diagnosis. CONCLUSIONS: Paediatric and adolescent females managed at our tertiary paediatric hospital are experiencing diagnostic uncertainty and the unnecessary ordering of imaging prior to a diagnosis of imperforate hymen. Targeted education is recommended to health professionals managing female paediatric and adolescent patients.

[Diagnosis and management of Imperforated Hymen in an infant]. / Diagnóstico y manejo de Himen Imperforado en una lactante menor.

INTRODUCTION: Imperforated hymen is the most frequent congenital malformation of the female genital tract. Most cases are not investigated in childhood, due to an insufficient genital examination. Its diagnosis and resolution must be early and definitive to avoid subsequent complications. OBJECTIVE: A clinical case of an infant with imperforated himen is presented. To update on genital examination technique necessary to detect this pathology in the newborn and infants, and the proper treatment. CLINICAL CASE: 3-months-old infant that consulted due to an increase in bulging volume in the introitus area. In the physical examination, the Valsalva's maneuver was performed allowed the ex pulsion of a homogeneous pearly mass with a smooth surface, between the labia majora, suggesting imperforate hymen. The study was complemented with gynecological ultrasound, which demons trated the presence of hydrocolpos, ruling out other anomalies. A hymenotomy was performed, which allowed for the evacuation of abundant serous material, with no bad smell, and then the hymenectomy was completed by resection of the hymenal membrane. In follow-up monitoring 4 months after the intervention, a widely permeable hymen was found. CONCLUSION: Neonatal care teams require training on the correct technique of external genital examination of the newborn and infant. Hymenectomy is the technique that allows definitely resolving the condition, avoiding complications.

An Unusual Case of Infertility: Urethral Coitus Due to Cribriform Hymen.

Urethral coitus is a rare type of sexual practice, usually due to vaginal agenesis or hymeneal anomalies. We report a case of urethral coitus in a healthy couple who were evaluated for infertility. The female partner had cribriform hymen and dilated urethral orifice but did not report any problems except infertility and her genital anatomy was normal. The male partner reported concerns over his penile size but was otherwise healthy. After incision of hymen, they were able to have vaginal coitus and successfully conceived. While urethral coitus is rare, it should be suspected in women presenting with infertility and a dilated urethral orifice.

The interdigitating Y-plasty procedure for the correction of transverse vaginal septa.

Transverse vaginal septa are rare congenital abnormalities of the female genital tract, the surgical management of which is hardly described in the literature. While thicker septa might require complex reconstructive surgery, this paper proposes a simple technique for the surgical management of thin septa, utilising two interdigitating Y-plasties, without the need for excision of any septal tissue. The authors also present their series of eight consecutive cases where this technique was used, with no major complications or any cases of vaginal re-stenosis. This technique can also be used in imperforate hymen correction, therefore it might also be of interest to the general gynaecologist. TWEETABLE ABSTRACT: Interdigitating Y-plasties in transverse vaginal septa: presentation of a new technique.