Himen imperforat en el diagnòstic diferencial de la massa vaginal / Himen imperforado en el diagnóstico diferencial de la masa vaginal / Imperforate hymen in the differential diagnosis of a vaginal mass

Introducció. L’himen és una membrana que envolta i cobreix parcialment l’introit vaginal. La presència d’un himen imperforat pot passar desapercebuda, donar símptomes obstructius de l’aparell genital i del tracte urinari en el període neonatal o presentar-se com a dolor abdominal amb amenorrea en l’adolescència, com a clínica més freqüent. Cas clínic. Presentem el cas d’una pacient de dos mesos amb diagnòstic d’himen imperforat, amb una fístula preauricular esquerra i una hèrnia umbilical concomitant. Davant de la manca de simptomatologia, s’adopta una conducta expectant fins als quatre anys; amb la persistència de l’hèrnia umbilical, s’indica la cirurgia correctora dels tres defectes, que es duu a terme sense incidències. Posteriorment, la pacient presenta una evolució correcta sense recidives. Comentari. L’obstrucció vaginal congènita sol detectar-se clínicament en la pubertat i és diagnosticada de forma poc freqüent durant el període de lactant. L’himen imperforat és la malformació congènita vaginal i l’anomalia obstructiva de l’aparell reproductor femení més freqüent, però no és l’única; per aquest motiu, és important fer un correcte diagnòstic diferencial de les masses vaginals, per donar el millor tractament dirigit i evitar una morbimortalitat més alta dels pacients. (AU)

Introducción. El himen es una membrana que rodea y cubre parcialmente el introito vaginal. La presencia de un himen imperforado puede pasar desapercibida, dar síntomas obstructivos del aparato genital y del tracto urinario en el período neonatal o presentarse como dolor abdominal con amenorrea en la adolescencia, como clínica más frecuente. Caso clínico. Presentamos el caso de una paciente de dos meses con diagnóstico de himen imperforado, con una fístula preauricular izquierda y una hernia umbilical concomitante. Ante la ausencia de sintomatología, se adopta una conducta expectante hasta los cuatro años; con la persistencia de la hernia umbilical se indica la cirugía correctora de los tres defectos, que se lleva a cabo sin incidencias. Posteriormente, la paciente presenta una correcta evolución sin recidivas. Comentario. La obstrucción vaginal congénita suele detectarse clínicamente en la pubertad y es diagnosticada de forma poco frecuente durante el período de lactante. El himen imperforado es la malformación congénita vaginal y la anomalía obstructiva del aparato reproductor femenino más frecuente, pero no es la única; por este motivo, es importante la realización de un correcto diagnóstico diferencial de las masas vaginales para dar el mejor tratamiento dirigido y evitar una mayor morbimortalidad en los pacientes. (AU)

Introduction. The hymen is a membrane that surrounds and partially covers the vaginal entrance. The presence of an imperforate hymen may go unnoticed, give obstructive symptoms of the genital tract and urinary tract in the neonatal period, or most commonly present as abdominal pain with amenorrhea in adolescence. Case report. We present a two-month-old girl diagnosed with imperforate hymen, with a left preauricular fistula and a concomitant umbilical hernia. In the absence of symptoms, conservative management was followed until four years of age, when with the persistence of the umbilical hernia corrective surgery of the three defects was performed without complications. Comments. Congenital vaginal obstruction usually occurs clinically during puberty and is rarely diagnosed during infancy. Imperforate hymen is the most common congenital vaginal malformation and obstructive anomaly of the female reproductive tract, although not the only one; for this reason, it is important to make a correct differential diagnosis of a vaginal mass in children to optimize management. (AU)

[A 14-year-old girl with cyclical abdominal pain]. / Een 14-jarig meisje met cyclische buikpijn.

In thisarticle, we present the case of a 14-year-old girl withcyclicalabdominalpainand a palpablemass in thelower abdomen duetoanimperforate hymen.

Validation of noninvasive focal depth measurements to determine epithelial thickness of the vaginal wall.

OBJECTIVE: This study investigates whether noninvasive focal depth (FD) measurements correlate with vaginal wall epithelial thickness (ET). If FD accurately reflects ET of the vaginal wall, this would allow noninvasive longitudinal assessment of (newly developed) treatment modalities aiming to increase ET, without the need for invasive biopsies. METHODS: Fourteen women, median age 62 years (inter quartile ranges: 57-65), undergoing vaginal prolapse surgery because of anterior and/or posterior compartment pelvic organ prolapse were included. We used the CytoCam, a handheld video microscope based on incident dark field imaging, and performed FD measurements of the vaginal wall before surgery. Histology was performed on tissue that was removed during the surgical procedure, and ET was measured in stained sections. We compared ET with FD interindividually, and determined the expected linear correlation and agreement between the two measurements. RESULTS: Seventeen ET measurements (mean 125 µm ±â€Š38.7, range 48-181 µm) were compared with 17 FD measurements (mean 128 µm ±â€Š34.3, range 68-182 µm). The lineair correlation between the two measurements was strong (r = 0.902, P < 0.01). Bland-Altman analysis demonstrated a mean difference of 13.5 µm when comparing ET to FD. CONCLUSIONS: The results demonstrate good agreement between ET and FD measurements. We consider the mean difference demonstrated with Bland-Altman analysis acceptable for these measurements. This suggests that FD accurately reflects ET, which further supports the use of FD to measure ET of the vaginal wall. For a complete assessment of the vaginal wall, FD measurements are preferably combined with the assessment of vaginal angioarchitecture.

Hymenal polyps in two infants.

Pathological conditions of the hymen are rare in everyday medical practice. Hymenal polyps are polypoid formations originating from the hymenal rim and are benign and disappear spontaneously within a few weeks of onset. We report two cases of hymenal polyps in two infants.

Obstructive anomalies of the gynecologic tract.

PURPOSE OF REVIEW: This review discusses current diagnosis, management and outcomes of obstructive anomalies of the gynecologic tract. RECENT FINDINGS: In this review, we will discuss the clinical presentation of obstructive anomalies, surgical management and reproductive outcomes following surgical intervention. SUMMARY: Identification of obstructive anomalies of the gynecologic tract is crucial when evaluating patients presenting with or without menses and cyclical pain. Surgical management is often the preferred modality for treatment, although menstrual suppression is recommended in certain circumstances.

[Postcoital bleeding: 68 case-reports and review of the literature]. / Les hémorragies post coïtales: à propos de 68 cas et revue de literature.

Consensual or imposed sexual act can cause traumas. Post coital bleeding is a common gynecological symptom. It can reveal serious problems. The aim of our study is to analyze the epidemiological, diagnostic and therapeutic profile as well as preventive measures in case of post coital tear. This is a prospective study, over two years, conducted in the Department of Obstetrics and Gynecology at the Center Hospital University Mohammad VI (CHU) in Marrakech. We collected 68 patients. The average age was 27 years. Most of the patients were nulliparous (89.7% of the cases). Half of the patients had traditional wedding. Sexual intercourse was consensual in 74% of the cases. Vaginal bleeding was the most frequent reason for consultation (98% of the cases). Hymenal lesions were found in 39% of the cases and the lesion involved the posterior fornix of the vagina in 35% of the cases. Therapeutic management consisted of a surgical suture in 97% of the cases, associated with blood transfusion in two patients and sexual abstinence of all patients for at least two weeks. The social context as well as the lack of sex education were often highlighted, hence the importance of psychological support to prevent both the impact of traumas on sexuality and the recurrences.

Spontaneous Reformation of Imperforate Hymen after Repeated Hymenectomy.

BACKGROUND: Imperforate hymen prevents menstrual blood drainage, which causes cyclic lower abdominal pain and amenorrhea. Untreated patients might develop serious complications such as endometriosis and infertility. Hymenectomy represents the adequate treatment. CASE: In a 16-year-old female virgin presented with recurrent lower abdominal pain, urine retention, and secondary amenorrhea after 3 hymenectomy surgeries. The examination revealed imperforate hymen. A fourth hymenectomy was performed with continuous locked sutures over all of the edges. SUMMARY AND CONCLUSION: Recurrent imperforate hymen after hymenectomy should be suspected if symptoms recur. Diagnosis can be achieved through meticulous clinical examination and appropriate imaging techniques.

Lumbalgia en adolescente de 12 años como manifestación clínica de hematocolpos por himen imperforado / Low back pain in 12-years old adolescent as clinical manifestation of hematocolpos secondary to imperforate hymen

Presentamos un caso de hematocolpos debido a himen imperforado, diagnosticado en paciente de 12 años que es remitida al Servicio de Urgencias por lumbalgia mecánica de 2 semanas de duración sin mejoría a pesar de tratamiento con antiinflamatorios no esteroideos y relajantes musculares. La paciente presentaba dolor lumbar intenso que interfería en el descanso nocturno, sin antecedente traumático previo, y asociaba las últimas 24 horas dificultad para realizar micción. Una anamnesis y exploración física detallada son suficientes para diagnosticar una patología que, aunque poco frecuente, tiene un tratamiento quirúrgico sencillo y cuyo diagnóstico puede evitar multitud de exámenes complementarios y tratamientos farmacológicos innecesarios (AU)

We present a case of hematocolpos due to an imperforate himen, diagnosed in a 12 years old patient who was referred to the Emergency Service because of a two weeks duration mechanic lumbago which did not improve despite the treatment with NSAIDs and muscle relaxants. The patient had severe low back pain that interfered with the night rest, with no previous history of trauma, and in the last 24 hours, also presented difficulty in urination. The study of the medical records and a physical exploration were enough to diagnose a pathology that, although rare, has a simple surgical treatment and whose diagnosis can prevent many complementary exams and unneccssary drug treatments (AU)

Hymenal lesions and legal outcome in sexually abused girls with a history of vaginal penetration.

PURPOSE: In many cultures, it is commonly accepted that the hymen remains unchanged throughout childhood, until it is torn at the first episode of sexual intercourse. Therefore, the definition of virginity is directly linked to a normal hymen. However, most girls referred for medical forensic colposcopic examination have normal or nonspecific findings, the prevalence of abnormal findings in girls with a history of genital penetration being only 4-6%. The aim of this study was to investigate the relation between hymenal findings seen at the colposcopic examination and the legal outcome: prosecution in court and conviction in court. RESULTS: During the 80-month period of our study, 426 girls with a median age of 9 years (range 0-15 years) were included. A history of at least one vaginal penetration was given in 226 of the girls with a median age of 12 years (range 2-14 years). The hymenal findings were described as normal in 125 of the 226 cases (55%). In 50 cases (22%), hymenal clefts were found, 17 (34%) of which were complete and 33 (66%) incomplete. The finding of hymenal clefts increased with age. Of the 226 cases of girls being sexually assaulted with vaginal penetration, 119 cases (53%) were prosecuted in court, 102 of which (86%) resulted in conviction. Thirty-five (70%) of the cases with hymenal clefts and 100 (57%) of the cases without hymenal clefts were prosecuted in court, showing a correlation between hymenal clefts and conviction; however, the correlation was not significant (χ(2) test=2.1 and P=0.14). In total, 29 (58%) of the cases with hymenal clefts and 88 (50%) of the cases without hymenal clefts were convicted in court, which shows no significance (χ(2) test=1.0 and P=0.33). CONCLUSIONS: The single most important feature for conviction in court is the child's testimony and not hymenal findings seen at the colposcopic examination. Especially the testimony of the older children leads to conviction, raising the question whether the videotaped testimonies are aimed at the court proceedings, or whether hearing the child's testimony directly in court has a more powerful effect. Overall, it is crucial that the videotaped police questioning of the younger children is performed by specialized personnel, with the aim of presenting the testimony in a detailed and credible manner in court, giving children of all ages a fair trial.

Hymenal stenosis and fibrosis in two adult women.

BACKGROUND: Hymenal abnormalities are most commonly a result of incomplete apoptosis of the urogenital sinus during embryology. Infrequently, however, noncongenital abnormalities of the hymen can occur that can cause significant sequelae such as severe introital dyspareunia. CASES: We report on two adult women who developed severe introital dyspareunia secondary to hymenal stenosis and fibrosis in the absence of other vulvovaginal pathology. Neither woman had point tenderness of the vulvar vestibule, but their symptoms of searing pain on vaginal penetration was reproduced by stretching the hymen with two fingers. In both cases, conservative treatments with vaginal dilators in combination with topical hormonal therapy failed to relieve their symptoms, but both women were subsequently successfully treated with hymenectomy. CONCLUSION: Hymenal stenosis and fibrosis can develop in the absence of identifiable vulvar dermatoses. If conservative treatment with topical hormonal therapy and vaginal dilators is unsuccessful, hymenectomy can restore normal coital function.

Spontaneous hymeneal endometriosis: a rare cause of dyspareunia.

Vulvar endometriosis can occur after surgery or trauma and cause dyspareunia. A 30-year-old woman presented with orificial dyspareunia lasting for 5 months. Her history was marked by a vaginal birth without perineal injury and the removal of a cyst from the left Bartholin's gland. On examination, we observed a selectively painful, superficial and retractile lesion, 5 mm in diameter at the junction of the hymen at some distance from the bartholinitis scar. Endometriosis was suspected due to the exacerbation of pain during menses. The surgery consisted of excision of the hymenal area of the painful lesion. Pathological examination confirmed the presence of endometrial tissue. The painful symptoms resolved and no additional treatment was administered. Any vulvar lesion, regardless of its appearance and location, can be related to endometriosis. Surgical resection is recommended to relieve the symptoms and provide histological proof.

Hematocolpos secundario a himen imperforado. Causa infrecuente de masa abdominal / Hematocolpos secondary to imperforate hymen. Rare cause of abdominal mass

Imperforate hymen is a rare congenital malformation that occurs in 0,1% of female newborns. Symtoms are variables and nonspecifics. The abdominal pain is the most frequent clinical presentation. The diagnosis is suspected and can to do in primary care with a simple genital exploration. The treatment is surgical and consist of a cross incision of hymen

The aim of this case is to highlight the importance of genital examination all newborns in reviews healthy child program for early detection of this malformation and prevent the occurrence of futher complications (AU)

The risk of misinterpreting genital signs of sexual abuse in cadavers: a case report.

The significance of genital findings in a case of suspected child sexual abuse has been widely debated in the past decades, as shown by the different classifications available in literature. In the case of postmortem examination, the search for signs of sexual abuse is considerably more difficult because of the superimposition of postmortem modifications, which may determine tissue modifications that can be mistaken for traumatic lesions. This study aims at reporting a case where presumed findings of the first autopsy were denied by histological analysis; in detail, what looked like a possible bruise of the hymen was correctly recognized as hypostasis (livor) of the hymenal tissue by histological analysis. This case report suggests caution in the analysis and discussion of genital lesions found during postmortem examination since the superimposition of cadaveric modifications may radically modify the morphology of soft tissues.

Himen imperforado / Imperforate hymen

El himen imperforado es una anomalía obstructiva del tracto genital inferior femenino que se da en menos del 0,1% de los recién nacidos. El hecho de no realizar una exploración ginecológica a adolescentes sintomáticas por pudor conlleva frecuentemente al retraso diagnóstico. Presentamos a una paciente adolescente sin menarquia remitida a urgencias para estudio de dolor abdominal cíclico asociado a una masa abdominal con retención de orina y estreñimiento. La simple inspección de los genitales externos nos permitió realizar el diagnóstico después de 2 años de sintomatología(AU)

Imperforate hymen is an obstructive anomaly of the female reproductive tract which occurs in less than 0.1% of newborns. Not performing an adequate gynecologic physical examination in symptomatic adolescent girls due to embarrassment can often delay its diagnosis. We present the case of an adolescent girl without menarche who was referred to our hospital for cyclic abdominal pain associated with an abdominal mass accompanied by urinary retention and constipation. Examination of her external genitalia allowed rapid diagnosis after a 2-year history of these symptoms(AU)

A uterovaginal septum and imperforate hymen with a double pyocolpos.

The presence of both a uterovaginal septum and imperforate hymen is described in a young patient presenting with ongoing chronic pelvic pain and a double pyocolpos. Ultrasound and magnetic resonance imaging scans were performed. The patient underwent laparoscopic adesiolysis, hymenotomy with drainage of 200 mL of pus, and excision of a complete longitudinal vaginal septum. Over the past 5 years of regular follow-up examinations, the patient has always reported regular menstrual cycles and an absence of pelvic pain.

Hymenal characteristics in girls with and without a history of sexual abuse.

This article reviews the recent literature on physical findings related to the hymen in pubertal and prepubertal girls with and without a history of sexual abuse. Characteristics of normal hymenal anatomy, acute traumatic findings, and characteristics of healed trauma are discussed, particularly with regard to changes in the interpretation of these findings that have occurred over time.

Concomitant resorptive defects of the reproductive tract: a uterocervicovaginal septum and imperforate hymen.

OBJECTIVE: To review a case of concomitant longitudinal uterocervicovaginal septum and imperforate hymen. SETTING: A university-based tertiary care center. PATIENT(S): A 14-year-old girl with a septum spanning the length of the uterus, cervix, and upper two-thirds of the vagina, as well as an imperforate hymen. INTERVENTION(S): Hymenotomy with subsequent vaginal septoplasty. MAIN OUTCOME MEASURE(S): NA. RESULT(S): NA. CONCLUSION(S): Anatomic anomalies of the reproductive tract may be found in tandem and when suspected, a full evaluation including advanced imaging to clearly delineate the exact anatomy, should be performed before proceeding with surgical correction.

Medical findings and legal outcomes in sexually abused children.

A previous study published in 2000 on a small group of children concluded that the medical examination in cases of sexual child abuse seldom provided legal proof of sexual abuse [J Forensic Sci 45(2000):115-7]. The present consecutive study included children referred to the police for a forensic medical examination. A colposcope was used to evaluate the anogenital findings which were classified as normal, nonspecific, and abnormal. Four hundred and eighty-two children were included. Abnormal anogenital findings were found in 38% of the girls and 20% of the boys, but there was no relation between abnormal anogenital findings and the two legal outcomes: "appearing in court" and "being convicted." However, the age of the child turned out to be a more important factor in relation to legal outcome than the physical findings. The results of this study suggest that the child's statement and not the physical findings were important for legal outcome.