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.

Himen: un epónimo y mito de larga data en terminologia anatomica / Hymen: a long-standing eponym and myth in terminologia anatomica

RESUMEN: En Terminología Anatómica el término himen es identificado con el número 3530. Es un pequeño tejido membranoso que normalmente ocupa una parte de la abertura vaginal externa en la mujer. La pertinencia del término himen ha sido poco abordada en la literatura del campo terminológico anatómico, por tanto, el objetivo del presente trabajo fue analizar este término, verificar su etimología y funcionalidad, y determinar cómo este ha sido considerado en algunos aspectos de orden cultural, clínico y jurídico. El término himen proviene del latín hymen que es préstamo del griego hymḗn ὑμήν que significa membrana. Con el valor general de cualquier membrana fue usado en Grecia desde el siglo V a.C., sin embargo, a través de un fenómeno de especialización latina, a partir de los siglos I y II d.C., el término fue usado con su significado actual. Su origen proviene del nombre del dios griego del matrimonio llamado Himeneo, lo que vincula el término a un epónimo y mito a la vez. Pese a lo anterior, creemos que su conservación en Terminología Anatómica se podría deber a su larga data de uso, aun cuando podrían existir mejores opciones para denominar esta estructura. El himen no presenta una función biológica conocida, sin embargo, ha tenido gran valoración a nivel cultural, clínico y jurídico, en el que el examen físico ha determinado conclusiones sobre la historia sexual de mujeres y niñas aun cuando las evidencias demuestran que no es una prueba precisa o confiable de la actividad sexual.

SUMMARY: In Terminologia Anatomica the term hymen is identified with the number 3530. It is a small membranous tissue that normally occupies a part of the external vaginal opening in women. The relevance of the term hymen has been scarcely addressed in the literature of the anatomical terminology field. Therefore, the objective of this work was to analyze this term, verify its etymology and functionality, and determine how it has been considered in certain cultural clinical and legal aspects. The term hymen comes from the Latin hymen, borrowed from the Greek hymḗn ὑμήν , which means membrane. With the general value of any membrane, it was used in Greece from the 5th century BC, however, through a phenomenon of Latin specialization, from the 1st and 2nd centuries AD, the term was used applying its current meaning. Its origin comes from the name of the Greek god of marriage called Hymenaeus, which links the term to an eponym and a myth at the same time. Despite the above, we believe that its conservation in Terminologia Anatomica could be due to its long history, even though there may be better options to name this structure. The hymen does not have a known biological function, however, it has been highly valued at a cultural, clinical and legal level, in which the physical examination has determined conclusions about the sexual history of women and girls even when the evidence shows that it is not an accurate or reliable proof of sexual activity.

[From virginity certificates to hymenoplasty surgery in France]. / Des « certificats de virginité ¼ aux hyménoplasties en France.

"In the Republic, it is not allowed to deliver virginity certificates, prior to marriage; in the French Republic, the laws of religion cannot prevail over the laws of the Republic" said President Emmanuel Macron in February 2020. Nevertheless, what about the religious status of these certificates? Why focusing only on virginity certificates without mentioning the concomitant practice of hymen rehabilitation? There is a whole range of revirginization surgical practices, such as nymphoplasty or vaginoplasty, among which hymenoplasty figures only incidentally?

TITLE: Des « certificats de virginité ¼ aux hyménoplasties en France. ABSTRACT: « Dans la République, on ne peut pas exiger des certificats de virginité pour se marier ; dans la République, on ne doit jamais accepter que les lois de la religion puissent être supérieures aux lois de la République ¼, telle est la déclaration en février 2020 du président Emmanuel Macron. Mais quel est donc le statut de ces certificats de virginité, est-il véritablement religieux ? Pourquoi se focaliser sur les « certificats de virginité ¼ sans jamais évoquer la pratique concomitante de la réfection d'hymen ? N'existe-t-il pas une diversité de pratiques chirurgicales participant du processus de revirginisation telle que la nymphoplastie ou la vaginoplastie ; l'hyménoplastie ne serait-elle que la pointe émergée de l'iceberg ?

The little tissue that couldn't - dispelling myths about the Hymen's role in determining sexual history and assault.

Conclusions about women's and girls' sexual history are made in some settings based on assumptions about the hymen, a small membranous tissue with no known biological function, which typically occupies a portion of the external vaginal opening in females. Clinicians, however, continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. We reviewed published evidence to dispel commonly held myths about the hymen and its morphology, function, and use as evidence in cases of sexual violence.An examination of the hymen is not an accurate or reliable test of a previous history of sexual activity, including sexual assault. Clinicians tasked with performing forensic sexual assault examinations should avoid descriptions such as "intact hymen" or "broken hymen" in all cases, and describe specific findings using international standards and terminology of morphological features.We call on clinicians to consider the low predictive value of a hymen examination and to: 1) avoid relying solely on the status of the hymen in sexual assault examinations and reporting; 2) help raise awareness of this issue among their peers and counterparts in law enforcement and the judicial system; and 3) promote fact-based discussions about the limitations of hymenal examinations as part of clinical education for all specialties that address the sexual or reproductive health of women and girls.

Diagnosis and Management of Hymenal Variants: ACOG Committee Opinion, Number 780.

At puberty, a patient with an imperforate hymen typically presents with a vaginal bulge of thin hymenal tissue with a dark or bluish hue caused by the hematocolpos behind it. Other findings that may be present include an abdominal mass, urinary retention, dysuria, constipation, and dyschezia. On evaluation, the goal is to differentiate an imperforate hymen from other obstructing anatomic etiologies, such as labial adhesions, urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Surgical intervention is necessary only in symptomatic prepubertal patients. After confirmation of the diagnosis, surgical intervention usually is deferred until pubertal estrogenization has occurred because the imperforate hymen may open spontaneously at puberty. It is important to complete an abdominal and a perineal examination. If the physical examination reveals a bulging hymen and ultrasonography reveals hematocolpos, further imaging is not required. However, if the diagnosis is not certain or there is a concern for a distal vaginal atresia, cervical atresia, an obstructed uterine horn, or transverse or longitudinal vaginal septum, magnetic resonance imaging is recommended. The ideal time for surgical intervention on hymenal tissue is before the onset of pain and after onset of pubertal development, when the vaginal tissue is estrogenized. Surgical management of clinically significant hymenal variations involves excision of the hymenal tissue and rarely is associated with long-term sequelae. If there is concern that the patient has a distal vaginal atresia or a transverse vaginal septum, the patient should be referred to a center with expertise in the management of these conditions.

Definition of apical descent in women with and without previous hysterectomy: A retrospective analysis.

BACKGROUND: While normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical prolapse are highly variable. OBJECTIVES: To investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for 'significant apical descent using receiver-operator characteristics (ROC) statistics. STUDY DESIGN: Retrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure "C". RESULTS: The records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 (SD 3.0, range 0-10). POP-Q point "C" was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 (sensitivity 0.73, specificity 0.67 with uterus in situ, sensitivity 0.59, specificity, 0.73 after hysterectomy). CONCLUSION: A cut- off for 'significant central compartment descent' of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy.

Impact of mechanical force on posterior hymen - Implications for sexual abuse injury interpretations.

BACKGROUND: Residual anogenital findings following sexual abuse are rare. There is a need for further understanding of the interpretation of hymenal findings. OBJECTIVES: This study evaluates which is more significant with respect to posterior hymenal tissue morphology - previous consensual penile vaginal penetrations or vaginal delivery. DESIGN: A post hoc study comparing nulliparous and parous hymen in heterosexually active female volunteers, with the focus on healed hymenal defects. Adult posterior hymen configuration was evaluated using labial separation or traction. When needed, the hymenal status was evaluated using a swab. A colposcopy with photography was used for documentation. Experts reviewed all taken photographs and recorded the posterior hymenal defects. Photographs were analyzed to determine the level of agreement. PARTICIPANTS: Eighty-seven adult female volunteers were recruited to participate in the study by a personal invitation to a gynecological examination to document anogenital findings. The examination was performed following consensual vaginal intercourse. Age ranged from 20 to 53 (median 26.6years). RESULTS: Single site posterior hymenal transections were significantly more likely in the nulliparous volunteers, compared to the parous volunteers (22/51, 43.1% vs. 4/36, 11.1%, p<0.001). A deep notch, which extends nearly to the base of the hymen was detected in one (2.0%) sexually active nulliparous volunteer, and surprisingly two (3.9%) volunteers had a single, more superficial hymenal notch, that is not considered a sign of previous vaginal penetration. The width of the ridge of the posterior vaginal wall in the vestibule was measured from the anterior part of the navicular fossa to the base of the hymen. The mean width of the ridge of the posterior vaginal wall was 3.1mm (SD2.2, range 0-8) in the photos of 41 nulliparous volunteers. The prevalence of 'double leaf hymen' was 2/87 (2.3%). The inter-rater reliability with a Kappa score of 0.69 indicated strong agreement. CONCLUSION: The myth "hymen is present only in virgins" has now been invalidated. The absence of posterior hymen increases delivery by delivery in adult female volunteers. The space between the anterior part of the navicular fossa and the base of hymen, 'the ridge of the posterior vaginal wall' in the vestibule was evaluated for the first time among studies evaluating hymenal status. Careful assessment of the ridge of the posterior vaginal wall is needed to avoid misinterpretations when evaluating the depth of a hymenal defect.

Is the hymen a suitable cut-off point for clinically relevant pelvic organ prolapse?

OBJECTIVES: The primary objective was to evaluate the ability of different anatomic cut-off points, as established in specialist urogynecology populations, to identify clinically relevant prolapse in a population of postmenopausal women with pelvic floor symptoms recruited from primary care. STUDY DESIGN: Cross-sectional study among 890 women (≥55 years) screened for pelvic floor symptoms. MAIN OUTCOME MEASURES: The Pelvic Floor Distress Inventory 20 was used to measure symptoms, and the Pelvic Organ Prolapse Quantification (POP-Q) system was used to assess prolapse. Areas under the curves, sensitivity, and specificity were calculated for the hymen as a cut-off point for symptomatic prolapse of the anterior and posterior vaginal wall. For the apical compartment, a cut-off point of -5cm relative to the hymen was used. RESULTS: Vaginal bulging was the only symptom reported more often with increasing POP-Q stages. Areas under the curves (95% confidence intervals) to discriminate between women with and without vaginal bulging symptoms were 0.66 (0.61-0.72), 0.56 (0.50-0.63), and 0.61 (0.55-0.66) for the anterior (Ba), posterior (Bp) and apical (C) compartment, respectively. When the hymen was used as the cut-off point, Ba had a sensitivity of 38.1% and a specificity of 82.4%, and Bp had a sensitivity of 13.3% and a specificity of 96.5%. For C, the cut-off point of -5cm relative to the hymen had a sensitivity of 37.9% and a specificity of 73.1%. CONCLUSIONS: The anatomic cut-off points for clinically relevant prolapse established in the specialist urogynecology population cannot adequately identify symptomatic prolapse in a population of postmenopausal women with pelvic floor symptoms recruited from primary care.

Appearance of external genital organs and types of hymen in Turkish female foetal cadavers.

The present study's purpose was to determine the size and morphometric development of the female external genital organs on foetal cadavers. Dimensions of labia majora, labia minora and clitoris, bilabial diameter, vertical and horizontal diameters of hymenal opening, distance between the external urethral orifice and hymenal opening, distance between the clitoris and external urethral orifice and anogenital distance were measured. The hymenal types were determined. Mean values of parameters according to gestational weeks, months and trimesters were calculated. Imperforate hymen were determined in the first trimester. Twenty-eight foetuses with annular hymen, 25 foetuses with imperforate hymen, and 1 foetus with septated hymen were determined in the second trimester. Twenty-four foetuses with annular hymen, 3 foetuses with imperforate hymen, 1 foetus with fimbriated hymen, and 1 foetus with hymenal tag were determined in the third trimester. All foetuses in the full term were determined with annular hymen.

Statement on virginity testing.

Virginity testing (virginity examination) is a gynecological examination that is intended to correlate the status and appearance of the hymen with previous sexual contact to determine whether a female has had or is habituated to sexual intercourse. Virginity examinations are practiced in many countries, often forcibly, including in detention places; on women who allege rape or are accused of prostitution; and as part of public or social policies to control sexuality. The Independent Forensic Expert Group (IFEG) - thirty-five preeminent independent forensic experts from eighteen countries specialized in evaluating and documenting the physical and psychological effects of torture and ill-treatment - released a statement on the practice in December 2014. In its statement, the IFEG outlines the physical and psychological effects of forcibly conducting virginity examinations on females based on its collective experience. The Group assesses whether, based on the effects, forcibly conducted virginity examinations constitute cruel, inhuman, or degrading treatment or torture. Finally, the IFEG addresses the medical interpretation, relevance, and ethical implications of such examinations. The IFEG concludes that virginity examinations are medically unreliable and have no clinical or scientific value. These examinations are inherently discriminatory and, in almost all instances, when conducted forcibly, result in significant physical and mental pain and suffering, thereby constituting cruel, inhuman and degrading treatment or torture. When virginity examinations are forcibly conducted and involve vaginal penetration, the examination should be considered as sexual assault and rape. Involvement of health professionals in these examinations violates the basic standards and ethics of the professions.

Injuries in prepubertal and pubertal girls.

In this chapter, examination techniques are first recommended, and then terminology for genital injuries that may occur after child sexual abuse or rape (e.g. lacerations, notch, transaction) are described. Current evidence for these injuries is provided. Areas of controversy (e.g. hymenal diameter, hymenal width) are described and completed with cautionary notes on inflammation, bruising, abrasions, bumps and mounds, tags, labial fusion, lichen sclerosis). The chapter concludes with a debate on normal findings that are reported to occur in up to 99% of children referred for examination.

Sexual assault in prepubertal girls: 'It is normal to be normal' - or is it? Evidence of vaginal penetration in prepubertal girls.

Study objective The purpose of this study is to evaluate the long-term effects of penile vaginal penetration in prepubertal girls. The specific emphasis is on whether there would be visible identifiable medical evidence of penetration on examinations done months or years after the event. Literature review The medical literature regarding this subject was reviewed specifically for defendable evidence supporting a statement that there would be no findings as well as those that suggested that there would be visible evidence of trauma. Specific definitions of sexual assault, visible anatomic change from trauma, and sexual penetration are established for clarity. The effect of the lack of estrogen on the genital tissue of prepubertal girls is reviewed in relationship to the potential effects of trauma. The average diameters of the hymenal opening in this age group and the diameter of the erect male penis were reviewed. Conclusion The result of the study both from review of the medical literature and an understanding of the anatomy and histology of the unestrogenized genitalia of the prepubertal girl makes it clear that if there has been forceful penile penetration of the hymen there will be both a history of pain and bleeding and healed evidence of this forceful penetration.

The prepubertal hymen.

Not so long ago, some doctors believed that they could determine, on the basis of examination of a girl's genitals, whether or not the girl had engaged in sexual intercourse. Even today, 'virginity checks' are conducted by doctors in some countries. Some Australian doctors still believe that it should be possible to determine, on the basis of examination findings, whether a child has been sexually abused. This article sets out to describe some of the common variations in hymenal anatomy in order to dispel myths and misperceptions surrounding genital examination findings in young girls.

Imperfuração himenal: seguimento de caso por dois anos / Imperforate hymen: follow-up case for two years

A imperfuração himenal é uma anomalia na qual o orifício vaginal é totalmente ocluído, o que retém a secreção menstrual. A incidência é variável com taxas de 0,014% a 0,1% em fetos a termo. No período pré-púbere, geralmente é assintomática. Descreve-se o caso de uma paciente de 15 anos de idade que procurou atendimento médico com queixa de dor no abdome inferior, aumento de volume abdominal progressivo em um ano e piora na primeira semana de cada mês. A história e o exame físico direcionaram ao diagnóstico de imperfuração himenal, confirmada como massa cística pélvica na ultrassonografia. O propósito deste relato é ilustrar a ocorrência de imperfuração himenal e seguimento pela ultrassonografia posterior à himenectomia, indicando prognóstico bom nos casos de imperfuração himenal sem anomalias do trato urinário.

The imperforate hymen is an anomaly in which the vaginal opening is completely occluded, causing retention of menstrual discharge. The incidence is very controversial and variable, ranging from 0.014% to 0.1% in fetuses at term. In the pre-puberty are usually asymptomatic. The authors describe the case of a 15-year-old patient who sought medical care complaining of pain in lower abdomen, progressive abdominal distention in one year and a worsening in the first week of each month. The history and physical examination directed to the diagnosis of imperforate hymen confirmed as a cystic mass on pelvic ultrasound. The purpose of this report is to illustrate the occurrence of imperforate hymen and follow-up ultrasonography after himenectomia, indicating good prognosis in cases of imperforate hymen without urinary tract abnormalities.

Changes in genital anatomy and microbiology in girls between age 6 and age 12 years: a longitudinal study.

STUDY OBJECTIVE: To study changes in genital anatomy and occurrence of human papillomavirus and Gardnerella vaginalis in girls resulting from growth and development. DESIGN: At age 11-12 years, an invitation was sent to 180 girls to attend a follow-up examination. All girls had previously participated in a study exploring anogenital anatomy and microbiology in children selected for non-abuse at age 5 and 6. The genital area was examined with a colposcope and microbiological samples for Gardnerella vaginalis (GV) and human papillomavirus (HPV) were collected. GV was identified by conventional criteria and HPV by a PCR method. RESULTS: Thirty-one girls were examined twice, at mean age 5.7 and 12.0 years. At first examination all were pre-pubertal. At second examination 21 girls were B2/P2 or above. Significantly more girls had developed a structure called a fossa groove. A thick and redundant hymen with a tendency of folding outward was more common at the second examination. Two girls had GV and one girl had HPV-16 identified. Another girl was classified to have a deep notch and a probable transection in her hymen, and this girl reported a painful insertion of a tampon. All girls denied sexual activity. CONCLUSION: The main genital finding in girls entering puberty is the hymen becoming thick and redundant with a tendency of folding out. In the study findings associated with sexual activity were discovered in two girls, and the possibility of alternative explanations is discussed.

[Expert evaluation of unusual anatomical structure of the genital organs and hymen in sexually assaulted victims].

The paper reports examples of expert examination of women with anomalous anatomical organization of external genitalia and hymen who have experienced sexual assault. Expert interpretation of these findings and their forensic medical implications is offered.

Hysteroscopic management of lower genital tract lesions in females with limited vaginal access.

OBJECTIVE: To show that hysteroscopy is a feasible and safe method of evaluation in females with limited vaginal access. DESIGN: Retrospective review of two patients who received hysteroscopy for evaluation of uterus didelphys with hemivagina and a cervical polyp. SETTING: Private hospital. PATIENT(S): Two patients with either a vagina septum or cervical polyp. INTERVENTION(S): Hysteroscopy for visualization and resection. MAIN OUTCOME MEASURE(S): Resection of a vagina septum and cervical polyp. RESULT(S): No more cyclic dysmenorrhea in the patient with uterus didelphys and cessation of abnormal bleeding in the patient with a cervical polyp. Our results suggest that hysteroscopy can provide precise visualization of vagina and cervical lesions if the approach is difficult with decreased access, and allows concurrent treatment of pathologic conditions accordingly. CONCLUSION(S): Hysteroscopy is favorable in the diagnosis and treatment of vaginal and cervical lesions in women with limited vaginal access because of age or a narrower vagina. In the Eastern culture, it is very important for females to maintain their state of virginity signified by an uninjured hymen ring. This problem is solved, as hysteroscopy allows the evaluation of malformations of the female genital tract.

Genital findings in prepubertal girls: what can be concluded from an examination?

INTRODUCTION: Interpretation of genital findings is a key component of the medical examination for suspected child sexual abuse. This study seeks to review the extent of evidence-based research on genital findings in prepubertal girls. METHODS: Literature review on normal genital anatomy in non-abused girls, case control studies comparing abused and non-abused girls, and observations of healing where the mechanism of injury is documented. RESULTS: A prolific literature exists on children examined for suspected abuse. By comparison there is a very little literature on children screened for non-abuse. Primary data on normal genital anatomy in girls after the neonatal period was found in 10 papers of non-abused girls and 6 case-control studies. The screening methods used to ensure that only non-abused children were assigned to non-abused groups were of variable standards. The evidence base on prepubertal girls selected for non-abuse using robust methodology is very small. The evidence base on healing of documented genital injury is contained in two case series, and a small number of case reports. Almost the entire evidence base on prepubertal genital anatomy in girls is derived from the USA. CONCLUSIONS: Knowledge of the American studies and the limited extent of the total evidence base are essential to interpretation. A posterior rim of hymen measuring at least 1mm is always present unless there has been trauma. There is such a wide range of normal hymen orifice size, that measurements are generally unhelpful. Genital injuries generally heal rapidly and most heal without residua. Hymen healing does not leave scarring, but scarring or vascular changes may occur to surrounding tissues. Except for deep lacerations hymen injury leaves no evidence of trauma. A full thickness transection through the posterior hymen is reliable evidence of trauma and does not heal without surgical repair.