- Email: [email protected]
Treatment of Microperforate Hymen With Serial Dilation: A Novel Approach
Accepted Manuscript Treatment of Microperforate Hymen with Serial Dilation: A Novel Approach Thalia R. Segal , MD Wendy B. Fried , MD Eileen Y. Krim , MD Deep Parikh , BS David L. Rosenfeld , MD PII:
S1083-3188(14)00218-6
DOI:
10.1016/j.jpag.2014.06.001
Reference:
PEDADO 1726
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 22 February 2014 Revised Date:
30 May 2014
Accepted Date: 2 June 2014
Please cite this article as: Segal TR, Fried WB, Krim EY, Parikh D, Rosenfeld DL, Treatment of Microperforate Hymen with Serial Dilation: A Novel Approach, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.06.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Treatment of Microperforate Hymen with Serial Dilation: A Novel Approach Thalia R. Segal, MD,1 Wendy B. Fried, MD,1 Eileen Y. Krim, MD,1 Deep Parikh, BS,2
SC
David L. Rosenfeld, MD1
North Shore University Hospital - LIJ Health System, Mahasset, NY 11030.
2
SUNY Downstate Medical Center, Brooklyn, NY 11203.
M AN U
1
Corresponding author: Thalia R. Segal
TE D
304 Community Drive, Apt 1G Manhasset, NY 11030
Fax: (516) 562 - 1299
EP
Tel: (646) 577 - 5120
AC C
Email: [email protected]
1
ACCEPTED MANUSCRIPT
ABSTRACT
RI PT
Background: Microperforate and imperforate hymens are one of the most common causes of vaginal outflow obstruction in the adolescent population. To date, these hymen anomalies are traditionally treated by hymenectomy with a cruciate excision.
SC
Cases(s): We report two cases of adolescent women with a microperforate hymen who were successfully and minimally invasively treated with progressive dilation with Hegar cervical
M AN U
dilators until a number 23 dilator was reached under anesthesia in the OR.
Summary and Conclusion: Minimally invasive treatment of microperforate hymen with the use of progressive cervical dilators may be an alternative technique to the traditional excisional hymenectomy. Our patients reported satisfaction, minimal postoperative pain or scarring at 2
TE D
weeks and 6 months after the procedure. This technique can be an additional option for all women, especially those with cultural beliefs in virginity.
AC C
hymen
EP
Keywords: hymenotomy, hymenectomy, surgical correction, imperforate hymen, microperforate
2
ACCEPTED MANUSCRIPT
INTRODUCTION
RI PT
An imperforate hymen is the most common congenital cause of outflow tract obstruction in women with an incidence of 1 in 1000. 1 While an imperforate hymen completely covers the opening to the vagina, a microperforate hymen typically has a pin-point sized opening.2
SC
Embryologically, both are the result of a failure to canalize the vaginal plate at 22 weeks
gestation and failure of the hymen to dissolve in utero. In the fetus, the hymen separates the
M AN U
urogenital sinus from the caudal end of the fused paramesonephric (Mullerian) ducts. This condition is usually not associated with any other anomalies in the Mullerian or urinary systems. It is hypothesized that failure of epithelial cells in the center of the hymen to degenerate, or abnormal, excess cell proliferation and coalescence all may cause a microperforate or
TE D
imperforate hymen. 3
Unlike an imperforate hymen which completely blocks vaginal outflow, women with a microperforate hymen may have no menstrual symptoms at all or may present with irregular
EP
postmenstrual spotting due to poor drainage. These patients usually seek gynecological assistance due to difficulty inserting tampons, dyspareunia, recurrent urinary tract infections or
AC C
malodorous discharge. Microperforate hymens predispose patients to ascending infections of the pelvis and urinary tract due to partial obstruction. 4 In some cases, visual inspection reveals a bulging hymen due to the retained menstrual blood, whereas in other cases this is absent and only a thick, tight hymenal ring is noted.
3
ACCEPTED MANUSCRIPT
Current management includes hymenectomy with a cruciate, X, or plus-shaped excision.
RI PT
In this case report, we offer a new technique of progressive dilation with Hegar dilators in
patients with a microperforate hymen. This may also be an alternative hymen sparing procedure
SC
for all women and particularly those with cultural beliefs for preserving their hymenal tissue.
CASE(S)
M AN U
A 13 year-old G0P0 with onset of menarche 2 weeks ago, presented to the GYN office due to her inability to insert a tampon. Her menstrual period lasted 7 days and was associated with mild dysmenorrhea. The patient attempted inserting a tampon multiple times and it was extremely painful and not possible. The patient denied having experienced vaginal intercourse,
TE D
either consensual or forced. Her only relevant gynecologic history was labial adhesions as a young child which was treated with topical estrogen preparations. She had no significant past medical or surgical history, no medications or allergies, and no social or family history. On
EP
physical examination, the patient was an anxious Tanner stage IV female who was in otherwise good health. Pelvic exam revealed a microperforate hymen that was visualized with parting of
AC C
the labia minora and could not admit a 5th digit. Our second case was a 16 year-old white female G0P0 who had onset of menarche at age 12. Her cycles came regularly every 28 days and last 7 days. She denied having experienced vaginal intercourse, either consensual or forced, and reported dysmenorrhea and inability to place a tampon. Prior attempts were met with pain and placement failure. She had no prior 4
ACCEPTED MANUSCRIPT
gynecologic, past surgical, family or social history, and she had no known drug allergies. Past
RI PT
medical history was significant for hypothyroidism, treated with synthroid. On physical
examination she was a Tanner stage IV female in otherwise good health with a microperforate hymen that would not admit a 5th digit.
SC
In both cases, the patients and their mothers were extensively counseled regarding
surgical treatment options including the traditional cruciate excision technique and a novel
M AN U
technique of dilation which was anecdotally equally effective and would preserve the integrity of the hymenal ring. Goals of therapy were discussed including comfortable tampon use, future sexual function and reproduction as well as the experimental nature of the technique and potential for scarring, re-closure, and possible need for additional surgery if unsuccessful. All
less invasive treatment option.
TE D
questions and concerns were addressed and the families and patients agreed to proceed with a
Both patients were taken to the OR, placed in dorsal lithotomy and examined under
EP
anesthesia to reveal similar microperforate hymens that barely admitted a 5th digit. In each case, progressive lubricated Hegar cervical dilators were introduced and left in place for 10 seconds
AC C
through the microperforate hymen. We began with a number 6 Hegar dilator, lubricated each dilator with surgilube, and increased the diameter of each dilator by 1/2 size, in a slow gradual fashion, until a number 23 Hegar dilator was reached. No surgical incision was created. At the conclusion of the procedure, the hymen comfortably admitted the examiners 2-gloved fingers. There was no bleeding and the total time to complete the procedure was ten minutes. 5
ACCEPTED MANUSCRIPT
Both patients were seen for follow up 2 weeks later and could easily insert and remove a
RI PT
regular tampon. At 6 months follow up both patients reported doing well, with patent hymens, inserting tampons easily without scarring or pain. Neither patient experienced vaginal
SC
intercourse in the interim since the dilation procedure.
SUMMARY AND CONCLUSION
M AN U
The gold standard technique for a microperforate or imperforate hymen is a cruciate incision of the hymen followed by excision of excess hymenal tissue. The vaginal mucosa is then sutured to the hymenal ring to prevent re-closure.3 After a search on Pubmed of “hymenectomy”, “hymenotomy”, “hymenoplasty”, “imperforate hymen”, “microperforate
TE D
hymen” there was only 1 case report found in the veterinary literature that discussed serial dilatation of a persistent hymen in alpacas and llamas. 5 There have been no reports in humans. Progressive dilation of the microperforate hymen with the use of Hegar dilators is a less invasive
EP
alternative for all women which may be equally effective and can be especially superior for patients concerned about retaining the hymenal ring for cultural or social reasons. We
AC C
extrapolate that this procedure can also be used for imperforate hymens with a small pinpoint incision prior to the dilatation technique. Alternative methods to traditional hymenectomy include a central or oval incision with insertion of a foley catheter,6 carbon dioxide laser, 7 or a simple vertical incision.2 Complications of any intervention include re-closure, bleeding, vulvovaginitis, dyspareunia and risks of anesthesia. 6
ACCEPTED MANUSCRIPT
The first reported successful use of a dilator for a gynecological condition was for vaginal
RI PT
agenesis in 1835.8 Since then, dilators have been used as a nonsurgical option for many other disorders including Müllerian agenesis, transverse vaginal septum,9 vaginismus,10 vulvovaginal strictures from Crohn’s disease or other autoimmune skin diseases, and pelvic radiation.11 In
SC
addition, vaginal dilators have been used for women having a posterior colporrhaphy to prevent postoperative dyspareunia.12 Consistent with other reports, the use of vaginal dilators to create a
M AN U
neovagina had an 88%-success rate in a 12-year retrospective review of patients with Müllerian aplasia.13
We have provided here a novel minimally invasive approach for patients with microperforate and imperforate hymens. This technique is less invasive and can be an additional
TE D
option for all women and may give women from cultures with a high value on virginity an alternative option that facilitates menstrual flow, tampon use, and preserves the integrity of the hymenal ring. Follow up studies are needed on larger numbers of patients and their outcomes,
EP
along with long-term studies on patient satisfaction with this procedure, dyspareunia, as well as
AC C
future rates of re-closure or complications.
7
ACCEPTED MANUSCRIPT
RI PT
REFERENCES
of amenorrhea. Fertil Steril 2006; 85(5 suppl): S148.
SC
1. American Society for Reproductive Medicine Practice Committee: Current evaluation
Obstet Gynecol 1974; 44(6):903.
M AN U
2. Capraro VJ, Dillon WP, Gallego, MB: Microperforate hymen A Distinct Clinical Entity.
3. Miller RJ, Breech LL: Surgical Correction of Vaginal Anomalies. Clinical Obstet and Gynecol 2008; 51(2):223.
4. Sanfilippo AM, Mansuria SM: Microperforate hymen resulting in pelvic abscess. J
TE D
Pediatr Adolesc Gynecol 2006; 19(2):95.
5. Tan RH, Dascanio JJ: Infertility associated with persistent hymen in an alpaca and a llama.
EP
Can Vet J 2008; 49:1113.
6. Acar A, Balci O, Karatayli R, et al: The treatment of 65 women with imperforate hymen by a
AC C
central incision and application of Foley catheter. BJOG 2007;114:1376. 7. Friedman M, Gal D, Peretx BA: Management of imperforate hymen with the carbon dioxide laser. Obstet Gynecol 1989; 74: 270. 8. Amussat J: Observation sur une operation de vagin artificiel pratigee avec success, par une
8
RI PT
ACCEPTED MANUSCRIPT
nouveau procède suivie de queoques reflection sur les vices de conformation du vagin. Gazette Medicale de Paris 1835; 50:785. 9. Edmonds DK: Congenital malformations of the genital tract and their management. Best Pract
SC
Res Clin Obstet Gynaecol 2003; 17(1):19.
10. Biswas A, Ratnam SS: Vaginismus and outcome of treatment. Ann Acad Med Singapore.
M AN U
1995; 24(5):755.
11. Amankwah YA, Haefner HK, Brincat CA: Management of Vulvovaginal Strictures/ Shortened Vagina. Clin Obstet Gynecol 2010; 53:125.
12. Antosh DD, Gutman RE, Park AJ, et al: Vaginal dilators for prevention of dyspareunia after
TE D
prolapse surgery: a randomized controlled trial. Obstet Gynecol 2013; 121:1273. 13 . Gargollo PC, Cannon GM, Diamon DA, et al: Should Progressive Perineal Dilation be
AC C
EP
Considered First Line Therapy for Vaginal Agenesis? J Urol 2009; 182:1882.
9
S1083-3188(14)00218-6
DOI:
10.1016/j.jpag.2014.06.001
Reference:
PEDADO 1726
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 22 February 2014 Revised Date:
30 May 2014
Accepted Date: 2 June 2014
Please cite this article as: Segal TR, Fried WB, Krim EY, Parikh D, Rosenfeld DL, Treatment of Microperforate Hymen with Serial Dilation: A Novel Approach, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.06.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Treatment of Microperforate Hymen with Serial Dilation: A Novel Approach Thalia R. Segal, MD,1 Wendy B. Fried, MD,1 Eileen Y. Krim, MD,1 Deep Parikh, BS,2
SC
David L. Rosenfeld, MD1
North Shore University Hospital - LIJ Health System, Mahasset, NY 11030.
2
SUNY Downstate Medical Center, Brooklyn, NY 11203.
M AN U
1
Corresponding author: Thalia R. Segal
TE D
304 Community Drive, Apt 1G Manhasset, NY 11030
Fax: (516) 562 - 1299
EP
Tel: (646) 577 - 5120
AC C
Email: [email protected]
1
ACCEPTED MANUSCRIPT
ABSTRACT
RI PT
Background: Microperforate and imperforate hymens are one of the most common causes of vaginal outflow obstruction in the adolescent population. To date, these hymen anomalies are traditionally treated by hymenectomy with a cruciate excision.
SC
Cases(s): We report two cases of adolescent women with a microperforate hymen who were successfully and minimally invasively treated with progressive dilation with Hegar cervical
M AN U
dilators until a number 23 dilator was reached under anesthesia in the OR.
Summary and Conclusion: Minimally invasive treatment of microperforate hymen with the use of progressive cervical dilators may be an alternative technique to the traditional excisional hymenectomy. Our patients reported satisfaction, minimal postoperative pain or scarring at 2
TE D
weeks and 6 months after the procedure. This technique can be an additional option for all women, especially those with cultural beliefs in virginity.
AC C
hymen
EP
Keywords: hymenotomy, hymenectomy, surgical correction, imperforate hymen, microperforate
2
ACCEPTED MANUSCRIPT
INTRODUCTION
RI PT
An imperforate hymen is the most common congenital cause of outflow tract obstruction in women with an incidence of 1 in 1000. 1 While an imperforate hymen completely covers the opening to the vagina, a microperforate hymen typically has a pin-point sized opening.2
SC
Embryologically, both are the result of a failure to canalize the vaginal plate at 22 weeks
gestation and failure of the hymen to dissolve in utero. In the fetus, the hymen separates the
M AN U
urogenital sinus from the caudal end of the fused paramesonephric (Mullerian) ducts. This condition is usually not associated with any other anomalies in the Mullerian or urinary systems. It is hypothesized that failure of epithelial cells in the center of the hymen to degenerate, or abnormal, excess cell proliferation and coalescence all may cause a microperforate or
TE D
imperforate hymen. 3
Unlike an imperforate hymen which completely blocks vaginal outflow, women with a microperforate hymen may have no menstrual symptoms at all or may present with irregular
EP
postmenstrual spotting due to poor drainage. These patients usually seek gynecological assistance due to difficulty inserting tampons, dyspareunia, recurrent urinary tract infections or
AC C
malodorous discharge. Microperforate hymens predispose patients to ascending infections of the pelvis and urinary tract due to partial obstruction. 4 In some cases, visual inspection reveals a bulging hymen due to the retained menstrual blood, whereas in other cases this is absent and only a thick, tight hymenal ring is noted.
3
ACCEPTED MANUSCRIPT
Current management includes hymenectomy with a cruciate, X, or plus-shaped excision.
RI PT
In this case report, we offer a new technique of progressive dilation with Hegar dilators in
patients with a microperforate hymen. This may also be an alternative hymen sparing procedure
SC
for all women and particularly those with cultural beliefs for preserving their hymenal tissue.
CASE(S)
M AN U
A 13 year-old G0P0 with onset of menarche 2 weeks ago, presented to the GYN office due to her inability to insert a tampon. Her menstrual period lasted 7 days and was associated with mild dysmenorrhea. The patient attempted inserting a tampon multiple times and it was extremely painful and not possible. The patient denied having experienced vaginal intercourse,
TE D
either consensual or forced. Her only relevant gynecologic history was labial adhesions as a young child which was treated with topical estrogen preparations. She had no significant past medical or surgical history, no medications or allergies, and no social or family history. On
EP
physical examination, the patient was an anxious Tanner stage IV female who was in otherwise good health. Pelvic exam revealed a microperforate hymen that was visualized with parting of
AC C
the labia minora and could not admit a 5th digit. Our second case was a 16 year-old white female G0P0 who had onset of menarche at age 12. Her cycles came regularly every 28 days and last 7 days. She denied having experienced vaginal intercourse, either consensual or forced, and reported dysmenorrhea and inability to place a tampon. Prior attempts were met with pain and placement failure. She had no prior 4
ACCEPTED MANUSCRIPT
gynecologic, past surgical, family or social history, and she had no known drug allergies. Past
RI PT
medical history was significant for hypothyroidism, treated with synthroid. On physical
examination she was a Tanner stage IV female in otherwise good health with a microperforate hymen that would not admit a 5th digit.
SC
In both cases, the patients and their mothers were extensively counseled regarding
surgical treatment options including the traditional cruciate excision technique and a novel
M AN U
technique of dilation which was anecdotally equally effective and would preserve the integrity of the hymenal ring. Goals of therapy were discussed including comfortable tampon use, future sexual function and reproduction as well as the experimental nature of the technique and potential for scarring, re-closure, and possible need for additional surgery if unsuccessful. All
less invasive treatment option.
TE D
questions and concerns were addressed and the families and patients agreed to proceed with a
Both patients were taken to the OR, placed in dorsal lithotomy and examined under
EP
anesthesia to reveal similar microperforate hymens that barely admitted a 5th digit. In each case, progressive lubricated Hegar cervical dilators were introduced and left in place for 10 seconds
AC C
through the microperforate hymen. We began with a number 6 Hegar dilator, lubricated each dilator with surgilube, and increased the diameter of each dilator by 1/2 size, in a slow gradual fashion, until a number 23 Hegar dilator was reached. No surgical incision was created. At the conclusion of the procedure, the hymen comfortably admitted the examiners 2-gloved fingers. There was no bleeding and the total time to complete the procedure was ten minutes. 5
ACCEPTED MANUSCRIPT
Both patients were seen for follow up 2 weeks later and could easily insert and remove a
RI PT
regular tampon. At 6 months follow up both patients reported doing well, with patent hymens, inserting tampons easily without scarring or pain. Neither patient experienced vaginal
SC
intercourse in the interim since the dilation procedure.
SUMMARY AND CONCLUSION
M AN U
The gold standard technique for a microperforate or imperforate hymen is a cruciate incision of the hymen followed by excision of excess hymenal tissue. The vaginal mucosa is then sutured to the hymenal ring to prevent re-closure.3 After a search on Pubmed of “hymenectomy”, “hymenotomy”, “hymenoplasty”, “imperforate hymen”, “microperforate
TE D
hymen” there was only 1 case report found in the veterinary literature that discussed serial dilatation of a persistent hymen in alpacas and llamas. 5 There have been no reports in humans. Progressive dilation of the microperforate hymen with the use of Hegar dilators is a less invasive
EP
alternative for all women which may be equally effective and can be especially superior for patients concerned about retaining the hymenal ring for cultural or social reasons. We
AC C
extrapolate that this procedure can also be used for imperforate hymens with a small pinpoint incision prior to the dilatation technique. Alternative methods to traditional hymenectomy include a central or oval incision with insertion of a foley catheter,6 carbon dioxide laser, 7 or a simple vertical incision.2 Complications of any intervention include re-closure, bleeding, vulvovaginitis, dyspareunia and risks of anesthesia. 6
ACCEPTED MANUSCRIPT
The first reported successful use of a dilator for a gynecological condition was for vaginal
RI PT
agenesis in 1835.8 Since then, dilators have been used as a nonsurgical option for many other disorders including Müllerian agenesis, transverse vaginal septum,9 vaginismus,10 vulvovaginal strictures from Crohn’s disease or other autoimmune skin diseases, and pelvic radiation.11 In
SC
addition, vaginal dilators have been used for women having a posterior colporrhaphy to prevent postoperative dyspareunia.12 Consistent with other reports, the use of vaginal dilators to create a
M AN U
neovagina had an 88%-success rate in a 12-year retrospective review of patients with Müllerian aplasia.13
We have provided here a novel minimally invasive approach for patients with microperforate and imperforate hymens. This technique is less invasive and can be an additional
TE D
option for all women and may give women from cultures with a high value on virginity an alternative option that facilitates menstrual flow, tampon use, and preserves the integrity of the hymenal ring. Follow up studies are needed on larger numbers of patients and their outcomes,
EP
along with long-term studies on patient satisfaction with this procedure, dyspareunia, as well as
AC C
future rates of re-closure or complications.
7
ACCEPTED MANUSCRIPT
RI PT
REFERENCES
of amenorrhea. Fertil Steril 2006; 85(5 suppl): S148.
SC
1. American Society for Reproductive Medicine Practice Committee: Current evaluation
Obstet Gynecol 1974; 44(6):903.
M AN U
2. Capraro VJ, Dillon WP, Gallego, MB: Microperforate hymen A Distinct Clinical Entity.
3. Miller RJ, Breech LL: Surgical Correction of Vaginal Anomalies. Clinical Obstet and Gynecol 2008; 51(2):223.
4. Sanfilippo AM, Mansuria SM: Microperforate hymen resulting in pelvic abscess. J
TE D
Pediatr Adolesc Gynecol 2006; 19(2):95.
5. Tan RH, Dascanio JJ: Infertility associated with persistent hymen in an alpaca and a llama.
EP
Can Vet J 2008; 49:1113.
6. Acar A, Balci O, Karatayli R, et al: The treatment of 65 women with imperforate hymen by a
AC C
central incision and application of Foley catheter. BJOG 2007;114:1376. 7. Friedman M, Gal D, Peretx BA: Management of imperforate hymen with the carbon dioxide laser. Obstet Gynecol 1989; 74: 270. 8. Amussat J: Observation sur une operation de vagin artificiel pratigee avec success, par une
8
RI PT
ACCEPTED MANUSCRIPT
nouveau procède suivie de queoques reflection sur les vices de conformation du vagin. Gazette Medicale de Paris 1835; 50:785. 9. Edmonds DK: Congenital malformations of the genital tract and their management. Best Pract
SC
Res Clin Obstet Gynaecol 2003; 17(1):19.
10. Biswas A, Ratnam SS: Vaginismus and outcome of treatment. Ann Acad Med Singapore.
M AN U
1995; 24(5):755.
11. Amankwah YA, Haefner HK, Brincat CA: Management of Vulvovaginal Strictures/ Shortened Vagina. Clin Obstet Gynecol 2010; 53:125.
12. Antosh DD, Gutman RE, Park AJ, et al: Vaginal dilators for prevention of dyspareunia after
TE D
prolapse surgery: a randomized controlled trial. Obstet Gynecol 2013; 121:1273. 13 . Gargollo PC, Cannon GM, Diamon DA, et al: Should Progressive Perineal Dilation be
AC C
EP
Considered First Line Therapy for Vaginal Agenesis? J Urol 2009; 182:1882.
9