Summary

Hymen is a thin membrane that covers the opening of vagina but allows menstrual blood to flow out. Certain conditions of the hymen, such as an imperforate hymen, block the flow of blood during periods and lead to complications such as no menstruation, pain, and discomfort.

In such conditions, a hymenotomy is done to correct the problem and facilitate the passage of menstrual blood. At times, the procedure can cause complications like pelvic inflammatory disease or infection. 

  1. What is hymenotomy?
  2. Why is hymenotomy recommended?
  3. Who can and cannot get hymenotomy?
  4. What preparations are needed before hymenotomy?
  5. How is hymenotomy done?
  6. How to care for yourself after hymenotomy?
  7. What are the possible complications/risks of hymenotomy?
  8. When to follow-up with your doctor after a hymenotomy?

Hymenotomy is a surgery to open up the hymen, the tissue that covers the opening of vagina in a female. Hymen is a thin membrane, commonly half-moon shaped, surrounding the vaginal opening. The membrane does not itself has a role but it permits the menstrual blood to pass out of the vagina. 

There are different types of anomalies of the hymen such as imperforate hymen, microperforate hymen, and septate hymen. An imperforate hymen can be identified at birth but is mostly diagnosed during teenage years. In this condition, the hymen covers the vaginal opening entirely and doesn’t allow the menstrual blood to pass out of the vagina. A microperforate hymen almost covers the vaginal opening, and although the opening is small, menstrual blood can flow out of the vagina. In a septate hymen, the extra skin in the middle causes the vagina to have two small openings instead of one. Surgeons recommend hymenotomy to treat all these types of anomalies in the hymen.

Surgeons recommend this procedure in the following conditions:

  • A perforated hymen with hymenal hypertrophy (enlargement of an organ or tissue with increase in the size of its cells) that does not allow intercourse.
  • An imperforate hymen that causes mucocolpos (mucus accumulation in the vagina), hematocolpos (blood accumulation within the vagina), or hematometra (collection or retention of blood in the uterus) at the onset of menstruation.

The symptoms for which this surgery is advised include:

  • Difficulty in inserting or removing a tampon 
  • Difficulty in sexual relations, i.e., a feeling of pain, discomfort or bleeding associated with intercourse
  • Lack of menstruation or prolonged menstruation
  • Mild pain in the abdomen
  • A palpable lump in the abdomen
  • Urinary retention
  • Building up of blood inside the vagina 

A hymenotomy may not be considered if you have a transverse vaginal septum (a wall of tissue runs horizontally in the vagina, blocking it) or distal vaginal atresia (the vagina may be absent or closed) and you will be referred to a clinic with experience in managing these issues.

The contraindications for surgery to treat an imperforate hymen include:

  • The surgeon’s inexperience
  • Failure to define the anatomy

You will need the following preparations before the surgery:

  • The healthcare practitioner will perform a thorough genital examination to see if the opening to your vagina is completely or partially blocked.
  • A magnetic resonance imaging (MRI) scan may be suggested if a diagnosis cannot be reached. 
  • A nasopharyngeal or moist cotton swab will be used to check the perforation of the hymen to verify the diagnosis. Ultrasonography may be suggested if longitudinal vaginal septum (a wall of tissue runs vertically down the length of the vagina, separating it into two cavities) is suspected.
  • Your consent will be sought once the benefits and possible risks of this procedure have been explained to you and your family. 

Hymenotomy is carried out in the clinic or in the operation theatre. An overnight stay in the hospital after the procedure may not be necessary. You can expect the following when you reach the hospital.

  • Before the procedure begins, you will be asked to change into a hospital gown. 
  • A needle may be inserted into your hand and will be attached to a drip to provide you with fluids and medicines.
  • You should take medicines, if any, prescribed by your doctor prior to the procedure. 
  • Inform your doctor if you are allergic to any medications or anaesthesia. 
  • An anesthesiologist will give you general or local anaesthesia so that you do not feel any pain during the procedure. 

The surgery is usually performed in the following manner for imperforate and microperforate hymen:

  • The surgeon will place in a urethral catheter (a hollow tube used to drain urine from the bladder) either before or during the operation to establish the correct position of the urethra.
  • He/she will make a U-shaped cut in your hymen, taking care to avoid your urethra. 
  • Then the surgeon will remove the hymenal mucosa (mucus membrane that covers the vaginal entrance) and stitch its edges with dissolvable interrupted sutures.

The steps to perform hymenotomy for a septate hymen are as follows:

  • The surgeon will use topical anaesthesia to numb the area of surgery.
  • He/she will place dissolvable stitches at the front end and back end of the septal tissue in your hymen.
  • Then, the surgeon will make a cut between the two sutures to remove the tissue, and apply an emollient (soothing) cream on your skin.

Once you reach home, you need to take the following care:

  • Apply an emollient like petroleum jelly or coconut oil to the operated area many times in a day while you are healing.
  • Keep the opening of the vagina dry and clean. 
  • If you feel pain, it can be managed with a topical anaesthetic jelly and nonsteroidal anti-inflammatory drugs.
  • An ice pack can be used to help prevent any swelling or discomfort.
  • You should expect an extended bleeding cycle for about two weeks. You may or may not experience heavy bleeding but can expect a discharge for one or two weeks.
  • Avoid using tampons and having sex for the first two weeks after surgery.
  • Wash the wound area using mild soap and warm water. Pat it dry and avoid rubbing. 
  • You can soak the area of surgery in warm water if you feel any discomfort.

When to see the doctor?

Visit or call your doctor right away if you observe the following symptoms:

  • Fever
  • Worsening pain
  • Heavy vaginal bleeding
  • Difficulty in passing urine
  • Foul-smelling discharge or if the discharge lasts for over two weeks 

The surgery carries the following risks:

  • Infection 
  • Damage to the urethra (a tube that carries urine from the bladder to the outside of the body during urination), bladder (an organ that stores urine), or rectum (last part of the large intestine)
  • Pelvic inflammatory disease

Your follow-up will be scheduled in two to four weeks after surgery to check if you are recovering well.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

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References

  1. Blask AR, Sanders RC, Rock JA. Obstructed uterovaginal anomalies: demonstration with sonography. Part II. Teenagers. Radiology 1991 Apr; 179(1): 84-8. PMID: 2006308.
  2. McCann J, Wells R, Simon M. Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990 Sep; 86(3): 428-39. PMID: 2388791.
  3. Stelling JR, Gray MR, Davis AJ, et al. Dominant transmission of imperforate hymen. Fertil Steril 2000 Dec; 74(6): 1241-4. PMID: 11119759.
  4. Rock JA, Zacur HA, Dlugi AM, et al: Pregnancy success following surgical correction of imperforate hymen and complete transverse vaginal septum. Obstet Gynecol 1982 Apr; 59(4): 448-51. PMID: 7078896.
  5. Olive DL, Henderson DY. Endometriosis and mullerian anomalies. Obstet Gynecol 1987 Mar; 69(3 Pt 1): 412-5. PMID: 3822289.
  6. Center for young women's health [Internet]. Boston Children's hospital. US; Types of Hymens
  7. Nationwide Children's [internet]. Nationwide Children's Hospital. Ohio. US; Hymenectomy
  8. Brigham Health [Internet]. Brigham and Women's Hospital. Massachusetts. US; Congenital Anomalies of the Hymen
  9. Joshi A, Tanwar H, Wagaskar V, Kaje Y, Satalkar MR. Imperforate hymen with acute urinary retention. J Case Rep. 2015;5:382-386.
  10. Laghzaoui O. Congenital imperforate hymen. BMJ Case Rep. 2016;2016:bcr2016215124.
  11. The American College of Obstetricians and Gynecologists [Internet]. Washington DC. US; Diagnosis and Management of Hymenal Variants
  12. National Health Service [Internet]. UK; Having an operation (surgery)
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