(27) Diagnosis of Imperforate Hymen: A Case Study for Quality Improvement

Background: Imperforate hymen, transverse vaginal septum, vaginal agenesis, and lower vaginal atresia are four common forms of vaginal outlet obstruction. Early differentiation between these anatomic variants is crucial to determine a correct diagnosis and ensure appropriate surgical timing to avoid unnecessary surgical revision or complication. Distinguishing between these variants relies initially on physical exam. When characteristic components are absent, it is critical to obtain imaging to distinguish between other obstructive vaginal anomalies as the presence of hematocolpos or hematometra may occur with many types of obstructive mullerian anomalies. A pelvic ultrasound may be ordered initially as it is more readily available but may not yield enough detailed information. In this circumstance, further imaging should be obtained prior to surgical intervention with Pelvic MRI; the gold standard imaging modality for reproductive tract anomalies. This case reminds the provider of the steps to take for the correct diagnosis as well as recommendations for specialist referral when the presentation is not that of a bulging membrane with blue hue at the introitus.

Case: A 13 yo female presented to an outside emergency room with severe, cyclic abdominopelvic pain. A pelvic ultrasound suggested hematometra. She was taken to the operating room due to pelvic exam findings concerning for no vaginal patency. A vaginal dimple was present without blue hue or bulging noted. Intraoperatively, an incision did not reveal release of menstrual contents. The surgery was aborted due to findings inconsistent with imperforate hymen. MRI Pelvis was ordered later and a diagnosis of cervicovaginal agenesis with hematometra was made. Menstrual suppression was then initiated with GnRh antagonist orally. A few years later, the patient was referred to Pediatric and Adolescent Gynecology.

Comments: For complex reproductive tract anomalies, pelvic MRI should be ordered following pelvic US as MRI best correlates with the type of anomaly. Avoid going to the operating room if the classic presentation of imperforate hymen is not visualized and confirmed to minimize complications. Optimize pain management to allow time to obtain adequate MRI Pelvis with contrast for optimal delineation of hymenal versus other vaginal and mullerian variants. This includes assessing distance from introitus to defect. Refer to a specialist with expertise in managing obstructive reproductive tract anomalies, when an anomaly other imperforate hymen is suspected.