29. Resealing of a Spontaneously Draining Imperforate Hymen

Abstract

<h3>Background</h3> Microperforate and imperforate hymen are ostensibly separate diagnoses on a spectrum of hymenal anomalies. The incidence of imperforate hymen is 1 in 1000 births, while the rate for microperforate hymen is unknown, with few case reports (1). A patient with an imperforate hymen is often symptomatic with obstructive features of the genitourinary tract, whereas a patient with a microperforate hymen may be asymptomatic, have recurrent infections, or report obstructive symptoms (1, 2, 3). We present a unique case of an imperforate hymen with spontaneous rupture, that resealed and then ruptured spontaneously again. <h3>Case</h3> A 12-year-old premenarchal female, with a history of imperforate hymen, diagnosed on specialist exam at age 3, presented to the emergency department (ED) with back pain and urinary retention. Following an abdominal exam, she passed many clots vaginally, saturating adult-sized diapers. She was diagnosed with menarche and discharged. She was referred to a pediatric gynecologist for follow-up. Following her ED visit she had continued bleeding with malodorous discharge, and stated she had been using tampons. An exam limited by patient tolerance was remarkable for no patent hymenal opening, no vaginal bleeding or discharge. She did not tolerate a q-tip test. A pelvic ultrasound was ordered for her puzzling presentation and uncertain anatomy and revealed a normal uterus, bilateral ovaries, and no evidence of hematocolpos. An exam under anesthesia (EUA) and vaginoscopy was planned. She subsequently reported a second presentation to an outside ED. She again reported back pain, constipation and inability to void. Similar to her first presentation, her symptoms were relieved by an episode of profuse vaginal bleeding with strong foul odor that resolved after a few days. EUA findings included normal clitoris with smegma, normal labia majora and minora, urethra, and no obvious hymenal patency with labial traction. With a recto-abdominal exam, a microperforation was identified. Bloody discharge was expressed, and a hysteroscope was gently passed. Vaginoscopy confirmed a normal vaginal canal and cervix. An uncomplicated hymenectomy was performed. At her postoperative visit, she had no complaints. Her exam was unremarkable and the tissue was healing normally; no follow-up was indicated. <h3>Comments</h3> This case sheds light on an atypical case where the lines between a microperforate hymen and an imperforate hymen were blurred. There are few case reports in the literature of resealing of the hymen after hymenectomy, but no other cases reporting resealing after spontaneous perforation (4, 5).