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. Simple incision and drainage of an imperforate hymen in a patient with hematocolpos should be avoided because of the increased risk of ascending infection and sepsis. Obstetrician–gynecologists should be aware that families may need education about the hymen and its role in sexual function. Typically, an imperforate hymen is an isolated issue and does not have long-term effects on fertility, sexual function, or obstetric outcomes. 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. The presentation and management of clinically significant hymenal variations differs depending on the age of the patient at onset of symptoms and associated complications. The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions: Surgical management of clinically significant hymenal variations involves excision of the hymenal tissue and rarely is associated with long-term sequelae. 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. 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. If the physical examination reveals a bulging hymen and ultrasonography reveals hematocolpos, further imaging is not required. It is important to complete an abdominal and a perineal examination. After confirmation of the diagnosis, surgical intervention usually is deferred until pubertal estrogenization has occurred because the imperforate hymen may open spontaneously at puberty. Surgical intervention is necessary only in symptomatic prepubertal patients. Other findings that may be present include an abdominal mass, urinary retention, dysuria, constipation, and dyschezia. ABSTRACT: 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.
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