Imperforate Hymen is the Most Common Obstructive Vaginal Anomaly

Independent Researcher, Croatia

*Corresponding author: Sinisa Franjic, Independent Researcher, Croatia; Email: [email protected]

Received Date: July 22, 2025

Published Date: October 16, 2025

Citation: Franjic S. (2025). Imperforate Hymen is the Most Common Obstructive Vaginal Anomaly. Mathews J Gynecol Obstet. 9(3):49.

Copyrights: Franjic S. © (2025).

ABSTRACT

The hymen is a thin membrane that partially covers the opening of the vagina in women. It is a structure that is present at birth and serves as a natural barrier to the vaginal canal. The hymen has long been associated with virginity and purity in many cultures, leading to myths and misconceptions about its appearance and function. Contrary to popular belief, the hymen can be stretched or torn through various activities other than intercourse, such as physical exercise, tampon use, or even just normal growth and development. The presence or absence of a hymen is not a reliable indicator of sexual activity or virginity. The hymen has no physiological role in sexual function and differs in appearance from person to person.

Keywords: Hymen, Imperforate Hymen, Pathology, Gynecology, Health.

INTRODUCTION

Hymen is a thin membrane that surrounds the opening to the vagina [1]. Hymens can come in diverse shapes. Hymenoplasty is more often than not a basic outpatient strategy that can be done in outpatient clinic beneath nearby anesthesia. Moreover called ‘revirgination’, it is planned to reestablish the hymen. It is regularly promoted as a ‘gift’ to one’s accomplice. This method is every so often asked by women of certain social foundations in which premarital sex is illegal and an intact hymen is considered prove of virginity. Seldom imperforate hymen is also experienced driving to hematocolpos. It can be isolated for free drainage of menstrual blood, emissions and sexual intercourse.

Degeneration

The hymen is at the intersection between the urogenital sinus and the sinovaginal bulbs [2]. Some time recently birth, the epithelial cells in the central parcel of the hymenal membrane deteriorate, clearing out a lean edge of mucous membrane at the vaginal introitus. This is known as the hymenal ring. When this degeneration comes up short to happen, the hymen remains intact. This is known as an imperforate hymen. It happens in 1 in 1,000 female births. These can result from deficient degeneration of the central parcel of hymen.

An imperforate hymen comes about in an obstacle to the outpouring tract of the regenerative framework. This can lead to a buildup of discharges in the vagina behind the hymen (hydrocolpos or mucocolpos) comparative to that seen with a transverse vaginal septum. If not recognized at birth, an imperforate hymen is frequently analyzed at adolescence in youths who display with essential amenorrhea and cyclic pelvic torment. These side effects are due to the aggregation of menstrual flow behind the hymen in the vagina (hematocolpos) and uterus (hematometra). In these patients, the physical examination may be outstanding for the nonattendance of an identifiable vaginal lumen, a tense bulging hymen, and conceivably expanding lower abdominal circumference. Treatment of imperforate hymen and other hymenal variations from the norm is with surgery to extract the additional tissue, empty any discouraged fabric, and make a normal-sized vaginal opening.

Pathology

Pathologic conditions of the hymen to a great extent result from failed canalization of the lumen of the vaginal canal and the vaginal vestibule during embryonic life [3]. The hymen is ordinarily patent at birth; in any case, a few pathologic varieties in the improvement of the hymen can happen counting septation, microperforation or total impediment named “imperforate.” Imperforate hymen is the rarest of these varieties and is found in 0.05–0.10% of infant girls. In spite of the fact that the majority of cases are intermittent, hereditary transmission has also been detailed with both overwhelming and latent legacy patterns.

An imperforate hymen most commonly comes to clinical consideration in youth when menarche happens and the distal vaginal impediment comes about in difficult hematocolpos (menstrual blood collected in the vagina). These young girls provide a history of a few months of cyclic pelvic torment. They may moreover involvement back torment, sickness, spewing, urinary recurrence, and stoppage as a result of the mass impact of the hematocolpos and hematometria. In spite of the fact that less common, these patients may show with peritoneal signs as a result of retrograde stream of menstrual blood through fallopian tubes and into the peritoneal depth. A microperforate hymen or a septate hymen will not deter monthly cycle. These conditions commonly come to clinical consideration when patients experience trouble with inclusion of a tampon or with vaginal intercourse.

Examination

A cautious examination of the outside genitalia is suggested by the American Academy of Pediatrics [3]. In spite of this proposal, the coincidental conclusion of imperforate hymen in the infant period is exceptional. In this circumstance, there is not proximal distension of the vagina by blood or liquid which makes visualization and conclusion more troublesome. Exceptionally occasionally, a infant examination may uncover a thin, white bulging membrane at the vaginal introitus. This pathologic finding is the result of amassing of genital tract emissions created auxiliary to in-utero presentation to maternal estrogen. The result of these emissions in a infant with an imperforate hymen is the improvement of a mucocolpos, which is by and large asymptomatic, but more promptly distinguished on schedule newborn examination.

Careful examination of the newborn is fundamental [4]. Careless examination of the genital structure of the infant may result in blunders of sex task. Ultrasound and/or MRI, examination beneath anesthesia, and conceivable laparoscopy or hysteroscopy give data for exact conclusion. One-third or more of children analyzed with genital tract irregularities will have related with peculiarities of the urinary tract such as missing kidney, horseshoe kidney, and duplication of ureters.

The pelvis is a space obliged by hard engineering and filled with gastrointestinal urologic and gynecologic viscera. The blood supply is wealthy, counting the outside and inner ileac arteries and veins, and various branches inside the pelvis. Engine nerves counting the sciatic, obturator, and femoral nerves travel the pelvis along the pelvic sidewall. Sensory nerves counting the genitofemoral nerve are externally found and effectively harmed. The ureter is closely set to the uterine supply route and is at chance for harm during hysterectomy strategies. A pelvic surgeon must be personally recognizable with the near dividing of basic pelvic structures to minimize chance of injury.

Genital Tract

Disorders of the genital tract include variations from the norm of the Müllerian framework as well as anomalies of the outside genitalia [5]. Genital tract disarranges will be found in 15% of youths who show with ordinary youthful improvement and essential amenorrhea. Common disorders of the genital tract incorporate Müllerian agenesis, imperforate hymen, and transverse vaginal septum. Imperforate hymen is the most visit obstructive female genital tract peculiarity, with an assessed recurrence of roughly 0.1%. Transverse vaginal septum is less common, happening in less than one in 20,000 females. Patients with these variations from the norm regularly show with grown-up auxiliary sexual characteristics, cyclic pelvic torment, and need of menses. A bulging hymen with hematocolpos, prove of an imperforate hymen, may be recognized on pelvic exam. MRI of the pelvis may be utilized to identify transverse vaginal septum and is moreover more delicate than ultrasound when barring other auxiliary anomalies. If a typical uterus and fallopian tubes are display, these people will create endometriosis as well since of the discouraged outpouring tract.

Menstrual Obstruction

Menstrual hindrance can be caused by a number of etiologies, the most common of which is imperforate hymen, with an evaluated frequency of 1 in 2000 women [6]. The starting examination was not steady with an imperforate hymen, which has the classic appearance of a somewhat blue, tense bulge at the introitus; subsequently, an MRI (Magnetic resonance imaging) was performed to advance depict the life structures. It is fundamental to delay surgical intervention until the correct obstructive inconsistency is distinguished in arrange to encourage surgical arranging and maintain a strategic distance from unseemly methods. In spite of the fact that imperforate hymen is the most common cause of deterred monthly cycle, other potential etiologies must be considered and incorporate a transverse vaginal septum, with an frequency of around 1 in 70 000 women, and other uncommon anomalies like distal vaginal atresia or agenesis, and cervical agenesis. In expansion, roughly 2–7% of patients with Mullerian agenesis (inherent nonappearance or underdevelopment of the uterus, vagina, or both) will have simple uterine horns that contain dynamic endometrium and hence may show with side effects of menstrual obstacle. All of these inconsistencies require more noteworthy surgical resection and postoperative care than imperforate hymen; subsequently, continuing to the working room earlier to satisfactory symptomatic testing is ill-advised.

Imaging modalities that may be accommodating in making the diagnosis in cases of menstrual obstacle incorporate ultrasound and MRI; in any case, MRI is most accommodating in characterizing inconsistencies of the regenerative tract, especially in recognizing the area and thickness of a vaginal septum and recognizing the nearness or nonappearance of a uterine cervix. Cases of cervical agenesis are especially vital to recognize, as making a fistula between the vagina and uterus in the nonattendance of a cervix may put the quiet at noteworthy chance for climbing contamination, sepsis and indeed passing. Conventional treatment of cervical agenesis has been hysterectomy; be that as it may, richness protecting strategies have been detailed with changing victory rates. Patients with cervical agenesis and crave for richness conservation are best overseen at teach with experience managing with these procedures.

The etiology of the transverse vaginal septum is thought to be failure of canalization and/or combination of the Mullerian ducts and urogenital sinus during embryogenesis. The area of the septum may be in the upper vagina (46%), center vagina (35%), or lower vagina (19%). Treatment of the transverse vaginal septum includes extraction of the septum with reanastamosis of the vaginal epithelium over and underneath the extracted septum. Drainage of the hematocolpos from underneath without extraction of the septum may put the quiet at chance for tireless hindrance and rising disease and ought to not be performed. In cases of a thick septum, surgical extraction may be postponed, and the understanding may select to perform preoperative dilator treatment to offer assistance thin out the septum and encourage extraction. On the other hand, the z-plasty method is thought to increment the circumference of the anastamosis line and in this way diminish the chance of stenosis. In uncommon cases, a skin unite may be required when the septum is so thick that the vaginal epithelium from the upper vagina does not reach that of the lower vagina. This can for the most part be maintained a strategic distance from, in any case, by performing the method when noteworthy hematocolops is display or by utilizing preoperative dilators as portrayed over, both of which can serve to increment the sum of vaginal epithelium to be mobilized and diminish the thickness of the vaginal septum.

Pregnancy is conceivable taking after surgical extraction of the transverse vaginal septum; in any case, pregnancy rates are detailed to be altogether lower in these women compared to those with a history of an imperforate hymen. The reason for this error is unclear, but it is conjectured that an imperforate hymen is more likely to be analyzed and rectified expeditiously, in this way diminishing the probability of resultant endometriosis.

Vaginal Atresia

Congenital absence of the uterus or vagina is due to a failure of combination and canalization of the caudad mullerian conduits [7]. The ovaries, tubes and uterine ligaments are shaped but the uterus is show as simple horns and the vagina is missing. Lesser degrees of vaginal atresia also happen, changing from failure of canalization of the lower portion to a total failure of improvement, but with a typical uterus or uterus didelphys show. In these last mentioned cases, cryptomenorrhoea will occur.

Uterovaginal atresia happens in 1 in 5000 women. The most common introduction is that of a young girl (15 years of age) being brought to see the gynecologist by her mother since she has failed to start to menstruate. The girl has ordinarily created auxiliary sexual characteristics, counting breast, pubic hair and vulval development. As these girls are ordinarily exceptionally anxious, examination in the outpatient division ought to be restricted to the outside structures. The mother ought to be completely educated of the require for a full vaginal and rectal examination of the child beneath common analgesic. An MRI gives great evaluation of the pelvic structures and an intravenous urogram (IVU) may be of esteem as there is an related urinary peculiarity in up to 30% of girls who have maldevelopment of the vagina and uterus.

Under anesthesia the outside genitalia are reviewed, the vaginal dimple investigated and, most valuable of all, a rectal examination is carried out. A laparoscopy can also be performed if past radiology has been indeterminate. A shallow examination of the persistent may propose that the vagina is show but imperforate. The hymen can be seen at the upper portion of a little vaginal dimple. In any case, on rectal examination and laparoscopy it is clear that the vagina is not created and the uterus is display as broadly uprooted streaks of tissue driving to the ovaries. A symptomatic highlight is the capacity to follow the uterosacral ligaments uninterruptedly over the front of the rectum. In spite of the fact that the diagnosis is ordinarily made when the girl is in her teens, treatment may be deferred until she wishes to set out on intercut. The chances of creating a valuable communication with the uterus are little and the prospects for multiplication infinitesimal.

Diagnosis

An imperforate hymen is a clinical diagnosis [3]. A characteristic history of cyclic pelvic torment in an juvenile understanding, in conjunction with a genital examination uncovering a tense bulging membrane at the vaginal introitus is adequate for diagnosis. On event, the diagnosis may be more troublesome if the thickness of the hindering film cannot be promptly decided by physical examination. In these circumstances, the differential diagnosis incorporates Mullerian irregularities, counting a transverse or longitudinal vaginal septum, labial attachments, androgen insensitivity disorder, or total Mullerian agenesis. Adjust determination is fundamental earlier to agent mediation as the administration of the previously mentioned conditions changes broadly and is not all around surgical. If the diagnosis of imperforate hymen is in address, a MRI is the best test to assess the pelvic life structures earlier to intervention. Especially in newborn girls, ultrasound may also be of utilize to decide the thickness of the hindering tissue and recognize pelvic structures.

If determination of an imperforate hymen is suspected in an juvenile understanding, gynecologic discussion ought to be gotten earlier to any endeavor to reduce hindrance. Whereas administration of an imperforate hymen is surgical, it is not a surgical crisis. Introductory accentuation ought to be set on absense of pain with a arrange for surgical decompression in the operating room by a prepared gynecologic specialist. Once satisfactory anesthesia is gotten in the working room, the enlarged hymenal tissue can be infused with a local anesthetic, and a cruciate entry point is made in the hymen to empty the hematocolpos. The abundance hymenal tissue is at that point extracted, and the mucosal edges are reapproximated to anticipate scarring and give hemostasis.

In a newborn girl with an imperforate hymen (with or without a mucocolpos present), surgical excision of the hymen is encouraged. This can be finished in the working room and is indistinguishable to the method portrayed over. If the hymenectomy is conceded in the newborn period and performed at adolescence, one must be careful of the hazard of a difficult hematocolpos shaping with start of menses. Since hymenectomy is encouraged by well-estrogenized tissue, it ought to be conceded until after adolescence if the conclusion is made exterior of the infant period.

Microperforate and septate hymens ought to as it were be surgically overseen if they are symptomatic. The most common complaints in patients with these conditions are failure to embed a tampon and trouble with sexual intercut. Surgical methods are individualized and ought to be performed by a gynecologic specialist with involvement in hymenal pathology.

Complications of hymenectomy are uncommon. Most patients recoup well and do not have any long-term regenerative results from the surgery. Since familial affiliations have been depicted, any descendant of a lady with a history of an imperforate hymen ought to be carefully inspected in the infant period for prove of the condition.

Antenatal determination of imperforate hymen and hydrocolpos has been detailed as early as the moment trimester [8]. In this case, drainage of the liquid ought to be the quick mediation in the neonatal period, delaying the last surgical strategy. Once in a while, prepubertal girls can be alluded with no self-evident hymenal opening or with a ineffectively obvious microperforation. In the nonattendance of a collection, conclusive surgery ought to be conceded until the child is peripubertal. The imperforate hymen is as a rule seen in girls in their early teenagers. On the clinical examination, the hymen may be visualized as a bluish bulge at the perineum. Transabdominal or translabial US may be utilized to affirm the determination. Depending on the circumstance, an imperforate hymen may not be recognized until an adolescent girl has repetitive bouts of lower stomach crampy torment but does not menstruate. The issue may endure through a few cycles until a pelvic mass gets to be apparent. This finding is demonstrative and no assist examination is required. A straightforward cruciate entry point of the hymen will discharge the menstrual stream and permit advance typical menstruations.

Mullerian Agenesis

Mullerian anomalies happen since of irregular arrangement or combination and resorption of the Mullerian antecedents [9]. There can be total nonappearance of the upper parcel of the vagina, the uterus, and the fallopian tube with Mullerian agenesis, or there can be fractional to total obstacle due to anomalous combination and resorption of the Mullerian antecedents coming about in conditions such as an imperforate hymen or a transverse vaginal septum. Other peculiarities do not display as amenorrhea but may show in discharging ladies as cyclic torment or vaginal/abdominal masses.

Patients with an imperforate hymen or a transverse vaginal septum will show with essential amenorrhea. Diagnosis can ordinarily be gathered from a physical exam, but imaging such as ultrasound or MRI will affirm the nearness and degree of the anomaly. Treatment is surgical, and the preoperative utilize of MRI or ultrasound will help the specialist in expecting the rectify approach based upon the patient’s specific anomaly.

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser {MRKH} syndrome) depicts persistent pathology that is characterized by nonattendance of the uterus and upper 2/3 of the vagina. Other deformities are common counting renal, skeletal, and once in a while hearing, cardiac, and computerized peculiarities. The frequency has been assessed to be 1 in 4500 females with the larger part of cases being intermittent, but there have been portrayed familial cases where the legacy appears to be autosomal prevailing. The patients regularly display with essential amenorrhea, are ordinarily created females with a shortened vagina, have typical ovarian function, and have an XX karyotype. Urinary tract deformities are common with MRKH disorder happening in as numerous as 40% of the patients. Diagnosis utilizes MRI and ultrasonography to affirm the degree of the irregularity. The advantage of an MRI is that it can moreover distinguish renal and skeletal inconsistencies amid the same examination. Other demonstrative endeavors incorporate screening for hearing shortfalls and cardiac abnormalities.

CONCLUSION

The most common obstructive vaginal anomaly is an imperforate hymen, a condition in which the hymen obstructs menstrual flow or other vaginal secretions. It indicates the presence of tissue that completely covers the vaginal opening. The hymen can rupture due to other activities, not just sexual intercourse.

ACKNOWLEDGEMENTS

None.

CONFLICTS OF INTEREST

The author declares that there is no conflict of interest.

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