The imperforate hymen results from unsuccessful canalization of the vaginal plate and failed degeneration of the hymenal epithelial cells. The most popular theory is that the hymen may fail to canalize with the rest of the vagina during development when the sinovaginal bulbs canalize at the site where the uterovaginal canal meets the urogenital sinus. It is thought that the hymen normally perforates during the perinatal period at approximately 22 weeks. The precise embryological origin of the imperforate hymen is controversial. The embryological origin of the lower third of the vagina is the urogenital sinus. The sinovaginal bulb develops into the vaginal plate. The distal point of contact of the Mullerian ducts with the urogenital sinus is the site of the proliferation of the urogenital sinus epithelium, thereby forming the sinovaginal bulb. The fusion of the Mullerian ducts forms the uterovaginal canal that gives rise to the uterus, cervix, and upper two-thirds of the vagina.

The close association of the Mullerian ducts and Wolffian ducts during development explains the high incidence of urinary tract anomalies in women who also have Mullerian anomalies. The Mullerian ducts grow caudally using the Wolffian ducts as guides. Additionally, the Wolffian duct induces the development of the Mullerian ducts from the coelomic epithelium of the paired urogenital ridges. The Wolffian duct develops from the paired urogenital ridges and grows caudally to induce the formation of the mesonephric tubules. The Wolffian ducts (mesonephric ducts) and Mullerian ducts (paramesonephric ducts) are the two main ductal systems that give rise to specific structures in the male and female genital and urinary tracts. EtiologyДuring urogenital development, the cloaca is divided by the urorectal septum to separate the ventral urogenital sinus from the dorsal anal canal. Because pediatricians, gynecologists, and pediatric urologists encounter this diagnosis in their practice, a multi-disciplinary approach to evaluation and treatment is optimal for the patient. Surgical treatment focuses on the prevention of recurrence of the imperforate hymen. Corrective hymenectomy may be delayed until puberty unless the child suffers from urgent complications of the pelvic mass, prompting emergent surgery to preserve renal function, treat an infection, or minimize infertility. This mass may cause mechanical obstruction of the urinary tract, leading to urinary retention, hydronephrosis, or acute renal injury. Hematocolpos or hematometra, the accumulation of menstrual blood in the vaginal or uterine cavities, can create a pelvic mass identified on physical exam as a blue, bulging perineal mass. Many patients remain asymptomatic until menarche when they present with cyclic abdominal pain and amenorrhea. Infants with an imperforate hymen may develop a mucocele from endogenous maternal estrogen stimulation. An imperforate hymen can present with obstructive symptoms of the female genital and urinary tract during the perinatal, pediatric, or adolescent years and is a rare cause of primary amenorrhea. When the hymen does not spontaneously rupture during neonatal development, it is referred to as an imperforate hymen.

The hymen is a thin membrane of stratified squamous epithelium circumscribing the vaginal introitus.

Discuss the importance of collaboration among the interprofessional team with the parents and patient to promote timely treatment of an imperforate hymen and maintain post-surgical follow-up to monitor for potential complications and fertility morbidity.

Summarize the various methods and alternatives to imperforate hymen treatment.

Outline the presentation of a patient with an imperforate hymen.

Describe the etiology of the imperforate hymen in the setting of female urogenital development.

This activity reviews the evaluation and treatment of imperforate hymen and highlights the role of the interprofessional team in improving care for patients with this condition. When the hymen, a thin membrane of stratified squamous epithelium circumscribing the vaginal introitus, does not spontaneously rupture during neonatal development, it is referred to as an imperforate hymen.

Hymenal tags