Introduction

The hymen (Latin, veil) is the anatomical doorway to the vagina, located between the vulvar vestibule and the vaginal canal. At birth, a membrane of connective tissue covered on both sides by stratified squamous epithelium, extends from the floor of the urethra to the fossa navicularis of the vestibule to partially occlude the vaginal orifice. At the interface of the introitus and the vagina, the hymen marks where the urogenital sinus (perineum) meets the vaginal canal, a mullerian structure.¹

The hymen has no known anatomical or physiologic function, although prepubertal protection from infection has been hypothesized.²

Usually a thin fibrous membrane, in some women the membrane may be thicker and there may be an anatomic variant, including imperforate hymen and incomplete hymenal fenestration (e.g. microperforate, septate, and cribiform hymens). Usually there is an opening for the exit of menstrual flow. For more on the hymen and its variants, see Annotaton N; click on The hymen and its variants

After penetration, irregular petal-like remnants of the membrane (carunculae myrtiformes, Latin, little piece of flesh) may remain. With vaginal delivery, further avulsion of the hymenal remnants enlarges them to larger tags that are frequently mistaken by women as warts or other pathology. Evaluation of the hymen by inspection alone is often insufficient. If permitted by the patient, gentle palpation with the tip of the finger to feel its resistant margins gives excellent information about the integrity of the tissue. But no clinical expert can say whether vaginal penetration has occurred or not.

Hymen before penetration, after penetration, and after childbirth (drawing by Dawn Danby from The V Book by Elizabeth G. Stewart, MD)

Failure of the central epithelial cells of the hymenal membrane to degenerate leads to imperforate hymen,³ but the condition may also arise from an inflammatory reaction such as lichen sclerosus affecting the hymen after birth.⁴ Lack of elastic fibers can result in a hymen that is abnormally thick, collagenous, and resistant to intromission. Penetration, in these cases, may result in only partial rupture of the hymen with ongoing dyspareunia with further attempts at vaginal intercourse. For more on the hymen:Annotation N: click on The hymen and its variants

Exam of the hymenal ring

The hymenal ring should be visually inspected, gently moving tags and flaps of tissue with around with a Q-tip prior to insertion of the speculum exam, evaluation of the pelvic floor, or bimanual exam. Provoked or spontaneous vulvodynia may manifest as pain in the vestibule near the hymenal ring or underneath a hymenal tag necessitating cautious assessment in this area.

Diagnosis

Diagnosis begins with a careful history and an index of suspicion for hymenal abnormality.

In all cases of vulvovaginal complaints, identification of the exact location of symptoms and symptom mapping is essential. The clinician must not overlook the potential sensitivity of the vestibule or the hymenal ring before insertion of the speculum or bimanual exam. Women who have had acute or chronic dyspareunia or pain specifically in the hymenal ring, will be fearful of pain on exam. Care must be taken to perform the exam only with permission. (Annotation D: Patient tolerance for genital exam). Evaluation begins with inspection and pain mapping undertaken gently around the hymen and its tags during the vulvovaginal exam. ( Annotation I: Pain and symptom mapping, and the Q-tip test). Identification of a bulging, intact membrane at the introitus yields the diagnosis of imperforate hymen.  In other cases, inspection and gentle palpation yield information on the shape and patency of the hymenal orifice, as well as its elastic or non-elastic quality. An incompletely fenestrated hymen with lack of elasticity may not admit a single digit. Scarring and strictures of the hymenal ring relating to lichen sclerosus or lichen planus will cause painful intromission and dyspareunia. In the adolescent, other signs of these dermatoses may go undetected, and this pain on penetration can be inaccurately thought to be caused by incomplete hymenal fenestration. A hymen scarred by dermatosis or altered by postpartum changes and lactational atrophy may admit one or two digits, but may be rigid and resistant to attempt to spread open the digits.

In other cases, there is no hymenal abnormality, but pain mapping shows tenderness in the vestibule at or adjacent to the hymenal ring. (Annotation K: Vulvar pain and vulvodynia ) Painful attempts at intromission may also be related to the involuntary muscle tightening called vaginismus, which may lead to extreme fear of pelvic exams or penetrative sex. Annotation D: Patient tolerance for genital exam and Pelvic floor dysfunction/vaginismus

Examination alone is insufficient to permit a conclusion that a hymen is intact. Medico-legal considerations are beyond the scope of this educational material.

More comprehensive information on the hymen and its variants is found in Annotation N; click on Hymenal variants in the menu.

Treatment

Imperforate hymen or incomplete hymenal fenestration, see Annotaton N; click on hymenal variants

Postpartum changes and lactational vulvovaginal atrophy

Reassurance that a return to normalcy will occur as lactation diminishes or on return of the menses may be sufficient. Treatment with a small amount of topical estrogen cream to the vestibule and hymenal ring twice a week may be helpful. Use of topical lidocaine prior to penetrative sex may also be helpful.

Stricture of the hymenal ring related to inflammation of lichen sclerosus or lichen planus

A scarred hymenal ring may be slowly dilated with progressive dilator use with lidocaine; perineoplasty with vaginal advancement may be required. (Atlas of Vulvar Disorders: click on LS or LP). Ongoing control of the inflammation of lichen sclerosis or lichen planus is with topical steroids is important.

Pelvic floor dysfunction/vaginismus

It is essential to recognize that dyspareunia may not resolve after hymenectomy until high tone pelvic floor dysfunction from pelvic floor muscle tightening in response to the pain is addressed with physical therapy for the pelvic floor. Annotation L: The pelvic floor  Hymenectomy is not the treatment for vaginismus. Pelvic floor dysfunction/vaginismus

Introduction

The bimanual exam⁵ is a key part of any gynecological exam, yielding information about the vaginal opening, the cervix, the uterus, and the adnexa. Every clinician who takes care of women of any age must be able to perform a bimanual exam accurately to ascertain normalcy and assess for pathology. The bimanual exam is often the determining factor in deciding whether further testing should take place.

In a busy office setting where an established patient is coming in to be evaluated quickly for “vaginitis,” it is sometimes acceptable to limit evaluation to the vulva and vagina, deferring the bimanual exam. However, if the patient has an appointment for a chronic or recurrent problem, for an issue that has not been previously well diagnosed, or for a problem that might relate to upper genital tract disease, a bimanual exam must be performed. In our vulvovaginal specialty practice, we perform the bimanual exam at the patient’s initial visit, if she is able to tolerate it, and subsequently only if necessary to further elucidate her situation.

How to perform a bimanual exam

Preparation for the examination

The bimanual examination is the last step of the vulvovaginal evaluation. Prior to performing it, a clinician will have:

Arranged for gloves, Q-tips and larger swabs for menstrual flow or excess secretions, pH strips, lubricant, range of speculae from pediatric to large, culture media, saline and slide or container for wet mount. We do not usually perform a Pap smear at the initial vulvovaginal consultation because the vaginal speculum is often not tolerated initially, and undiagnosed inflammation or marked atrophy may result in atypia. It is important to be clear whether referring clinician of vulvovaginal clinician is responsible for following HPV and Pap testing.

Obtained the woman’s permission to do the exam. (Annotation D: Patient tolerance for genital exam), and requested that she undress from the waist down, providing a gown or drape, although some women do not wish to use one.

If indicated, completed the abdominal exam with the woman in the recumbent position.

Requested that she bring her hips to the edge of the examining table, (the words “scoot down” are childish and demeaning to many women) providing guidance to her as she is concerned that she will fall off the table.

Positioned patient in stirrups, with back of the table comfortably adjusted.

Explained to the the patient about looking at and touching the vulva.

Learned if there is allergy or irritation from office lubricant to obtain an alternative if necessary.

Uncovered the vulva and lower abdomen by moving the center of the drape up over the mons, flattening the drape on the abdomen

Evaluations before the bimanual exam

Complete these crucial steps prior to the bimanual examination

• Careful scrutiny of the vulvar architecture, skin color, and texture. (LINK Annotation E Detailed, systematic vulvar examination) Be sure to gently separate folds and separate tissues for adequate inspection.
• Location of any reported symptoms are located. (LINK Annotation I Pain and and symptom mapping and the Q-tip test). Insert the plain Q-tip for pH before use of water, saline or lubricant that may alter pH.  It is possible that there is enough pain with symptom and pain mapping that the examination must be terminated for the present.
• If the initial evaluation has been tolerated, the next step includes application of a small amount of lubricant to the index and middle fingers of your dominant hand to perform
• Single  lubricated digit evaluation of the pelvic floor (LINK Annotation L The Pelvic floor). Once again, the examination may need termination at this point. If the evaluation has been tolerated, the next step includes
• Speculum examination and examination of the cervix (LINK Annotation M Speculum examination and examination of the cervix)
• Evaluation of the vaginal architecture (LINK Annotation N The vaginal architecture)
• Evaluation of the vaginal epithelium (LINK Annotation O The vaginal epithelium)
• Inspection of amount and characteristics of vaginal secretions with samples for microscopy and cultures (LINK Annotation P Vaginal secretions) and removal of the speculum.
• Digital evaluation of the hymenal ring, above.

The actual bimanual exam

• To begin the bimanual exam, spread the labia and insert your lubricated index and middle fingers into the vagina, down and back, trying to avoid contact with the anterior structures of urethra and bladder.
• Place your other hand on the patient’s lower abdomen. Examine the cervix: palpate the cervix with your index finger noting size, shape, and consistency.
• Gently move the cervix side to side between your fingers and note mobility and tenderness.
• Tilt the cervix gently up and forward and note mobility and tenderness. Cervical motion tenderness is an important sign of pelvic disease.
• Examine the body of the uterus by continuing to lift the cervix with the vaginal hand. Press downward with the abdominal hand and palpate the uterus between the upper and lower hands (if possible). Estimate uterine size and note consistency and tenderness.
• Examine the adnexal structures: Pull back vaginal hand to clear cervix. Reposition vaginal hand into the right fornix, palm up. Sweep the right ovary downward with the abdominal hand 3 or 4 cm medial to the iliac crest to encircle the ovary gently between the fingers of both hands (if possible). Note its size and shape along with any other palpable adnexal structures. Pull back and repeat on the left side.
• Cover the vulva with the drape and assist the patient to remove her feet from the stirrups and sit up. Commend the patient on a job well done and tell her if the exam is normal or if you have any concerns. Leave the room and allow the patient to dress before continuing with the consultation.

The bimanual examination is normal if

• Vagina is without masses or tenderness.
• Cervix is smooth, without lesions. Motion of the cervix causes no pain.
• Uterus is normal size, shape, and contour. It is non-tender.
• The adnexa (tubes and ovaries) are neither tender nor enlarged.