Annotation Q: hymenal ring and bimanual exam

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The Hymen:Introduction

The hymen is a membrane attached to the posterior half or two-thirds of the  vaginal orifice. It is horizontal when the subject is erect. It has two surfaces, an inferior surface towards the vestibule and a superior surface towards and continuous with the rugae of the vagina. The hymen usually has two borders:  one attached border around the vaginal orifice and a free opening large enough to allow the flow of menstrual blood after puberty. 1 The hymen is present in the majority of female infants although it is occasionally absent at birth.

While many misconceptions prevail regarding the anatomy of the female genitalia, more has been written about the hymen than any other structure2, leading to a large degree of both mystery and marked socio-legal importance.

Epidemiology

 Imperforate hymen, despite being the commonest female genital tract malformation, is a rare occurrence with a prevalence of 0.014-0.1%.3 It mostly presents during puberty,4 although diagnoses in utero and during the newborn period5  and childhood are also documented.6

Normal anatomy and pathophysiology

The hymen arises from the endoderm of the urogenital sinus epithelium; it represents the junction of the sinovaginal bulbs with the urogenital sinus. During embryological life, one or more openings in the hymen occur to form a connection between the lumen of the vagina7 and the vestibule to permit the outflow of menstrual blood.

The hymen is formed of fibrous connective tissue covered on both the vestibular and vaginal surfaces by stratified squamous epithelium. The amount of elastic fibers is variable. Some hymens are rich in elastic fibers while others are mainly formed of collagenous fibers, a finding that supports the clinical observation that the hymen is of variable consistency and elasticity. In some females it tears easily; in others, it is elastic enough to allow sexual intercourse without being torn; in others, it is thicker and more fibrotic, resistant to intromission. 8Depending on the elastic fiber content, it may or may not rupture with sexual activity, or may rupture in athletics or activity unrelated to sexual activity. Frequently, with penetration, the hymen does tear; with childbirth it is destroyed, leaving small tags around the orifice, the myrtiform caruncles.9 Women often mistake hymenal tags for ominous bumps or warts; the hymenal tags are completely normal.

There are many variations in the structure and shape of the hymen: annular, crescentic, septate, or cribriform. The hymen may gape even in sexually non-abused preschool girls.10 The hymen may change in shape during the first three years of life, e.g. from a ring to a crescent; these changes vary by race.11 Hymenal ridges, bumps, tags, bands, and anterior notches, as well as perianal redness, smooth areas, venous engorgement, and skin tags are should be considered normal findings. 12

The vascular supply of the hymen is rich. Multiple capillaries reach the superficial layer of the epithelium 13 The vascularity is the cause of the severe bleeding which occasionally accompanies hymenal rupture.

The hymen is not richly supplied with nerve fibers. The free border of the hymen has none in order to facilitate painless intromission, while the attached border is relatively rich in nerve fibers.14 Sexual experts advise that when a woman, receptive to the sexual encounter, is properly aroused and fully naturally lubricated, intromission, even for the first time, is not painful.

The function of the hymen is not clear, but is thought to include innate immunity as it provides a physical barrier to infections during the pre-pubertal period when the vaginal immunity is not fully developed. 15

Etiology and risks

Failure of the central epithelial cells of the hymenal membrane to degenerate leads to imperforate hymen,16 but the condition may also arise from an inflammatory reaction such as lichen sclerosus affecting the hymen after birth.17 Lack of elastic fibers can result in a hymen that is abnormally thick , collagenous, and resistant to intromission. Penetration results in only partial rupture of the hymen with ongoing dyspareunia with further attempts at vaginal intercourse.

Provoked or unprovoked vulvodynia may manifest as pain in the vestibule near hymenal ring or underneath a hymenal tag. It is important to distinguish if pain comes from a congenital hymenal abnormality, from inflammatory scarring from lichen sclerosus, or from localized provoked vulvodynia near the hymen, but in the vestibule. By definition, the cause of vulvodynia is unknown. (Annotation K: Vulvar pain and provoked and unprovoked vulvodynia)

Clinical manifestations of disorders of the hymen

Imperforate hymen

Imperforate hymen can present during three main stages in life: in utero, in the new-born through childhood, and at puberty.18 If present in the neonate it can cause urinary retention because of fluid from the vagina building up and putting pressure on the urethra. Toddlers or young adolescents can present with urinary retention19 for the same reason, although this is rare.20 There is one reported case of imperforate hymen associated with other congenital abnormalities (bilateral hydronephrosis, polydactyly and laryngocele) in a female neonate with hydrometrocolpos and urinary retention.21

Among prepubertal girls,imperforate hymen will present as primary amenorrhea. Menarche has occurred but there is no flow as blood accumulates in the vagina, then in the uterus with hematocolpos and hematometrium. Cyclic cramping may occur, but many patients are free of symptoms. Secondary amenorrhea can occur with spontaneous closure of a previously perforate hymen; micro perforations yield initially light menses, but ongoing stenosis leads to complete obstruction and amenorrhea. 22

Secondary amenorrhea may also result from stenosis of the hymenal orifice after surgical or sexual trauma,23 or as failure of a hymenotomy. The margins of the incision adhere and eventually occlude vaginal outflow leading to amenorrhea. 24

Recurrent cyclical pelvic pain and low back pain accompany accumulating menstrual blood that distends the vagina and uterus and can irritate the sacral plexus and nerve roots. 25

Urinary outflow obstruction can manifest as acute urinary retention from pressure on the bladder by the distended uterus. Angulation occurs at the bladder neck and the urethra kinks. 26

Intestinal obstruction from the distended uterus can lead to constipation and tenesmus. 27

A pelvic mass representing the distended uterus may be palpated on abdominal or rectal examination. A bulging hymen is observed on vulvar inspection. Pelvic ultrasound or MRI reveals a cystic retropubic mass. 28

Incomplete hymenal fenestration

Incomplete fenestration of the hymenal opening [microperforate, septate, or cribiform (figure 2)] is often asymptomatic. Patients may seek gynecologic evaluation because of inability to insert tampons, douches, or vaginal creams, or because of difficulty with coitus. In addition, women with microperforate hymens may present with postmenstrual spotting or malodorous discharge due to partial obstruction and poor drainage. If the menstrual products are not fully evacuated from the vagina, the retained blood may become infected and lead to bilateral tuboovarian abscesses.

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 thought to be caused by incomplete hymenal fenestration (Annotation K: Vulvar pain and provoked and unprovoked vulvodynia, and Annotation D: Patient tolerance for genital exam, section on vaginismus.)

Diagnosis

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

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 undertake 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. A hymen scarred by dermatoses may admit one or two digits.  but is rigid and resistant to attempt to spread open the digits (Atlas of Vulvar Disorders)

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 provoked and unprovoked vulvodynia, and Annotation D: Patient tolerance for genital exam, section on 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.

Differential diagnosis

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

Hymenal ring pain and provoked or unprovoked vulvodynia (Annotation K: Vulvar pain and provoked and unprovoked vulvodynia, and Annotation D: Patient tolerance for genital exam, section on vaginismus.)

Treatment

Imperforate hymen

Repair of the hymen can be performed at any age; the procedure is facilitated if the tissues have undergone estrogen stimulation. Thus, the newborn, postpubertal, or premenarchal time periods are ideal for the hymenal repair.  Surgical repair, performed under anesthesia, consists of an elliptical incision in the membrane close to the hymenal ring  followed by evacuation of the obstructed material. Extra-hymenal tissue is excised using electrocautery to create a normal sized orifice and the vaginal mucosa is sutured to the hymenal ring using 3-0 or 4-0 vicryl or chromic suture to prevent adhesion and recurrence of the obstruction.  29 This procedure may be  optimized with the use of  carbon dioxide laser, which both cuts and repairs simultaneously.

Incomplete hymenal fenestration

Treatment of microperforate, septate, and cribriform hymens involves resection of the excess hymenal tissue to create a functional hymenal ring, as described above. The excess hymenal tissue is excised with the use of electrocautery and interrupted sutures are placed to reapproximate the tissue.

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). Ongoing control of the inflammation of lichen sclerosis or lichen planus is essential with topical steroids. (LINK Atlas of Vulvar Disorders)

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. LINK Annotation L The Pelvic Floor)

Hymenectomy is not the treatment for vaginismus.  (Vaginismus https://vulvovaginaldisorders.org/pelvic-floor-dysfunction/)


The Bimanual Examination:Introduction

The bimanual exam30 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.

References

  1. Marhan M, Saleh A. The microscopic anatomy of the hymen. Anat Rec 1994; 149:313-18.
  2. O’Connell HE, Sanjeevan KV. Anatomy of female genitalia. In: Women’s Sexual Function and Dysfunction, Goldstein I, Meston CM, Davis SR, Traish AM, eds. London, Taylor & Francis, 2006:109.
  3. Basaran M, et al. Hymen sparing surgery for imperforate hymen; case reports and review of the literature. J Pediatr Adolesc Gynecol. 2009;22(4):e61–e64.
  4. Dane C, et al. Imperforate hymen-a rare cause of abdominal pain: two cases and review of the literature. J Pediatr Adolesc Gynecol. 2007;20(4):245–247
  5. Ayaz UM, et al. Ultrasonographic diagnosis of congenital hydrometrocolpos in prenatal and newborn period: a case report. Medical ultrasonography. 2011;13(3):234–236
  6. Basaran M, et al. Hymen sparing surgery for imperforate hymen; case reports and review of the literature. J Pediatr Adolesc Gynecol. 2009;22(4):e61–e64.
  7. Katz VL, Lentz GM. Congenital abnormalities of the female reproductive tract. In: Comprehensive Gynecology, 5th edition, Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Philadelphia, Mosby Elsevier, 2007:245.
  8. Marhan M, Saleh A. The microscopic anatomy of the hymen. Anat Rec 1994; 149:313-18.
  9. Katz VL. Reproductive Anatomy. In: Comprehensive Gynecology, 5th edition, Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Philadelphia, Mosby Elsevier, 2007, 45.
  10. Myhre AK, Berntzen K, Bratlid D. Genital anatomy in nonabused preschool girls. Acta Paediatr. 2003; 92:1452-62.
  11. Berenson AB. A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics. 1995; 95:490.
  12. Berenson AB. the prepubertal genital exam: what is normal and abnormal. Curr Opinion in Obstet Gynecol 1994;6:526-530.
  13. Marhan M, Saleh A. The microscopic anatomy of the hymen. Anat Rec 1994; 149:313-18.
  14. Marhan M, Saleh A. The microscopic anatomy of the hymen. Anat Rec 1994; 149:313-18.
  15. Basaran M, et al. Hymen sparing surgery for imperforate hymen; case reports and review of the literature. J Pediatr Adolesc Gynecol. 2009;22(4):e61–e64.
  16. Liang C et al. Long-term follow-up of women who underwent surgical correction for imperforate hymen. Arch Gynecol Obstet. 2003;269(1):5-8.
  17. Neill SM, Lewis FM. Basics of vulval embryology, anatomy, and physiology. In: Ridley’s The Vulva, 3rd edition, Chichester, Wiley-Blackwell, 2009:12.
  18. Mwednda AS. Imperforate hymen- a rare cause of acute abdominal pain and tenesmus:case report and review of the literature. Pan Afr Med J 2013;15:28
  19. Sharifraghdas F, Abdi H, Pakmanesh H, Eslami N. Imperforate hymen and urinary retention in a newborn girl. J Pediatr Adolesc Gynecol. 2009 Feb;22(1):49-51.
  20. Adali E, Kurdoglu M, Yildizhan R, Kolusari A. An overlooked cause of acute urinary retention in an adolescent girl: a case report. Arch Gynecol Obstet. 2009 May;279(5):701-703. Epub 2008 Sep 6.
  21. Ozturk H, Yazici B, Kucuk A, Senses DA. Congenital imperforate hymen with bilateral hydronephrosis, polydactyly and laryngocele: a rare neonatal presentation. Fetal Pediatr Pathol. 2010 Jan;29(2):89-94.
  22. Khan ZA et al. Imperforate hymen: a rare case of secondary amenorrhea. J Obstet Gynaecol 2011;31(1):91-92.
  23. Khan ZA et al. Imperforate hymen: a rare case of secondary amenorrhea. J Obstet Gynaecol 2011;31(1):91-92.
  24. Abu-Ghanem S, et al. Recurrent urinary retention due to imperforate hymen after hymenotomy failure: a rare case report and review of the literature. Urology. 2010;78(1):180–182.
  25. Dane C, et al. Imperforate hymen-a rare cause of abdominal pain: two cases and review of the literature. J Pediatr Adolesc Gynecol. 2007;20(4):245–247
  26. Abu-Ghanem S, et al. Recurrent urinary retention due to imperforate hymen after hymenotomy failure: a rare case report and review of the literature. Urology. 2010;78(1):180–182.
  27. Mou JWC, et al. Imperforate hymen: cause of lower abdominal pain in teenage girls. Singapore Med J. 2009;50(11):e378–e379.
  28. Lui CT, et al. A retrospective study on imperforate hymen and hematocolpos in a regional hospital. Hong Kong J Emerg Med. 2010;17(5):435–440.
  29. Laufer M. Diagnosis and treatment of congenital anomalies of the vagina. In: UpToDate. Basow DE (Ed). UpToDate, Waltham, Ma., 2015.
  30. Rathe R.http://medinfo.ufl.edu/year1/bcs/clist/pelvic.html. 2000.