Microperforate (Pinhole) hymen and infertility; a rare case report

doi:10.4236/ojog.2012.23060

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Open Journal of Obstetrics and Gynecology, 2012, 2, 287-288 OJOG

http://dx.doi.org/10.4236/ojog.2012.23060 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

Microperforate (pinhole) hymen and infertility: A rare

case report

Davut Güven1, Kadir Bakay2*, Serkan Kuruoglu1

1Department of Ob s tetrics and Gynecology, 19 Mayis University School of Medicine, Samsun, Turkey

2Private Hospital Department of Obstetrics and Gynecology, Turkey

Email: *[email protected]

Received 15 May 2012; revised 19 June 2012; accepted 30 June 2012

ABSTRACT

Introduction: Female genital tract anomalies may have

a devastating impact on the potential for sexual acti-

vity and fertility. Microperforate (pinhole) hymen is

one of them. Microperforate hymen can lead to infer-

tility, primary amenorrhea, acute or chronic pelvic

pain, abnormal vaginal bleeding, dysuria, pollakiuria

or a foul-smelling vaginal discharge. Aim: We aim to

report a patient who had intercourse problems and

infertility complaints later found to have a microper-

forate hymen. Discussion: Pinhole opening of hymen

may permit passage of fluids. Consequently sponta-

neous pregnancy can occur rarely. A few reports

showed pregnancies with intact hymen without pene-

tration of penis. But in general patients have fertility

problems. Conclusion: The results of the surgery are

similar in all techniques and the particular surgical

centre will have its own preference of which tech-

nique it prefers since after diagnosis definitive treat-

ment is surgical and effective. Failure to manage

these patients correctly may have long-term sequelae

for their psych ologic al, se xual an d reproductive health.

Keywords: Hymen; Pinhole; Microperforate; Infertility

1. INTRODUCTION

Female genital tract anomalies are widely variable. And

these anomalies may have a devastating impact on the

potential for sexual activity and fertility. Varieties of the

hymen are one of them. Hymenal anomalies are derived

from incomplete degeneration of the central portion of

the hymen. These anatomic variants include imperforate,

pinhole (microperforate), septate, and cribriform. Pinhole

hymen is a congenital obstructive vaginal membrane

with a minimal opening and incomplete obstructive pa-

thology usually permitting normal menstrual flow. This

is a rare form and frequently mistaken for an imperforate

hymen. The opening up pinhead can be a passage for

menstrual bleeding and sperms. Therefore these women

may have delayed diagnosis.

2. AIM

We aim to repor t a patient who had intercourse pro blems

and infertility complaints later found to have a micro-

perforate hymen. Even though this is a unique case we

aim to highlight the importance of vaginal examination

and definitive treatment that can have a dramatic effect

on sexual health and fertility.

3. CASE REPORT

A 29 years old woman presented to our clinic complain-

ing of infertility. She was married for 1.5 years and

stated that she had regular menstruations, periods lasting

about five days each month. There were no urinary

symptoms, dysmenorrhea nor spotting. She also men-

tioned pain and difficulty with attempted or completed

intercourse. She was diagnosed with vaginismus and

infertility several times, but vagin al examination was not

possible because the patient did not want it.

On examination she appeared to be normal. Secondary

sex characters were well developed. Visual inspection of

her external genitalia revealed a thick and tight mem-

brane covering the vagina with only a pinpoint opening

(Figure 1). We described that as pinhole (microper-

forated) hymen. And transabdominal sonography re-

vealed normal uterus and adnexa, and no other abnormal

findings were noted. Hematological and biochemical test

results were normal as well.

Excess hymenal tissue was resected to create a func-

tional hymenal ring under general anesthesia. An elec-

trocautery was used to excise hymenal tissue. Then re-

dundant fragment of the membrane was cut away to al-

low adequate coitus. To prevent introital stenosis, we

sutured the edges to the introitus. Examination after the

resection showed a normal vagina and cervix. She had

intercourse after two mounts of the operation.

*Corresponding a uthor.

OPEN ACCESS

D. Güven et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 287-288

288

Figure 1. Pinhole (microperforate) hymen.

4. DISCUSSION

Hymen is an embryologic remnant that usually perforates

during the later stages of embryonic development and

remains as a thin fold of mucous membrane. Hymenal

anomalies occur if the genital tubercule fails to break-

down or rupt ur e [1,2].

These anomalies may cause many symptoms. Com-

mon symptoms seen in hymenal malformations include

primary amenorrhea, acute or chronic pelvic pain, ab-

normal vaginal bleeding, dysuria, pollakiuria or a foul-

smelling vaginal discharge. Non-obstructive anomalie s lik e

microperforate, septate or cribriform hymen may even be

found incidentally on routine examination .

Sometimes patients may present with vaginismus and

these patients may not permit even an external vaginal

examination. Usually their main complaint is dispauron ia

and unsuccessful intercourse due to a closed vaginal ori-

fice. Our patient was evaluated for infertility for six

months and because she did not want a vaginal examina-

tion diagno si s was del a y e d.

Pinhole opening of hymen may permit passage of

fluids. Consequently spontaneous pregnancy can occur

rarely. A few reports showed pregnancies with intact

hymen without penetration of penis [3,4]. But in general

patients present with fertility problems.

In rare cases microperforate hymen can be found in

the secondary closure of the hymen. Two stations can

cause the secondary closure of the hymen; following

sexual child abuse and another two cases in pregnancy;

one followed by a previous surgical incision of the hy-

men at an early age and the other closed spontaneously

during preg nan c y [5].

5. CONCLUSIONS

Microperforate hymen can lead to recurrent urinary tract

infections and ascending pelvic infections. Recurrent

urinary tract infections can occur because of pooling of

urine in the functional urogenital sinus and invasion into

the urethra [6]. So pelvic examination is a must in pre-

pubertal and adolescent patients who have complaints of

recurrent urinary infections.

Failure to manage these patients correctly may have

long-term sequelae for their psychological, sexual and

reproductive health [2].

The results of the surgery are similar in all techniques

and the particular surgical centre will have its own pre-

ference of which technique it prefers since after diagno-

sis definitive treatment is surgical and effective [2].

REFERENCES

[1] Bhatnagar, K.P., Nettleton, G.S. and Nakajima, S.T. (2002)

Female ge nital anomalies affecting reproduction. Fertility

and Sterility, 78, 899-915.

[2] Edmonds, D.K. (2003) Congenital malformations of the

genital tract and their management. Best Practice & Re-

search Clinical Obstetrics & Gynaecology, 17, 19-40.

[3] Goto, K., Yoshinari, H., Tajima, K. and Kotsuji, F. (2006)

Microperforate hymen in a primigravida in active labor:

A case report. The Journal of Reproductive Medicine, 51,

584-586.

[4] Topcuoglu, M.A., Koc, O., Timuroglu, T. and Donmez, M.

(2010) Microperforate hymen and pregnancy: A case re-

port. http://tipdergisi.ibu.edu.tr/arsiv/2010/123/9.pdf

[5] Onan, M.A., Turp, A.B., Taskiran, C., et al. (2005) Spon-

taneous closure of the hymen during pregnancy. Ameri-

can Journal of Obstetrics and Gynecology, 193, 889-891.

doi:10.1016/j.ajog.2005.03.025

[6] Bakos, O. and Berglund, L. (1999) Imperforate hymen

and ruptured hematosalpinx: A case report with a review

of the literature. Journal of Adolescent Health, 24, 226-

228. doi:10.1016/S1054-139X(98)00077-9