Sunxiang Ma , Hua Lei, Wenyi Huang, Qingfeng Li

Introduction

       Hymen is a mucosa fold at the introitus of vagina. Hymen is usually ruptured at the first sexual intercourse; therefore in some cultures (e.g. Mediterranean, African, Chinese and Koran) its intact condition is the symbol of virginity or chastity. A bride has to be a virgin before marriage. If a bride cannot show her bloody sheet on the wedding night, herself and her family will be blamed. The bride may suffer divorce, violence, and even “honor killing”. To avoid revenge from her husband and protect her family honor, the young women who have had sexual experience before marriage may request hymen repair. Hymen repair, is also described as hymenorrhaphy, hymenoplasty, hymen reconstruction, hymen refashioned or revirgination. The procedure is illegal in most Arab countries and performed unofficially. In Western society hymenorrhaphy is legal and done for many women officially, although some surgeons may think it is related to deception and refuse to perform the procedure. InChina, hymenorrhaphy is legal and is comparable with other female genital cosmetic  procedure. Many plastic surgeons encounter young girls consulting and requesting for hymenorrhaphy.

       Most of English literatures regarding hymenorrhaphy discussed whether the hymen should even be reconstructed or described the status quo of hymenorrhaphy’s request and performance in a certain country. Very few reports describe the techniques and results after hymenorrhaphy. However, many Chinese literatures describe how to reconstruct hymen and how to improve operative outcome. In this chapter, the authors introduce their technique and report their unique experience  of hymenorrhaphy.

Anatomy and Classification

       Hymen is an anular and thin fold of mucosa, consisting of epithelium and connective tissue, comparatively poor in blood vessels, containing few nerves and those not especially related to the sympathetic nervous system. It locates at the introitus of vagina. Hymen is usually ruptured and bleeding at first sexual intercourse or when suffering varied traumas. A ruptured hymen never heals by itself in adults. Hymen is an insignificant anatomic structure in females. Its rupture does not cause any physiological disfunction.

       The shape of ruptured hymen is varied. To our knowledge, no report analyzed the morphous of ruptured hymen and correlated the morphous to the hymen reconstruction result. McCann’s study described varied appearances of injured hymen after healing in prepubertal and adolescent girls. Basing on our clinical observation and McCann’s study, we classify the cleft morphous of ruptured hymens into five types: a), I-type. There is no tissue defect between two edges of wound. Two edges of wound are well defined and closely approximated. The cleft shape is like “I”. b), ⊥-type. There is no tissue defect. A laceration extends from edge to base and continues to extend along base bilaterally. All edges of wound are closely approximated. The cleft shape is like “⊥”. c), V-type. There is a tissue defect near free edge of hymen. Two edges of cleft are approximated or connected at base while distant or separated at hymen free edge. The cleft shape is like “v”. d), △-type. There is a tissue defect near the base of hymen. Two edges of cleft are close at free edge while distant at base of hymen. The cleft shape is like “△”. e), U-type. There is a tissue defect between two edges of cleft. Two edges of cleft are distant from free edge to base of hymen. The cleft shape is like “U”. (Figure 1) The hymen may have one or more defects and the types of defects are variable.   

       In our clinical case serires, most lacerations extend entire width of hymen, especially for women who had sexual intercourse experience. (Figure 1) Some lacerations extend more than halfway width of hymen. Few lacerations extend less than halfway width of hymen. We think the lacerations extending less than halfway do not destroy the integrity of hymen ring. To repair these lacerations is not helpful to revirgination. Therefore, our hymenorrhaphy mainly aims at lacerations extending totally or more than halfway width of hymen.

       Our classification of hymen laceration is based on when the patient is in the lithotomy position and nympha is pushed aside as much as possible.

Indications

       Women who had sexual intercourse experience before marriage and request to reconstruct hymen to mimic virgin to protect their new amor or marriage are primary candidates for hymenorrhapy. Some women who have never had sexual intercourse but their hymens torn by other ways, such as trauma, vigorous sporting activities, and surgical procedures, can also be candidates.  They request hymenorrhaphy for fear that their boyfriend or new husband suspects their viginality.  Women who had their hymen repaired for several times for some motivations, or who had vaginal delivery or induction delivery history, are not the candidates for such hymenorrhapy because their hymen has been severely torn with little remnant left in place. Women who some related medical diseases, such as venereal diseases, vaginal infection and diabetes, should be excluded.

Preoperative assessment

       Adequate consultation in the office is very important to either patients or surgeons. The surgeon should inquire the patient about her motivation of requesting surgery, sexual intercourse history, childbearing history, menstrual history and related medical history (e.g. venereal diseases, vaginal infection and diabetes). Patients should be informed that hymenorrhaphy does not necessarily lead to bleeding from ruptured hymen at first intercourse after surgery. Patients who have unrealistic expectations should be excluded. Careful observation of the hymen before operation is critical and  reconstructive result is better if the width of the hymen is not more than 3 mm and the thickness of the hymen thickness is more than 2 mm. The less the number of tearing, the better the operative result will be. The cleft shape is also related to the final operative result. I and⊥-shape have better result than V, △ and U-shapes. The procedure should not be performed in menstrual and ovulation period because vagina secretion interferes with wound healing. Vaginal or perineal infection should be treated and cleared before the surgery.

Results

       Hymenorraphy is usually confidential. The patient fears their connection with the surgeon arouse her boy friend or her family’s suspicion. Therefore, the follow-up about hymen bleeding on wedding night is quite difficult. The healing condition of repaired hymen on the postoperative day 7 is the primary content of the follow-up, which is the basis to judge the result after the surgery. The successful hymen  reconstruction can be determined if over 80% of a cleft healed. From 2000 to 2007, 80 patients were reconstructed with the approximation technique.

Table 1. The summary of 168 hymen clefts repaired with the approximation method

Discussion

       Complications of hymenorrhaphy are minor and can be managed easily. Only a few complain odynuria, which is usually due to the irritation of wound at 12 o’clock position but resolve soon after the wound heals. The Bleeding, severe postoperative pain, infection, uroschesis, rectal fistula, retention of menses did not occur in our cases.

       A failed hymenorrhaphy can not induce any physiological disfunction. However, in terms of sociology and psychology, the failed reconstruction of ruptured hymen usually results in patients and their family’s depression, anxiety, fear, despair, even suicidal risk. Therefore, an endeavor to improve the success ratio of hymen reconstruction is very important. We have learned from the above results that some ruptured hymens can not be successfully reconstructed by the approximation method, especially for thin I and ⊥-type, V-type,△-type and U-type cleft, because of poor blood supply and higher wound tension on approximation. Therefore, we attempted to use flap transposition to enhance blood supply of cleft edge and decrease wound tension on approximation. The result from our recent 30 cases demonstrated that the success rate was improved by transposition flap technique. But a few ruptured hymens were not reconstructed successfully in our serires. Unfortunately, except one English article which advocates a cerclage method, there is no scientific reports in the literature on how to improve the surgical technique for hymenorrhaphy. Therefore, hymenorrhaphy has less been developed and the patient should well be informed the fact.

       Besides improving hymenorrhaphy technique, patient education is also too important to be ignored. For example, an intact hymen is not necessarily ruptured or bleeding at first sexual intercourse due to extra elasticity or worse blood supply, a reconstructed hymen is similar to an intact hymen. Therefore, surgeons should advise patients and their family of the fact so that patients can be ready to face the situation of no bleeding on the “wedding” night.