Vulvar lacerations
Vulvar lacerations may arise from accidental trauma or from physical or sexual abuse. Frequently, on physical exam, a single vessel is identified as the source of the bleeding. It is very tempting to secure hemostasis and repair the child’s vulvar laceration using local anesthesia. However, repair can seldom be accomplished under these conditions. Most children do not remain sufficiently immobile for the sutures to be properly placed and the operative field kept sterile. Vulvar lacerations in prepubertal children should be repaired under general anesthesia, even when the laceration is small and a single pumping vessel is identified as the source of the bleeding. The laceration should be debrided and irrigated, all bleeding vessels identified and ligated, and the wound closed with fine absorbable suture material. If the location of the laceration suggests that the vagina, urethra, bladder or rectum might be involved in the injury, these structures are examined while the patient is anesthetized. Lacerations involving the posterior fourchette not involving the hymen must be differentiated from dehisced labial adhesions or failure of midline fusion. Skin suturing should be avoided in the treatment of vulvar lacerations. Sutures, if necessary, should be placed with the child under general anesthesia or conscious sedation to decrease additional trauma for the child. A vulvar abrasion may be the source of bleeding which can be controlled with the application of absorbable gelatin sponge (Gelfoam) or absorbable hemostat of oxidized regenerated cellulose (Surgicel).
The most common cause of vulvar hematomas in children is “straddle” injuries. Straddle injuries occur when a child straddles an object as he or she falls, striking the urogenital area with the force of his or her bodyweight. Injury is the result of compression of soft tissues against the bony margins of the pelvic outlet. These injuries occur most often during bicycle riding, falls, and playing on monkey bars.
The prepubertal child with a vulvar hematoma presents with a swollen, ecchymotic, tender labial lesion. Vulvar hematomas are usually small in size, well localized, and do not present a life-threatening event nor require special treatment. Most hematomas will resolve spontaneously. Small hematomas can be controlled by bedrest and applying pressure with an ice pack. Treatment with ice is recommended during the first 12–24 hours after injury to reduce edema. The ability to urinate should also be assessed because large hematomas may obstruct the urethra. If the hematoma has not expanded after a minimum of 4 hours of observation, the patient has spontaneously voided clear urine, and the hematoma is not large enough to cause her undue distress, a nonsurgical approach may be used. A hematoma that enlarges, causes considerable pain, and/or obstructs the urethra must be treated surgically. The hematoma should be incised, the blood clots evacuated, and actively bleeding vessels identified and ligated. The use of a drain is not necessary if complete hemostasis is secured. The cavity is then closed in layers. If the bed of the hematoma continues to ooze then the use of a pack and drain for 24 hours may be considered.
Inspection and palpation of the vulva, along with a rectal examination, must be performed in order to identify the lesion’s full extent and to identify any collection of concealed blood.
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