In pediatric and adolescent patients, genital trauma can be from accidental injury or intentional assault. Genital trauma can range by the mechanism of trauma and by the severity and type of injury. , Types of trauma include blunt, penetrating, insufflation, burns, or coital injuries from consensual sex or sexual assault. Genital trauma can also be in the context of multiple injuries, such as a patient involved in a motor vehicle accident with a pelvic fracture. Genital injuries can be lacerations, hematomas, contusions, burns, bites, abrasions, and crushing injuries from pelvic fractures. ,
Straddle injuries are the most common mechanism of genital trauma in the pediatric population and typically involve blunt trauma. This injury results when a subject straddles an object forcefully, which commonly includes bicycle crossbars, playground equipment, bathtub ledges, or furniture. , Most straddle injury cases occur under 10 years of age and are more common in the summer months. As most straddle injuries are the result of blunt trauma with objects not capable of penetrating above the pelvic floor, they are generally amenable to nonoperative management. ,
Although straddle injuries are the most common, any genital trauma in children can cause anxiety to guardians and caregivers because of the location of the injury and potential concerns for future gynecologic and psychosexual development. , In any patient with a history of genital trauma, thorough history and examination is needed. It is imperative to always consider sexual assault or abuse in any child presenting with a genital injury so that interventions can be implemented to reduce long-term sequelae.
Prevalence
Pediatric genital injuries account for 0.2% to 0.8% of all reported childhood trauma and can be classified by mechanism, location, and intention. , The prevalence of accidental genital trauma is best described by three cohort studies evaluating pediatric patients presenting to the emergency department, excluding cases of intentional injury and abuse ( Table 17.1 ). In the cohorts by Spitzer, Iqbal, and Dowlut-McElroy and their colleagues, straddle injures were the most frequently encountered mechanism of injury, accounting for 70.5% to 82% of cases. , , Accidental penetrating injuries were less prevalent, accounting for 4.7% to 6% of cases in two cohorts , and 11% of cases in another. Trauma classified as other forms of injury, including motor vehicle accidents, was reported occurring in 12% of cases in one cohort.
| Study | N | Age (mean) | Type of Injury | Location of Injury | Management |
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| Spitzer et al. | 105 | 5.6 |
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| Iqbal et al. | 167 | 6.9 |
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| Dowlut-McElroy et al. | 359 | 6.0 |
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Iqbal and Dowlut-McElroy and their colleagues reported injury prevalence to specific genital structures among 167 and 359 patients, respectively, with accidental genital trauma. Both reported that the labia was the most frequent site of injury (63%–64%), followed by the perineum (21.5%–23%), the vagina (5.9%), and then the rectum and anus (2.9%–5%). Hymen disruption was observed in 8.4% to 10% of cases. , Spitzer and colleagues reported among 105 pediatric patients that 37% had anterior injuries (defined as the 9 o’clock to 3 o’clock positions on the vulva) and 62% had injuries to the posterior region of the vulva. In this cohort, only 4.7% of injuries involved the hymen.
Lacerations are the most common type of injury, reported in up to 86% of accidental trauma, followed by abrasions/contusions (9%) and hematomas (4%). Complete injuries through the rectum are more likely to occur with penetrating trauma compared with straddle or blunt injuries.
Sexual activity and abuse
Intentional injury from abuse or assault can cause genital trauma, and the examination should be performed by a provider with expertise in child sexual abuse. The prevalence of genital injury from sexual abuse can vary depending on the methodology employed for examination and time since assault. In one study among 14- to 19-year-old patients reporting sexual assault, 19% had hymenal injury and 36% had tears in the posterior fourchette. In another study of 1500 pubertal and prepubertal females examined acutely after assault, diagnostic findings were 12.5 times higher for children reporting genital penetration compared with those reporting only contact. In children, even though it is uncommon, an acute laceration of the hymen of any depth or complete transection below 3 and 9 o’clock is suggestive of sexual abuse. Perineal trauma in children under age 4 also raises suspicion of abuse.
It is also known that with consensual sexual activity, genital trauma can result, although this is not well studied. One study evaluating patients with a history of assault and a comparison group of patients with recent consensual sex found that the posterior fourchette was the genital area most likely injured in both groups. A study among 51 adolescents after consensual sexual activity found that lacerations at the 6 o’clock position were seen in approximately 60% and hymenal lesions, often bruises, in 50%.
Etiology and pathophysiology
The impact of rising estrogen levels in puberty has a protective effect on genital tissue against minor trauma. 
In younger, prepubertal patients who are unestrogenized, the genital tissues are relatively fragile and lack significant distensibility. Minor trauma can expose underlying capillary beds, and bleeding can appear excessive relative to the degree of injury. At puberty, with increasing estrogen concentrations, the vagina and hymen become more distensible and less likely to tear with gentle distention such as with tampon use. However, blunt or forceful trauma can still result in lacerations or other injury.
The vulva and pelvic structures have a rich blood supply, and vulvar hematomas develop when the labial branches of the internal pudendal artery are injured. Injury to these vessels occurs when soft tissue and pelvic fascia compress against the pelvic bones during blunt impact ( Fig. 17.1 ). Hematomas can be extensive, as bleeding will track along the planes of the subcutaneous pelvic fascia. , Pressure from an expanding hematoma can affect a patient’s ability to void, can cause necrosis of the skin overlying the hematoma, and can result in tissue sloughing.
Clinical presentation/evaluation
Blunt straddle injury
Genital pain and bleeding are the most common presenting symptoms after blunt, nonpenetrating genital trauma, such as a straddle injury. In one series 89% of the cohort presented with pain and bleeding, and other presenting complaints included the inability to void or complaints of dysuria. , ,
Crush or penetrating injuries
More severe penetrating injuries can present with gross hematuria or rectal bleeding.
Vulvar and vaginal bleeding from lacerations or hematomas can be profuse because of the rich blood supply of the pelvic structures. ,
Motor vehicle accidents are a common mechanism of injury resulting in pelvic fracture, which can involve bone shards that cause vaginal lacerations. One study found that 17% of children with pelvic fractures sustained genitourinary injuries.
Penetrating injuries are defined as a piercing injury of the genitourinary or anorectal tissues. These injuries are usually more extensive, more commonly involve trauma to the hymen and vagina, and in rare cases cause visceral injury. , Deep internal vaginal injuries can potentially damage the uterine artery or other branches of the internal iliac artery. These deep injuries can lead to bleeding and accumulation of blood in the perivaginal space, and the patient may not have signs of significant external genital trauma.
Injuries from sexual activity
Patients presenting with genital trauma after consensual sexual activity may have certain risk factors for laceration. These risk factors include first coitus, coitus after a long period of abstinence, insertion of foreign objects during activity, congenital vaginal abnormalities, and coitus in association with drug or alcohol use. In rare cases, vaginal rupture can occur. This is described as a laceration several centimeters in length in the posterior aspect of the vaginal wall involving the posterior fornix. In case reports, bleeding can be profuse and even lead to hemorrhagic shock. It is suggested that vaginal rupture may be more frequent after pelvic surgery, pelvic disease, or systemic diseases such as inflammatory bowel syndrome or Ehlers-Danlos syndrome.
Other injuries: Burns and insufflation
Other less common presentations of genital trauma include insufflation injuries, burns, and animal bites. Insufflation injuries to the vagina can be from high-pressure water jets in association with activities such as riding a jet ski, water skiing, or playing in a water park. ,
Genital injuries caused by burns are rare because the thighs provide protection to the genital area, unless the burns are very extensive. Burns to the genital region can be the result of accidental immersion burns or abuse. In children less than 5 years of age the most common causative agent was immersion in hot bath water. , Patients can have animal bites to the genitals, but also could have human bites as the result of rough play, fighting, or sexual activity. Patients with bites can present with cellulitis resulting from microorganisms in human saliva that can cause infection.
With any accidental or intentional genital trauma, the history given by the child, guardians, and any witnesses is the most important element in the initial evaluation. Ideally the patient and other present adults should be questioned separately for corroboration. A verbal child who is injured is typically forthcoming in telling the story of their accident. Clues of sexual abuse include a nonambulatory child; perineal, vaginal, or hymen injury without history of penetrating trauma; extensive or severe trauma; presence of nongenital trauma; and lack of correlation between the history and findings on physical examination. , ,
Physical examination
Vital signs, airway, breathing, circulation, and evaluation of the sites and sources of trauma should be included in the initial approach. The severity of the trauma, amount of bleeding, and patient stability determine how a physical examination should be performed. In a stable, cooperative patient without severe injuries, an examination can be done without sedation. Children may be reticent to cooperate with a genital examination because of either fear or pain. 
Force or coercion should never be employed to complete an examination, and in many cases, the use of sedation will allow the provider to get a more thorough evaluation. Examination alone cannot distinguish intentional versus accidental injury, and the examination in an abused child may be normal or nonspecific. ,
During the examination, the provider should systematically examine the genital structures, and any injury should be described in detail, including appearance, location, and size. Normal genital anatomy should also be documented. A complete physical examination also allows inspection for other injuries (inflicted or accidental). Description of injuries can employ the pneumonic TEARS (tears, ecchymosis, abrasions, redness, swelling) to assist in documentation, with each element defined as follows , :
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Tears: Any breaks in tissue integrity, including fissures, cracks, lacerations, cuts gashes, or rips.
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Ecchymosis: Skin or mucous membrane discolorations caused by damage to small blood vessels beneath the skin or mucosal surface bruising. Extravasation of blood in tissues below an intact epidermis.
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Abrasions: Skin excoriations caused by removal of the epidermal layer with a defined edge. Exposure of the lower epidermis or upper dermis. Most commonly caused by lateral rubbing or sliding against the skin in a tangential manner. The outermost layer of skin is scraped away from the deeper layers.
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Redness: Erythematous skin which is abnormally inflamed because of irritation or injury without a defined edge or border.
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Swelling: Edematous or transient engorgement of tissues.
There are various ways to optimize a genital examination in younger patients. Young patients can be examined in the supine position with downward outward traction of the labia, with gentle separation of the labia, or in the prone knee-chest position (see Chapter 1 ). One study reported that combining methods demonstrated a greater chance of identifying additional signs of trauma than when only using one examination technique. Application of topical analgesic such as 2% to 5% lidocaine gel over the injury and use of 30- to 60-cc syringes or bulb syringe with warm water or saline irrigation can also help achieve a better examination. Likewise, compression with towels or moist cloths can also be helpful to slow bleeding. Patient comfort can also be aided by child life specialists or distraction.
The examination of a genital laceration includes visualizing the full extent of the injury. Lacerations of the vagina may extend into the fornix, and in prepubertal patients lacerations beyond the hymen are difficult to visualize with external genital examination alone. In these cases, vaginoscopy with a small hysteroscope or cystoscope can be beneficial to visualize the vaginal walls, fornices, and cervix. This tool can also identify the rare cases where vaginal laceration extends into the peritoneal cavity. In the rare instance where the peritoneal cavity is involved in the injury, an exploratory laparotomy or laparoscopy should be performed to determine the full extent of the injuries.
Burn injuries are classified as first, second, and third degree based on whether the burn is limited to the epidermis, involves both epidermis and dermis, or shows more extensive involvement of the epidermis, dermis, and underlying tissue, respectively. For patients with burn injuries, accidental burns are nonuniform in depth and have irregular borders. These burns can be patchy and superficial as the child quickly withdraws from the hot object or liquid. Inflicted burns, as in the case of child abuse, will have well-demarcated lines and uniform depth.
Thorough examination in children is important, as missed genital injuries can result in chronic vulvovaginal concerns such as discomfort, stenosis, and chronic fissures. Furthermore, in patients with intentional assault resulting in genital trauma, missed injuries on examination can delay involvement in psychological support, which is important in long-term management.
Imaging techniques
Imaging studies are determined by the overall degree of trauma. Diagnostic imaging in one analysis did not aid in medical decision making in patients with blunt genital trauma, and examination under anesthesia remained the standard of care. In the setting of an expanding hematoma, or to appreciate the extent of a hematoma, transperineal ultrasonography can be used. Major injuries that include extension into the urinary tract, rectum, or peritoneal cavity will need multidisciplinary consultation. For urinary tract injuries, voiding cystourethrogram or computed tomography imaging can be used.
Differential diagnosis
Although a history of accidental or intentional trauma narrows the diagnosis, there are other conditions that can present with genital pain and bleeding in the pediatric population. Lichen sclerosus is a unique dermatologic condition in the pediatric population that can present with acute vaginal bleeding from subepithelial hemorrhages. This dermatologic condition can be misinterpreted as trauma, as these subepithelial hemorrhages can look similar to abrasions or contusions. Acute vulvovaginitis in prepubertal patients or the presence of a foreign body can present with pain and vaginal bleeding. Patients with vulvovaginitis on examination will have erythema and swelling of vulvar structures. These patients will not have a history consistent with trauma.
Management and treatment
An overview of the management approach for patients with genital injury is detailed in Fig. 17.2 . The need for surgical intervention in pediatric and adolescent genital trauma is low, and 79% to 87% of genital injuries in this population have been reported to be managed expectantly. , , The highest risks associated with the need for examination under anesthesia include those with penetrating injuries; injuries larger than 3 to 4 cm in size; injuries involving the hymen, vagina, urethra, and anus; injuries that extend beyond the labia; a patient who is unable to tolerate an examination; inability to see the full extent of the injury; and bleeding that cannot be localized. , Other reviews found that penetrating injuries, a diagnosis of sexual assault, and injuries from motor vehicle accidents also conveyed higher risk of needing assessment under anesthesia. , , Older children may also convey an increased need for sedation after genital trauma. It is thought that older children may be more active and sustain more forceful injuries. They also may be more difficult to examine in the emergency department or have a higher degree of anxiety about their injuries than younger children.
