Fiona M. Lewis Traumatic injury to the vulva can occur in a number of situations. Obstetric injuries are very common, while non‐obstetric trauma is rare, but can occur as a result of accidental or non‐accidental factors involving chemical, thermal, or radiation damage. The vulva may also be involved in self‐harm. This chapter deals with obstetric and accidental injury to the vulva. The effect of sport on the vulva is also considered, as although not always directly related to severe injury, there are specific conditions that can affect keen sportswomen. In any patient presenting with features that may be related to injury, sexual assault must always be considered, and referral to the appropriate specially trained medical forensic experts is mandatory. This is an extensive topic that is outside the scope of this book but is covered in separate publications devoted to the subject. Tears and lacerations to the vulva are extremely common in vaginal delivery. Most are grade I, affecting the perineal skin or II involving the perineal muscles but not the anal sphincter. Perineal massage in the antenatal period can reduce the risk of perineal scarring [1]. Vulval lacerations that are not bleeding or causing any change in anatomy can be treated conservatively. More extensive tears will require suturing. Vulval haematomas can also occur in the post‐partum period and are managed in the same way as those occurring with accidental injury (see below). Embolisation has been used in some cases [2]. Haematomas under the levator ani muscle may occur as the result of an inadequate episiotomy repair, which allows continual ooze into the surrounding tissues. Injuries to the vaginal wall and vulva that affect the perineum are important as they may be associated with functional disturbances later. Obstetric tears can also occur in the labia minora, where they may eventually pigment. They usually heal spontaneously, but mucous cysts may develop after healing of the torn mucosa. Radial tears (Figure 54.1), labia minora perforations (Figure 54.2), and labial detachment (Figure 54.3) are also possible complications and can be easily repaired by excision and suturing Clitoral tears are rare, only occurring in 0.5% in a large series [3]. The only factor that was associated with a reduced incidence of these was epidural anaesthesia. Scars from episiotomy or tears can be seen in the midline of the perineum or laterally. They can sometimes be associated with cysts or endometrial deposits. Figure 54.1 Radial tear in right labium minus. It is recognised that minor trauma can occur with normal intercourse [4], and this can then be difficult to distinguish from that seen in assault. There was no correlation with age, use of lubricants, or taking the oral contraceptive pill. Using the TEARS (Tears, Ecchymosis, Abrasions, Redness, Swelling) criteria, at least one feature was found in 55% women examined within 24 hours of consensual intercourse [5]. In a series of 51 adolescents, some minor injury was seen in 73% overall, but in 90% of those where it was the first sexual encounter [6]. Figure 54.3 Labial detachment. Figure 54.2 Perforation in left labium minus. One of the common problems encountered in practice is that of recurrent fissures after intercourse. These mainly occur at the fourchette and hymenal ring. These fissures are a cause of superficial dyspareunia, but it is often more painful after intercourse in contrast to the history in provoked vulvodynia. Following penetration, the patient senses vulval tearing, sometimes accompanied by bleeding, and this may be followed for several days by spontaneous localised burning of the vulva, often triggered by micturition. The problem occurs at exactly the same site with every intercourse. If the patient is seen within 48 hours of intercourse, the fissure is usually easily seen in the midline, running from the fourchette into the vestibule (Figure 54.4). White linear scarring may be visible (Figure 54.5). It is important to exclude any vulval dermatosis or infection which can predispose to fissuring, but these are rarely found. The cause of the fissuring is not understood. Some authors have suggested membranous hypertrophy of the fourchette [7], but most of the patients have simple fragility at the site without any hypertrophy. Figure 54.4 Midline fissuring. Medical treatment can help some patients. Regular emollients and sometimes a topical oestrogen applied directly to the area will help and in one series 13 of 20 patients resolved with medical treatment alone, but several were found to have a coexisting dermatosis [8]. In those who fail with this, surgical treatment can be considered. The fissure is excised and a perineoplasty is done to repair the area [9]. Excision of the vestibular mucosa including the fissure with dissection and cleavage of the posterior vaginal wall for 2–3 cm is required. This provides a flap of vaginal wall that can be used to fill in the defect, and the tissue can be sutured without tension. Wound dehiscence and infection are the main complications. These occur in young nulliparous women and are one cause of superficial dyspareunia [10]. Post‐coital bleeding with pain at the same site are the typical symptoms. These fissures are arranged in a radial fashion around the hymenal ring usually between 3 and 4 and 8 and 9 o’clock (Figure 54.6). They may be uni‐ or bilateral and look like linear erosions or ulcers if deep. They can extend from the hymenal ring into the vagina or nympho‐hymenal sulcus. If there is no scarring, they will not be visible unless the patient is seen within 2–3 days of intercourse and the hymen is displayed well. This is best achieved by holding the labia between the thumb and index finger and stretching them gently out and down. The fissures heal rapidly within a few days, leaving behind a pale scarred site, but this then will repeatedly tear at each intercourse. Avoiding coitus, even for long periods, does not prevent recurrence. Spontaneous cure does occur but may take a long time. Figure 54.5 Scarring after fissuring at right posterior vestibule. Figure 54.6 Mechanical hymenal fissure of hymenal ring at 9 o’clock. The treatment entails the excision of the fissures sagitally and re‐suturing the edges of the vestibular and vaginal mucosa transversely.
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Vulval Trauma
Obstetric injury
Trauma with consensual coitus
Post‐coital fissures
Fossa navicularis fissures (granuloma fissuratum)
Hymenal fissures
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