KEY QUESTIONS
What are some clinical scenarios that present with vaginal and vulvar trauma?
How should the initial evaluation of vaginal and vulvar trauma be approached?
What other considerations must be made when evaluating a patient experiencing vaginal or vulvar trauma?
What treatment options exist for vaginal and vulvar trauma?
What complications are associated with vaginal and vulvar trauma?
CASE 56-1
An 8-y.o. girl is brought to the emergency room by her parents after suffering a fall at school. She was playing on the monkey bars when she missed a bar and fell forward, straddling the rung of a ladder at the end of the bars. She did not hit her head. She began crying immediately. In the emergency room, she walks hunched over, unable to abduct her thighs. Blood is present on her pants at the crotch.
Her vital signs are as follows: axillary temp 37.4°C, blood pressure 99/59, pulse 110, and respiratory rate 22. Upon examination, the labia majora are erythematous bilaterally. The left side is significantly enlarged compared to the right, with purple ecchymosis and edema present. Upon palpation, the left labium majus is hard and tender. There is a superficial laceration at the inferior right labium majus that is hemostatic.
CASE 56-2
A 29-y.o. healthy female presents to the emergency room with heavy vaginal bleeding. She states that the bleeding began after sex with a new partner 4 hours ago and has continued since that time. She states that she has heavy bleeding, with clots, and has needed to change her tampon every 1–2 hours. Her last menstrual period was 1 week ago. She does not use any birth control. She states that this was consensual sex, and that no foreign objects were placed in her vagina. She has not had any nausea or vomiting, although she does feel lightheaded. She has never had an episode like this before. She denies any history of sexually transmitted infection or abnormal menses.
In the emergency room, she appears to be in no acute distress, but you note blood on her pants. Her vital signs are as follows: axillary temp 37.7°C, blood pressure 120/65, pulse 110, and respiratory rate 22. Upon examination, the external genitalia appear normal. She has blood and small clots in the vaginal vault. Her cervix appears normal, but there is persistent bleeding inferior to the cervix in the posterior fornix. No other lacerations are noted.
In the wide range of trauma sustained by women and girls, perineal and vaginal traumas are relatively uncommon. In children age 0 to 16 years, the incidence was 8% of all traumas at Level 1 trauma centers. The mechanisms of injury vary based on age. Motor vehicle collision (MVC) was the most common cause of blunt trauma for children 0 to 16 years and ultimately made up 90% of all perineal and vaginal injuries for 15- to 16-year-olds.1 In children younger than 10 years old, falls were the main mechanism of injury, with bicycle-related perineal trauma being the leading cause (accounting for 89% of injuries for children 5–14 years of age).
The most common symptom upon presentation is bleeding from the perineum. A total of 60% of female patients who present with blunt perineal trauma will note bleeding, although many patients present with relatively few symptoms, if any. Due to the lower overall number of perineal trauma cases, these patients are at increased risk of having their genitourinary injuries go undiagnosed, especially in the setting of other injuries. Worrisome consequences from missing these injuries include vaginal, vulvar, or ureteral stenosis and fistulas, which may interfere with subsequent reproductive and urologic function. The obstetric and gynecologic (OB/GYN) hospitalist, as a readily available consultant, may be in a position to help close this gap in Emergency Department (ED) trauma care.
Nonobstetrical genital injuries also can be due to consensual and nonconsensual intercourse or sexual assault. In addition, vaginal foreign bodies can lead to vaginal trauma. This chapter will review the ED evaluation and management of injuries related to vulvar and vaginal trauma. The specifics of the procedures used to treat vaginal and vulvar hematomas are discussed in Chapter 70. The repair of perineal lacerations is discussed in detail in Chapter 62.
The main mechanism of injury that affects the vulva and perineum is blunt trauma causing mechanical compression of the soft tissues against the bony pelvis. This can be caused by falls, sexual assault, foreign body insertion, and coitus.2 Minor injuries such as abrasions and scant bleeding are noted in the majority of cases. Details about the anatomy (Fig. 56-1) and the blood supply are described in the rest of this chapter within specific differential diagnoses.
FIGURE 56-1.
Anterior (superficial space of the anterior triangle) and posterior perineal triangles. On the left are the structures noted after the removal of Colles’ fascia. On the right are the structures noted after the removal of the superficial perineal muscles. (Reproduced with permission from Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, NY: McGraw-Hill; 2016.)
Hematomas form secondary to injury to the pudendal artery and its branches, which provide the blood supply to the vulva (Fig. 56-2). The pudendal artery itself is a substantial branch of the iliac artery. These arteries and their venous drainage are located within the superficial fascia of the anterior and posterior pelvic triangle. As the vulva is comprised of mostly loose connective tissue and smooth muscle, it is very compliant and can contain a significant amount of blood. In the setting of brisk bleeding, which would be clinically observed as rapid expansion of the hematoma, such a hematoma can become large enough to cause hemodynamic instability.3
The vaginal blood supply is made of a rich plexus of blood vessels that branch off of the uterine artery. If a patient sustains vaginal lacerations, they are most often minor, and most do not need surgical intervention. However, there have been cases of deep lacerations of the vaginal side walls, deep sulcal tears, and partial or complete circumferential lacerations at the fornices. In the setting of such injuries, patients can be at risk of hemorrhage. In the case of sulcal tears, there is also the risk of retroperitoneal bleeding and hematoma formation (Fig. 56-3).
FIGURE 56-3.
The vaginal and surrounding structures. The retractors demonstrated the potential spaces immediately anterior and posterior to the vagina, where large volumes of blood may accumulate. Note also the proximity of the vagina to the rectum, urethra, and bladder, leading to the possibility that these structures are injured with any vaginal trauma. (Reproduced with permission from Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, NY: McGraw-Hill; 2016.)
Perineal lacerations involved abrasions that affect the skin overlying the perineal muscles (and possibly the muscles themselves) and can involve the anal sphincter. The degree of laceration depends on the structures involved (Fig. 56-4).
FIGURE 56-4.
Classification of perineal lacerations. A. First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane, but not the underlying fascia and muscle. These include periurethral lacerations, which may bleed profusely. B. Second-degree lacerations also involve the fascia and muscles of the perineal body, but not the anal sphincter. These tears may be midline but often extend upward on one or both sides of the vagina, forming an irregular triangle. C. Third-degree lacerations extend farther, to involve the external anal sphincter. D. Fourth-degree lacerations extend completely through the rectal mucosa to expose its lumen, and thus they involve disruption of both the external and internal anal sphincters. (Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al: Williams Obstetrics, 24th ed. New York, NY: McGraw-Hill Education, Inc; 2014. Photo contributors: Drs. Shayzreen Roshanravan and Marlene Corton.)
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
