Non-obstetric vulval trauma

Non-Obstetric Traumatic Vulvar Hematomas in Premenarchal and Postmenarchal Girls

BACKGROUND

Traumatic non-obstetrical hematomas of the vulva are rare, and most reports only involve adult patients. There are no data on presentation, management, and outcomes from either conservative or surgical management in pediatric and adolescent patients. The objective of this project was to compare the etiology, treatment, and outcomes of traumatic vulvar hematomas occurring in premenarchal and postmenarchal young women.

METHODS

A retrospective chart review was performed on females aged 0-24 years seen at a tertiary care academic center using ICD 9 and 10 codes for traumatic vulvar hematoma from 2006-2019. Data describing their clinical presentation and course were collected. IRB approval was obtained.

RESULTS

Twenty patients, aged 3-23 years (median age of 13.5 years) were identified. All 8 premenarchal patients presented with a straddle injury, whereas only 50% of postmenarchal patients were found to have a straddle injury. Other etiologies among postmenarchal patients included consensual sexual intercourse and recent vulvar surgery. Hematoma diameter ranged from 1-3 cm in premenarchal patients and 0.4-7 cm in postmenarchal patients. Associated perineal lacerations were reported in 50% of the premenarchal girls and 8% of postmenarchal young women. Of the 8 premenarchal patients, 5 were managed conservatively, and 3 were taken to the operating room for repair of perineal lacerations; 1 patient also underwent evacuation of a 3-cm hematoma. Of the 12 postmenarchal patients, 5 had surgical intervention, 2 for pain secondary to large 7-cm hematomas and 3 for suspected vulvar abscesses, which were identified as hematomas after drainage. One patient in each group required a Foley catheter for comfort. Two postmenarchal patients required a second surgery for further wound management. One premenarchal patient with surgical treatment required a follow-up exam under anesthesia. Four patients were admitted for pain and postoperative observation, 1 of whom was premenarchal. Eleven patients were seen for follow-up, and 10 were doing well. One postmenarchal patient in the conservative management group returned to the Emergency Department with continued pain 10 days later.

CONCLUSIONS

In this study that examined traumatic vulvar hematomas in premenarchal and postmenarchal young women, the only mechanism of injury in premenarchal girls was straddle injury, and surgical intervention was usually needed only for repair of perineal lacerations, not a primary hematoma. In the postmenarchal patients, surgical intervention was undertaken for larger hematomas and suspected vulvar abscesses. Our study suggests that most hematomas up to 3 cm in premenarchal patients and up to 6 cm in postmenarchal patients can be managed conservatively.

Pediatric and Adolescent Gynecologic Emergencies

Diagnosis of gynecologic emergencies in the pediatric and adolescent population requires a high index of suspicion to avoid delayed or incorrect diagnoses. This article aims to dispel common misunderstandings and aid with diagnosis and management of 3 common pediatric and adolescent gynecologic emergencies: adnexal torsion, vulvovaginal lacerations, and nonsexually acquired genital ulcers.

Vaginal Swelling After Intercourse: A Case Report

Introduction: A vulvar hematoma is a hemorrhagic fluid collection in the female external genitalia. The majority occur as an obstetrical complication, especially during labor. Non-obstetrical vulvar hematomas are usually the result of trauma, with coitus being the most common etiology. Case Report: We present the case of a 25-year-old woman with significant vaginal pain and swelling after vigorous sexual intercourse. She exhibited tenderness and swelling of the left labia majora and minora. The differential diagnosis included bleeding, abscess, and deep venous thrombosis. Laboratory studies were normal and computed tomography of the pelvis indicated the swelling was most likely due to blood. The patient was taken to the operating room, and approximately 150 cubic centimeters of clot was evacuated. The patient had an uneventful recovery and was discharged home the next day. Conclusion: This case illustrates the unique presentation and challenges in making the diagnosis of vulvar hematoma.

A systematic review of penetrating perineal trauma in a civilian setting

PURPOSE

Penetrating injuries to the perineum and associated pelvic organs have largely been reported in the military. Given the rarity of presentation and unique clinical characteristics of these injuries, we set out to address the gap in the literature in civilian settings.

METHODS

A systematic review of studies addressing penetrating perineal trauma from January 2000 to April 2021 was performed. Outcomes of interest were the epidemiology, associated injuries, management, follow-up, and patient outcomes.

RESULTS

26 studies were included in this review, reporting on a total of 2316 patients. Most injuries occurred in males (88.1%), with gunshot wounds (88.2%) representing the most common aetiology, followed by knife wounds (5.0%), impalement (3.1%), coital injuries/sexual assault (1.5%), and others (2.4%). Regarding associated injuries, anorectal (n = 1419, 69.4%), bladder (n = 351, 32.4%), penile (n = 282, 20.8%), scrotal (n = 375, 27.7%), and testicular (n = 229, 16.9%) occurred frequently. Bony injuries involved the pelvis (n = 88, 8.1%) and femoral fractures (n = 5, 0.5%), while soft-tissue injuries involved the inguinal region (n = 19, 1.6%) and buttocks (n = 14, 1.3%). Vascular injuries occurred in 79 (7.8%) patients. Regarding patient outcomes, 65 (4.8%) deaths were reported, and significant morbidity was detected with a mean injury severity score of 18.4 detected in the cohort. In terms of complications of injury, wound/infective complications (n = 135, 61.3%) and fistula formation/leakage (n = 16, 0.7%) featured prominently.

CONCLUSION

Penetrating perineal trauma in the civilian population poses a considerable challenge to clinicians, compounded by the potential for multisystem injury requiring involvement of different medical and surgical specialties.

Management of non-obstetric traumatic vulvar haematoma: a retrospective review of 33 cases

The cases of non-obstetric traumatic vulvar haematomas are rare, and there is a lack of consensus statements for the necessity of surgical intervention. We retrospectively analysed the data of 33 cases (mean age: 25.7 years) of non-obstetric traumatic vulvar haematoma (mean haematoma size: 8.4 cm). Women who underwent surgery (surgery group) were compared to those who received conservative management (conservative group). Twenty-four patients underwent surgery; most cases were of haematoma removal and primary closure. Nine patients received conservative management, such as ice bag application, antibiotics, or analgesia. The rate of deviation of the contralateral vulva because of haematoma was higher (54.2% versus 11.1%, p = .047) and the mean haematoma size was larger (9.5 versus 5.2 cm, p = .004) in the surgical than in the conservative group. While conservative management affects cases of minor vulvar haematoma, surgical evacuation of haematoma can be performed in cases of large haematoma (mean size: 9.5 cm), severe pain, distorted vulvar anatomy, and invisible urethral opening for indwelling urinary catheter.IMPACT STATEMENTWhat is already known on this subject? Cases of non-obstetric traumatic vulvar haematomas are rare. There are no consensus statements for the necessity of surgical intervention.What do the results of this study add? The study showed that surgical evacuation of haematoma can be performed in cases of large haematoma (mean size: 9.5 cm), severe pain, distorted vulvar anatomy, and invisible urethral opening for indwelling urinary catheter. Moreover, surgical management could hasten recovery.What are the implications of these findings for clinical practice and/or further research? The results of this study can be used in counselling non-obstetric traumatic vulvar haematomas. Further research is needed to confirm these findings.

Non-obstetric vulva haematomas in a low resource setting: two case reports

Vulva haematomas are uncommon outside the obstetric population, with an incidence of 3.7% and represent only 0.8% of all gynaecological emergencies. The first case is a 24-year-old G2P1011 referred after the failure of conservative management of a progressively increasing right labia majora swelling. Vulva incision, exploration and relieve of hematoma were done under local anaesthesia. The second case is a 17-year-old G1P1001, a student who presented with spontaneous pain and swelling of the left labia majora. The swelling was rapidly increasing, tense and tender. It spontaneously ruptured, clots were drained and the wound was packed. Vulva hematomas are not very common hence necessitating careful assessment, right diagnosis and management. Management could be conservative (analgesics, local compression) as well as surgical in cases of hemodynamic instability, rapidly increasing size of hematoma and pain intensity. Prompt surgical management reduces the risk of infection and longer hospital stays, which is important in low resource settings like ours.

Analysis of non-obstetric vaginal and vulvar trauma: risk factors for operative intervention

Vaginal and vulvar trauma may occur accidentally or because of an act of violence. Due to its rarity, little is known about risk factors effecting need for operative intervention. We sought to perform a large descriptive analysis of adult non-obstetric vulvovaginal trauma (VVT) and elucidate risk factors for requiring operative intervention. A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. Patients ≥ 16 years old with vaginal or vulvar trauma were identified. Risk factors for surgical intervention were identified using a multivariable logistic regression analysis. From 2,040,235 female patients, 2445 (< 0.2%) were identified to have VVT with the majority being injury to the vagina (68.6%). In patients with injury to the vagina, age > 65 (OR = 0.41, CI 0.26-0.62, p < 0.001), Injury Severity Score > 25 (OR = 0.66, CI 0.50-0.86, p = 0.01) and victims of rape (OR = 0.39, 95% CI 0.26-0.57, p < 0.001) were less likely to require operative intervention. In patients with injury to the vulva, age > 65 (OR = 0.45, CI 0.21-0.94, p = 0.02), victims of rape (OR = 0.26, CI 0.08-0.87, p = 0.01) and gunshot violence (OR = 0.10, CI 0.02-0.59, p = 0.02) were less likely to require operative intervention, but those with a concomitant injury to the vagina were more likely to require operative intervention (OR = 2.56, CI 1.63-4.03, p < 0.001). Injuries to the vagina or vulva occur in < 0.2% of traumas. Interestingly, in both vulvar and vaginal trauma, older age, and involvement in rape were associated with lower risk for operative intervention. A combined injury to the vagina and vulva increases the need for operative intervention.

Spontaneous vulvar hematoma as a rare manifestation of congenital hypofibrinogenemia. Case report

Introduction: Congenital fibrinogen disorders are rare conditions in which there are quantitative and qualitative alterations of factor I; the vast majority of patients are asymptomatic.Case presentation: A 19-year-old female patient with a history of congenital hypofibrinogenemia presented with spontaneous vulvar hematoma along with hypotension, tachycardia, stupor and hematoma of 20cm in the right labium majus. On admission, the young woman had hemoglobin 6.6 g/dL, fibrinogen 74 mg/dL and prolonged clotting times. She received red blood cells transfusion and cryoprecipitates, followed by surgical drainage and intravenous fibrinogen replacement, adjusting the dose according to fibrinogen levels in plasma. The patient presented progressive improvement without hemorrhagic recurrence and fibrinogen levels within the target values until hospital discharge.Discussion: Afibrinogenemia and hypofibrin­ogenemia are part of the quantitative factor I disorders; in the first case, there is total absence of circulating fibrinogen, and in the second case the levels are below 150 mg/dL. Sponta­neous vulvar hematoma as a severe hemorrhagic manifestation is not frequent in symptomatic patients; its treatment is based on fibrinogen replacement in an individualized manner and surgical management when required.Conclusion: Hypofibrinogenemia is a rare dis­ease, and fibrinogen replacement is one of the mainstays of treatment.

Evacuation of a large traumatic vulvar haematoma with an intravaginal cosmetic approach

A healthy youngwoman presented 3 days after a jet ski accident with a large left vulvar haematoma measuring 12 cm. Immediately postinjury, she was managed conservatively in the emergency room of another hospital. However, the haematoma continued to slowly expand. She presented to our clinic with difficulty walking and severe discomfort. Decision was made to drain the haematoma surgically. The patient was sceptical to have scarring on her vulva. Thus, the haematoma was evacuated by a vertical incision on the left vaginal sidewall. After evacuation and achieving haemostasis, the was closed with two interrupted sutures. Edges of the incision were secured similar to marsupialisation with five interrupted sutures to allow continual drainage. Her discomfort resolved immediately postsurgery and she had an uncomplicated postoperative course. The intravaginal approach yielded superior aesthetic result with no scarring on the external vulva.

Non-obstetric traumatic vulvar hematoma: Conservative or surgical approach? A case report

Non-obstetric vulvar hematomas are rare and few cases have been reported in the literature. There are no clinical guidelines for their management. In most cases they can be treated conservatively but in some cases surgical intervention will be necessary. We present the case of a patient with a traumatic vulvar hematoma who required surgical treatment; we also review the literature on this gynecological pathology. Our case highlights the importance of early surgical intervention to reduce associated morbidity and to minimize hospital stay.

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Most traumatic vulvar hematomas are small and can be managed conservatively.

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Non-obstetric genital hematomas can reach a volume that may cause hemodynamic instability.

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Vulvar hematomas more than 4 cm across may cause necrosis and require surgical assessment.

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If surgical intervention is necessary, all the blood clots must be removed without excessive manipulation.

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Surgical intervention is necessary if the hematoma is expanding, of if there is hemodynamic instability or persistent pain.

A case of vulvar hematoma with rupture of pseudoaneurysm of pudendal artery

Vulvar hematomas are uncommon outside of the obstetric population and may be the result of trauma to the perineum. Vulvar hematomas most often present with low abdominal pain and urologic and neurologic symptoms. The vulva has rich vascularization that is supplied by the pudendal artery, a branch of the anterior division of the internal iliac artery. We describe a rare case of a 15-cm-sized vulvar hematoma with the suggested rupture of a pseudoaneurysm of the left pudendal artery without trauma injury. A 14-year-old girl presented with sudden pain and swelling in her left labium and was successfully treated with selective arterial embolization and surgical evacuation. We provide a literature review and discuss patient treatment and management strategies.