Evaluation and management of female lower genital tract trauma
- Marc R Laufer, MD
Marc R Laufer, MD
- Professor of Obstetrics, Gynecology, and Reproductive Biology
- Harvard Medical School
- Gretchen Makai, MD
Gretchen Makai, MD
- Director, Minimally-Invasive Gynecologic Surgery
- Department of Obstetrics and Gynecology
- Christiana Care Health System
Any female child, adolescent, or adult with a complaint of vaginal pain or genital bleeding or swelling should undergo a careful examination to look for vulvar or vaginal trauma or laceration. It should also be kept in mind that patients with vulvar or vaginal trauma sometimes present with abdominal or low back pain as their chief complaint. External lesions can be identified easily, but need to be carefully evaluated for deeper extension. Internal lesions are more difficult to assess.
Patients may not be forthcoming with details of the events that caused the trauma, therefore identifying those at risk is a crucial step in management. The history should always be consistent with the physical findings; further questioning is important if there is a discrepancy. The possibility of sexual abuse or assault must always be considered.
Evaluation and management of female lower genital tract trauma is reviewed here. The differential diagnosis of female genital tract bleeding is discussed separately. (See "Differential diagnosis of genital tract bleeding in women".)
Obstetric — Lacerations of the cervix, vagina, and/or vulva commonly occur during childbirth. Risk factors associated with lower genital tract trauma in the obstetric setting include nulliparity, large baby, precipitous birth, operative delivery, and/or episiotomy. Obstetric injuries are discussed in detail separately. (See "Operative vaginal delivery" and "Shoulder dystocia: Risk factors and planning delivery of at risk pregnancies" and "Approach to episiotomy" and "Obstetric fistulas in resource-limited settings".)
●Vulvar trauma – The rich vascular supply to the perineum places it at risk for bleeding from trauma. Vulvar hematomas are the most common sequelae.
- Bond GR, Dowd MD, Landsman I, Rimsza M. Unintentional perineal injury in prepubescent girls: a multicenter, prospective report of 56 girls. Pediatrics 1995; 95:628.
- Merrit DF. Genital trauma. In: Pediatric & Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR (Eds), Wolters Kluwer Lippincott Williams & Wilkins, Philadelphia 2012. p.293.
- Kanai M, Osada R, Maruyama K, et al. Warning from Nagano: increase of vulvar hematoma and/or lacerated injury caused by snowboarding. J Trauma 2001; 50:328.
- Merritt DF. Vulvar and genital trauma in pediatric and adolescent gynecology. Curr Opin Obstet Gynecol 2004; 16:371.
- Okur H, Küçïkaydin M, Kazez A, et al. Genitourinary tract injuries in girls. Br J Urol 1996; 78:446.
- Virgili A, Bianchi A, Mollica G, Corazza M. Serious hematoma of the vulva from a bicycle accident. A case report. J Reprod Med 2000; 45:662.
- Jana N, Santra D, Das D, et al. Nonobstetric lower genital tract injuries in rural India. Int J Gynaecol Obstet 2008; 103:26.
- Goldberg J, Horan C, O'Brien LM. Severe anorectal and vaginal injuries in a jet ski passenger. J Trauma 2004; 56:440.
- Niv J, Lessing JB, Hartuv J, Peyser MR. Vaginal injury resulting from sliding down a water chute. Am J Obstet Gynecol 1992; 166:930.
- Smith BL. Vaginal laceration caused by water skiing. J Emerg Nurs 1996; 22:156.
- Wilson F, Swartz DP. Coital injuries of the vagina. Obstet Gynecol 1972; 39:182.
- Emans SJ, Woods ER, Flagg NT, Freeman A. Genital findings in sexually abused, symptomatic and asymptomatic, girls. Pediatrics 1987; 79:778.
- Jones JS, Dunnuck C, Rossman L, et al. Significance of toluidine blue positive findings after speculum examination for sexual assault. Am J Emerg Med 2004; 22:201.
- Parker JD, Hibbert ML, Dainty LD, et al. Micro-hydrovaginoscopy in examining children. Obstet Gynecol 2000; 96:772.
- Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol 1998; 159:956.
- Netto Júnior NR, Ikari O, Zuppo VP. Traumatic rupture of female urethra. Urology 1983; 22:601.
- Niemi TA, Norton LW. Vaginal injuries in patients with pelvic fractures. J Trauma 1985; 25:547.
- Takayama T, Mugiya S, Ohira T, et al. Complete disruption of the female urethra. Int J Urol 1999; 6:50.
- Friedel W, Kaiser IH. Vaginal evisceration. Obstet Gynecol 1975; 45:315.
- Lal P, Mohan P, Sharma R, et al. Postcoital vaginal laceration in a patient presenting with signs of small bowel perforation: report of a case. Surg Today 2001; 31:466.
- McColgin SW, Williams LM, Sorrells TL, Morrison JC. Hemoperitoneum as a result of coital injury without associated vaginal injury. Am J Obstet Gynecol 1990; 163:1503.
- Sadler DW, Pounder DJ. Fatal air embolism occurring during consensual intercourse in a non-pregnant female. J Clin Forensic Med 1998; 5:77.
- American College of Obstetricians and Gynecologists. Antibiotic Prophylaxis for Gynecologic Procedures. Clinical Management Guidelines for Obstetrician-Gynecologists, ACOG bulletin Number 24, American College of Obstetricians and Gynecologists, Washington DC 2001. p.268.
- Minassian VA, Jazayeri A, Prien SD, et al. Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstet Gynecol 2002; 100:1239.
- Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev 2010; :CD000006.
- Lundquist M, Olsson A, Nissen E, Norman M. Is it necessary to suture all lacerations after a vaginal delivery? Birth 2000; 27:79.
- Dhulkotia JS, Alazzam M, Galimberti A. Tisseel for management of traumatic postpartum haemorrhage. Arch Gynecol Obstet 2009; 279:437.
- Benrubi G, Neuman C, Nuss RC, Thompson RJ. Vulvar and vaginal hematomas: a retrospective study of conservative versus operative management. South Med J 1987; 80:991.
- Gianini GD, Method MW, Christman JE. Traumatic vulvar hematomas. Assessing and treating nonobstetric patients. Postgrad Med 1991; 89:115.
- Mok-Lin EY, Laufer MR. Management of vulvar hematomas: use of a Word catheter. J Pediatr Adolesc Gynecol 2009; 22:e156.
- Sachs, PB. Women's diagnostic imaging, case fifteen: Factor II deficiency with vulvar hematoma. www.uhrad.com (Accessed on May 03, 2012).
- Kunishima K, Takao H, Kato N, et al. Transarterial embolization of a nonpuerperal traumatic vulvar hematoma. Radiat Med 2008; 26:168.
- Whiteside JL, Asif RB, Novello RJ. Fibrin sealant for management of complicated obstetric lacerations. Obstet Gynecol 2010; 115:403.
- Harlow BL, Wise LA, Stewart EG. Prevalence and predictors of chronic lower genital tract discomfort. Am J Obstet Gynecol 2001; 185:545.
- Munarriz R, Talakoub L, Somekh NN, et al. Characteristics of female patients with sexual dysfunction who also had a history of blunt perineal trauma. J Sex Marital Ther 2002; 28 Suppl 1:175.
- PHYSICAL EXAMINATION
- PERIOPERATIVE MANAGEMENT
- REPAIR OF LACERATIONS
- - Superficial lacerations
- - Deep lacerations
- - Extension beyond the vagina
- MANAGEMENT OF HEMATOMAS
- FOLLOW UP
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS