Evaluation and management of female lower genital tract trauma

INTRODUCTION — 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 "Causes of female genital tract bleeding".)

ETIOLOGY

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 "Assisted (operative) vaginal birth" and "Shoulder dystocia: Risk factors and planning birth of high-risk pregnancies" and "Approach to episiotomy" and "Obstetric fistulas in resource-limited settings".)

Gynecologic

●Vulvar trauma – The rich vascular supply to the perineum places it at risk for bleeding from trauma. Vulvar hematomas are the most common sequelae.

In adult patients, the labia majora are comprised of large fat pads, which act to protect the vulva against injury. In contrast, children lack well-developed fat pads in this area and often engage in play activities predisposing them to vulvar trauma; thus, they are more likely to sustain vulvar injuries than adults. (See "Straddle injuries in children: Evaluation and management".)

Vulvar and perineal injuries in gynecologic practice most commonly occur due to blunt trauma, particularly in the straddle position. Bicycle, automobile, or other athletic accidents are often causative events, but coitus-related activity also plays a role [1-7].

●Vaginal trauma – Most vaginal injuries occur as a result of penetrating trauma. Causes include nonconsensual or forceful consensual coitus, penetration by a foreign object, pelvic fracture, and hydraulic or pneumatic forces (eg, water or air insufflation from jet ski accidents or water skiing) [8-11]. Risk factors include first coitus (usually associated with hymenal lacerations); hypoestrogenic states (menopause, lactation, postpartum); inebriation; history of pelvic irradiation; and anatomic abnormalities [11]. (See "Congenital anomalies of the hymen and vagina".)

Multiple studies have looked for types or patterns of injuries more common in victims of sexual abuse in order to establish etiology of injuries [3,12]. A definitive pattern confirming or refuting abusive versus accidental vulvovaginal trauma has not been determined, despite use of multiple examination tools (vaginoscopy, colposcopy, toluidine blue dye) [12-14]. (See "Evaluation of sexual abuse in children and adolescents".)

HISTORY — In the pediatric and adolescent age groups, patient history has been shown to be as important as physical examination in determining the cause of trauma [3,12]. In children, hymenal disruption (especially from 3 to 9 o'clock) can be indicative of penetrating injury and should raise suspicion for abuse. It is important to remember that a normal genital examination does not exclude the possibility of sexual abuse. (See "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

PHYSICAL EXAMINATION — Physical examination should always be performed in the presence of a chaperone. If sexual abuse, nonconsensual coitus, or excessive brutality is suspected, it is important to take special care to avoid any additional trauma to the victim and to consult a practitioner trained in assessing victims of sexual violence. In addition, it may be necessary to perform specific documentation and procedures to obtain forensic evidence; details are outlined elsewhere. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)

Pain during the examination may be controlled, if necessary, with analgesics or anesthetics, as described below (see 'Sedation/anesthesia' below). In the pediatric age group, sedation or anesthesia may be necessary to gain a full understanding of the extent of the injury to facilitate the examination, assessment, and repair [15].

Vulva — The labia, clitoris, urethra, perineum, and rectum are examined at the start of any pelvic examination. It is essential that the examining physician be familiar with normal variants of the external female genitalia. (See "Gynecologic examination of the newborn and child", section on 'Evaluation of the hymen' and "Congenital anomalies of the hymen and vagina".)

Clues to external trauma include skin lacerations, redness, edema, ecchymosis, asymmetry of the labia, and localized tenderness. Labial fluctuance, swelling, and pain can indicate hematoma formation. If gross swelling without ecchymoses is noted, translabial ultrasound can be helpful in distinguishing between edema and a collection of blood. In the area of the Bartholin glands, diagnosis of an acute cyst or abscess should be made with caution in patients with a recent history of trauma because hematomas in this region can have a similar presentation. (See "Bartholin gland masses".)

Perineum — The perineum is the supportive layer of tissue between the introitus and the rectum. This area may sustain a significant portion of the force exerted during penetrating trauma. Perineal lacerations or tears are classified as follows:

●First degree – Involving only the perineal skin.

●Second degree – Involving the perineal body and deeper tissues.

●Third degree – Extending into the capsule and muscle of the rectal sphincter.

●Fourth degree – Extending through the sphincter and into the rectal mucosa.

These classifications help the clinician determine both extent of injury and approach to repair.

Vagina — Inspection of the vaginal introitus and the hymenal ring can be achieved by gentle downward and outward traction on the perineum/inferior labia. Internal vaginal examination with a sterile speculum should include rotation of the speculum to entirely visualize all four vaginal walls. The integrity of the vaginal fornices (cervicovaginal junction) must be carefully assessed, as the most commonly reported sites for coital vaginal laceration are the posterior fornix and lateral vaginal walls. A thorough evaluation is important because if the injury is not appropriately diagnosed and managed, inadequate healing may result in a fistula between bladder and vagina or bowel and vagina.

In cases of minor lacerations, the pressure of the open speculum may lead to hemostasis temporarily and thus conceal the injury; the lesion may bleed again when pressure is released. Visualizing the laceration while releasing and slowly retracting the speculum will help to prevent this from occurring.

If brisk bleeding from any area obscures an adequate examination, the vagina should be packed with sterile gauze and the patient taken to the operating room for evaluation and control. Vaginal trauma may cause serious damage to internal organs, especially the lower urinary tract [16-19]. Urethral catheterization can be useful to look for hematuria, suggestive of bladder injury. However, the urethra itself may be disrupted, in which case catheter placement may be traumatic or very difficult. Cystoscopy, voiding cystourethrogram, or other urologic studies may help elucidate the nature of injury. Urethral injuries should be evaluated by an experienced urologist or urogynecologist prior to intervention.

Digital rectal examination is performed to determine sphincter tone, assess mucosal integrity, expose any rectal bleeding, and further evaluate for posterior vaginal injuries. Bony prominences in the pelvis and perineum should be palpated and evaluated for tenderness suggestive of fracture.

An upright abdominal film looking for free air under the diaphragm is indicated if there is suspicion that a vaginal laceration has extended into the peritoneal cavity [20,21]. However, trauma occurring inside the vagina may result in damage to internal organs even in the absence of vaginal mucosal laceration. In most of these case reports, patients were evaluated for hemoperitoneum or small bowel injury [22]. Fatal air embolism has also been reported [23]. Such instances highlight the need for thorough patient evaluation.

PERIOPERATIVE MANAGEMENT — Potential complications should be identified, if possible, prior to any intervention. Obtaining intravenous access and choosing an appropriate operative setting are important considerations for all of the procedures described below. Consultation with an experienced emergency department clinician, gynecologist, or surgeon and adequate sedation/anesthesia are of paramount importance. Utilizing resources such as child life specialists to prepare younger children and adolescents can facilitate the examination; distraction techniques can also be helpful [24].

Antibiotics — Prophylactic antibiotics are not usually required for repairs of vulvar and vaginal trauma [25]. Prophylaxis against sexually transmitted infections is appropriate in individual cases, such as sexual assault victims. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Sexually transmitted infection post-exposure prophylaxis'.)

Sedation/anesthesia — Vulvar and perineal trauma may be associated with pain and discomfort out of proportion to the size of the injury due to the sensitivity of this area. Lidocaine (1 percent solution) injected locally is useful for providing anesthesia for suturing and is the most frequently used anesthetic for minor injuries. A small gauge needle (eg, 22) is used for injection; however, a spinal length needle may be needed for reaching deep vaginal areas. The periclitoral region and the perineal skin anterior to the rectum are exquisitely sensitive and special care should be taken to apply adequate analgesia in these areas.

Topical lidocaine jelly (2 percent) may be injected into the urethra for pain control during catheterization but is generally not as effective on the external genitalia [26]. Oral or intravenous pain medication may be required for patients with significant pain or distress, and young girls may require conscious sedation or general anesthesia [15]. All general anesthesia is given in an anesthetizing setting (operating room). (See "Procedural sedation in children: Approach".)

REPAIR OF LACERATIONS

Vulva — Vulvar trauma can cause significant bleeding because the area is highly vascular and the loose subcutaneous tissues afford little resistance to hematoma formation (picture 1). Bleeding vessels should be targeted for suture repair, if they can be identified, to prevent collection of blood. Hemostatic superficial lacerations may be left open, but actively bleeding lacerations should be closed. Puncture wounds are cleaned and assessed for deeper trauma and foreign bodies before closing.

Before suturing near the clitoris and urethra, the clinician should weigh whether repair of these areas may be more traumatic or painful than leaving the laceration to heal by secondary intention. If repair is needed to achieve hemostasis or tissue reapproximation, a fine absorbable synthetic suture (such as monocryl) is utilized; use of catgut suture may increase post-repair pain [27], placing shallow through-and-through interrupted sutures to reapproximate skin edges. Deeper lacerations (>3 to 4 mm deep) may require an initial deep suture layer if there is bleeding, but it is important to avoid putting extra foreign material in the wound. If deep lacerations appear infected, then the wound should be packed with saline-moistened gauze two or three-times daily and allowing it to heal by secondary intention.

Repair of traumatic vulvovaginal lacerations is the same irrespective of the cause of the injury (obstetric delivery or nonobstetric cause) (figure 1 and figure 2 and figure 3).

Vagina

Superficial lacerations — Minor vaginal trauma is not generally associated with significant pain or blood loss unless a major blood vessel is torn. Bleeding from hymenal injuries is usually minimal and requires no treatment. Superficial vaginal lacerations limited to mucosal and submucosal tissues can be left alone if hemostatic, otherwise styptic (silver nitrate, ferric subsulfate [Monsel solution]) or simple tamponade may suffice if bleeding is light. Such lacerations are repaired with fine absorbable synthetic sutures under local anesthesia only if there is a need for hemostasis or tissue reapproximation [28]; use of catgut suture may increase post-repair pain [27]. If electrocautery is used, it is important to avoid deep or widespread thermal injury because of the vagina's proximity to the bowel and bladder, as well as risk of infection in the resulting necrotic tissue.

Deep lacerations — Repair of deep or complicated vaginal lacerations requires both an operator and a surgical assistant, and is best performed in a surgical suite to obtain adequate exposure. Regional or general anesthesia may be needed due to pain and pressure from retraction or extensive suturing. Blood products should be available for transfusion in the event of brisk bleeding.

Deep or large vaginal lacerations may be repaired in one or more layers depending upon the tissues involved. A running locked absorbable suture is used to obtain initial hemostasis. The anchoring stitch should be placed above the apex of the laceration, and each stitch should reach the base of the tear to avoid creating pockets for hematoma/seroma formation. The proximity of the bladder anteriorly, small bowel and rectum posteriorly, and the ureters and uterine vessels deep in the lateral vaginal fornices are important to consider as they can be included in placement of large deep sutures.

The mucosal edges are reapproximated with fine absorbable synthetic sutures. If the hymenal ring is involved, it should be reapproximated to itself. The perineum and or rectal sphincter may need additional stitches for support. Repair of third and fourth degree perineal lacerations is discussed in detail separately. (See "Delayed surgical management of the disrupted anal sphincter" and "Approach to episiotomy".)

Emergency use of fibrin sealants has been reported for treatment of vaginal lacerations after surgical management has failed to control bleeding [29]. Further information is needed regarding use of these adjuncts for this type of injury. (See "Management of hemorrhage in gynecologic surgery".)

Deep lacerations that appear infected, if hemostatic, may be left open or closed with placement of a drain (picture 2A-B). Povidone iodine-moistened vaginal packing is often placed in the vagina for 24 hours after repair to assist in achieving hemostasis. A Foley catheter should be inserted to drain the bladder as a vaginal pack may obstruct outflow from the urethra.

Extension beyond the vagina — Laparoscopy or an exploratory laparotomy may be needed for assessment of a deep vaginal laceration that extend through the posterior cul-de-sac (pouch of Douglas) and into the peritoneal cavity to rule out damage to internal organs. A urologist or urogynecologist should evaluate any trauma extending to the urethra or bladder.

Lacerations extending into the rectum should be evaluated and treated by an experienced gynecologic or general surgeon. In severe cases, diverting colostomy may be indicated. These lacerations have a high incidence of infection, wound breakdown, and risk of rectovaginal fistula formation and sphincter incontinence. (See "Rectovaginal and anovaginal fistulas".)

MANAGEMENT OF HEMATOMAS — Management of vulvar and vaginal hematomas varies; the literature is inconclusive regarding benefits of conservative treatment versus surgical interventions [30,31].

Vulva — If possible, vulvar hematomas are best left undisturbed so as to avoid introducing bacteria and undertaking a potentially difficult surgical procedure (picture 1). Bleeding leading to a vulvar hematoma is often venous and from multiple sites, thus it can be difficult to isolate and control surgically.

The rationale for conservative management is that soft tissue swelling and space limitations will cause tamponade of bleeding vessels. Patients may be uncomfortable with such swelling, but they should be reassured the body will naturally reabsorb the blood and edema over time. Ice packs may be applied to the perineum for the first 24 hours to minimize swelling and narcotic or nonnarcotic analgesia are administered to manage pain. Large vulvar hematomas often interfere with urination. A Foley catheter should be placed upon initial evaluation because, if the hematoma is still expanding, late placement may not be possible without sedation or anesthesia (picture 3) [13]. Some hematomas may rupture spontaneously (picture 4).

Surgical intervention may be necessary if there is vast expansion of the hematoma on physical examination or a falling hematocrit. Persistent hemorrhage can lead to hemodynamic instability or put the tissue at risk of necrosis, and thus the clinician should be vigilant otherwise bleeding that tracks posteriorly, vaginally, or into the retroperitoneum may not be recognized promptly.

If the hematoma is drained, one approach is to make an incision large enough to allow visualization of bleeding vessels, which are ligated if possible. A suction/irrigation devise may be helpful in clearing the clot and debris (picture 5). The space created by the incision is reapproximated using in interrupted or figure-of-eight stitches of monofilament absorbable suture to avoid trapping bacteria. The incision can then be repaired as described above (see 'Repair of lacerations' above). A drain may be helpful (picture 6), as incision of the hematoma exposes the underlying tissues to a nonsterile environment and predisposes it to infection.

An alternate approach is drainage of the hematoma with a small incision with no attempt to visualize and ligate bleeding vessels. We have found this approach to be successful as long as a drain is left in place; we have utilized a word catheter which permits for drainage and decreases the risk of superinfection in a closed space [32].

Interventional vascular procedures for embolization of vessels have been reported [33,34], but are rarely employed.

Use of other matrix or tissue hemostatic agents has been reported and may be an alternative option for treatment in difficult cases. The use of a fibrin sealant with hemostatic and tissue-sealing adjunctive properties was successful in a case of refractory bleeding and failed surgical management of an expanding vulvar hematoma [35].

Vagina — The approach to vaginal hematomas is similar to that for vulvar hematomas. Vaginal hematomas larger than approximately 4 cm may need to be opened and evacuated to ligate bleeding vessels. If all bleeding vessels are not ligated adequately before the mucosal edges are closed, another hematoma may develop. If stable, these hematomas can be watched, but if they are enlarging or if bleeding continues, they too should be opened, evacuated, and the bleeding points ligated. Vaginal packing with a povidone iodine-moistened gauze may be helpful for tamponade.

As discussed above, the possibility of retroperitoneal bleeding from torn and retracted vessels must also be considered if the patient becomes unstable (see 'Extension beyond the vagina' above). Interventional vascular procedures for embolization of vessels are rarely indicated. If surgical management fails to control bleeding of an opened vaginal hematoma, emergency use of fibrin sealants may be an option [29].

FOLLOW-UP — Sitz baths are often prescribed two or three times daily to help with hygiene until external lacerations are healing well. Depending upon the extent of trauma, pelvic rest for three to four weeks is also recommended to avoid disruption of healing tissue. Analgesics, such as nonsteroidal anti-inflammatory drugs and narcotics, are used for short-term pain control. Topical lidocaine has minimal efficacy. Further supportive measures include use of vaginal lubricants for coitus and (vaginal) estrogen supplementation in hypoestrogenic patients. Pressure necrosis of the swollen external genitalia may be prevented by having patients rest primarily on their side or back.

Patient counseling after vaginal laceration is tailored to individual circumstances, and emotional consequences of such an injuries should not be overlooked. Studies suggest patients who suffer trauma of the genital tract are more likely to suffer dyspareunia, sexual dysfunction, and chronic pain of the lower genital tract and pelvis [36,37].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abnormal uterine bleeding" and "Society guideline links: Genitourinary tract trauma in adults".)

SUMMARY AND RECOMMENDATIONS

●Etiology – Vulvar hematomas (picture 1) are the most common sequelae of blunt trauma to the genitalia, whereas most vaginal injuries occur as a result of penetrating trauma. (See 'Etiology' above.)

●History – Patients with lower genital tract injury in nonobstetric settings may not be forthcoming with details of the preceding events. 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. (See 'Introduction' above and 'History' above.)

●Physical examination

•Physical examination should always be performed in the presence of a chaperone. If sexual abuse, nonconsensual coitus, or excessive brutality is suspected, it is important to take special care to avoid any additional trauma to the victim and to consult a practitioner trained in assessing victims of sexual violence. (See 'Physical examination' above.)

•Vaginal trauma may cause serious damage to internal organs and injuries to the lower urinary tract. Urethral injuries should be evaluated by an experienced urologist or urogynecologist prior to intervention. (See 'Physical examination' above.)

●Repair of lacerations

•Before suturing near the clitoris and urethra, the clinician should weigh whether repair of these areas may be more traumatic or painful than secondary healing alone. If repair is needed to achieve hemostasis or tissue reapproximation, then we use fine absorbable interrupted sutures (eg, monocryl). (See 'Repair of lacerations' above.)

•Deep or large vaginal lacerations may be repaired in one or more layers. Exploratory laparotomy or laparoscopy may be necessary for full evaluation of deep lacerations that extend through the posterior cul-de-sac and into the peritoneal cavity to rule out damage to internal organs. Diverting colostomy may be needed if the gastrointestinal tract is involved. (See 'Repair of lacerations' above.)

●Management of hematomas

•If possible, vulvar hematomas are managed conservatively with ice, analgesia, and pelvic rest. A Foley catheter is recommended if the hematoma is large since it often interferes with urination. (See 'Management of hematomas' above.)

•Expansion of a vulvar or vaginal hematoma or a falling hematocrit are indications for prompt surgical intervention as persistent hemorrhage can lead to hemodynamic instability and other complications. If bleeding vessels are not ligated adequately before the edges are closed, another hematoma may develop. However, in many cases, the vessels cannot be identified so the incision is closed and a drain is left in place (picture 2B and picture 6). (See 'Management of hematomas' above.)