Gynecological Trauma

Definition/ Etiology:

Gynecological trauma involves the external and internal female reproductive organs:

• Vulva
• Clitoris
• Urethra
• Vagina
• Cervix
• Perineum
• Rectum

Any person who complains of pain, bleeding, or swelling of the vulva should be evaluated for further injury to the vagina as well.  Internal injuries are much more difficult to assess.

History should be consistent with the injury.  It may take time for the patient to become comfortable with providing history.  Utilize SANE staff if available and appropriate.

Pathophysiology:

Vulvar injury mechanisms:

• Usually, blunt trauma
• Straddle injuries

Risk factors:

• Girls and adolescents are more likely to have vulvar injuries. They may not have yet developed the fat pads of the labia majora which protect the vulva from injury.
• Bicyclists
• Motorcyclists
• Gymnasts 

Vulvar injury sequelae:

• hematoma due to the rich vascular supply

Vaginal injury mechanisms:

• nonconsensual or forceful consensual coitus
• penetration by a foreign object
• pelvic fracture
• hydraulic or pneumatic forces (eg, water or air insufflation from jet ski accidents or water skiing)

Risk factors: 

• first coitus (usually associated with hymenal lacerations) 
• hypoestrogenic states (menopause, lactation, postpartum) 
• history of pelvic irradiation
• anatomic abnormalities

Vaginal injury sequelae:

• Fistulas

Differences in sex development, or DSD, is the term used to describe congenital abnormalities in reproductive organs.  These patients may delay care due to concerns about compassion of healthcare workers.  The same is true with the transgender community.  It is important to address patients respectfully and be aware that gender expression may not match physical reproductive organs.  Also, in some cultures, even in the US, female genital mutilation is common, and can have unintended outcomes such as difficulty urinating and menstruating, as well as pregnancy complications.

Clinical Presentation:

• skin lacerations
• erythema
• edema
• ecchymosis
• asymmetry of the labia
• localized tenderness
• localized fluctuance 
• Bleeding
• Hypovolemic shock if internal bleeding
• Septic shock if bowel perforation, etc

Collaborative Management:

• Social worker
• Child protection team if appropriate
• cystoscopy
• voiding cystourethrogram
• Urinalysis
• Upright abdominal x-ray
• Surgical team to eval extent of internal injuries
• Serial CBC if bleeding/hematoma

If patient confirms sexual assault:

• Gonorrhea / chlamydia swab
• HIV serology
• PEP (post-exposure prophylaxis)

Evaluation | Patient Monitoring | Education:

• Sitz baths
• Pelvic rest
• Donut pillow to  prevent pressure necrosis of edematous external genitalia
• Ice packs with cloth barrier
• Counseling referral
• Evaluate ability to void. Foley may be needed if swelling interferes with urination.
• Analgesia

Linchpins (Key Points)

• Listen carefully and compassionately, without judgment.
• Monitor vitals carefully due to potential for internal injury.
• Utilize SANE staff if assault/abuse is suspected.
• Reproductive organs may not match patient’s gender expression.
• Consult social worker if abuse is suspected.