Interesting Case Rounds

Rebecca Burton-MacLeod

R4, Emerg Med

June 28th, 2007

Case

• 11F transferred from PLC to ACH ED after sustaining a vulvar hematoma

• Pt was skateboarding and fell off, landing on her buttocks

• Immediate pain to perineum• Pt stated that swelling noted to genitals

within 5min; when parents arrived home 1hr later, marked swelling

History

• Any other questions you wish to ask?

Case cont’d

• On examination:– Hemodynamically stable

– ++ purplish-discolouration bulging mass to R labia; small laceration at 6 o’clock position on R labia

– L labia appears normal

– Unable to examine vaginal opening or other midline structures due to swelling

– Anus normal

– No other signs of trauma

Physical exam

Vulvar hematomas

Vulvar hematoma

• Blood supply:– Pudendal artery– Posterior rectal artery– Transverse perineal artery– Posterior labial artery

Causes of injury

• Straddle injuries (75% of cases in peds)

• Sexual abuse

• Kicks

• Self-inflicted wounds

Vulvar hematoma

• Mgmt ?

Mgmt

• No further rapid expanse of hematoma

• Pain control

• Ice packs to groin

• Observe for ability to void

• D/W Gyne

Vulvar hematoma

Kanai M et al. Warning from Nagano: increase of vulvar hematoma and/or lacerated injury caused by snowboarding. J Trauma. 50(20). 2001.

Mgmt

• Conservative– Small hematomas

– No rapid expanse

– Patient able to void

• Surgical– Large, rapidly

expanding hematomas

– Inability to void due to swelling

– Infective complications

Mgmt

• Conservative mgmt:– Observation– Ice packs– Ice Sitz baths– Tetanus (if appropriate…)

Surgical mgmt

• I + D

• Ligation of bleeding arteries

• If suspected retroperitoneal hematoma:– Laparoscopy – Exploratory celiotomy

Imaging

• U/S ?

• Case report – Blunt straddle injury with L labial swelling and

++ pain– Transperineal U/S performed to more

accurately measure size and extent of vulvar hematoma

U/S

CT

Summary

• Conservative mgmt if small, nonexpanding hematoma

• Involve Gyne if rapidly expanding, unable to urinate

• No role for imaging at this time…

Questions ?