Description

An 18-year-old woman presented to the emergency room in a tertiary maternity hospital with severe vulval pain and an inability to pass urine. Examination of her external genitalia revealed a large swollen right vulval haematoma (figure 1). She reported the symptoms had been present for 3 days following a collision on a push-bicycle, where the handle bars of the bicycle collided directly with her external genitalia. There was extreme pain associated with movement, micturition and defecation. She had no difficulty weight-bearing, and had normal lower-limb musculoskeletal function and range of motion, within the limitations of the severe pain from the labial haematoma.

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Figure 1

Vulval haematoma. Inferior tear in tissue actively bleeding from oedematous vulval tissue (white arrow).

Physical examination was notable for a primarily right-sided distended vulva, with overt ecchymoses and purpural discolouration (figure 1). The inferior portion of the swollen right vulvar tissue was grossly oedematous with an area tearing apart and bleeding (white arrow). The abdomen was soft, with a palpable bladder. Using topical lignocaine and inhaled nitrous oxide for analgesia a urinary catheter was placed, which drained 1 L of clear urine. Analgesia administered included intravenous paracetamol, intravenous dexketoprofen and intravenous morphine.

The patient was taken to theatre for examination under anaesthesia; a large labial wall defect on the inferior border of the swelling was found and no incision was necessary. A significant amount of organised haematoma was removed by manual evacuation. The haematoma was solidified and appeared to have self-limited with a tamponade effect. It did not extend into the vaginal wall, and the cavity was extensively washed out with and packed with a povidone–iodine wick. Given the 3-day delay in presentation to our services, and the tamponade effect no specific artery or bleeding source was identified. The patient recovered well postoperatively with no urinary complications and minimal analgesic requirements, and on 3-month follow-up had recovered with no further concerns.

Vulval injuries of this nature are most often seen postnatally in women following childbirth, in particular following operative vaginal deliveries (eg, ventouse and forceps deliveries).1 2 Other causes include trauma, forceful intercourse, sexual abuse, injection into genital vessels and saddle injuries, as in this case relating to certain sporting activities (cycling, horse riding etc).3–5 Most labial and vulval injuries can be managed with conservative measures, though on occasion require surgical intervention if functional impairments arise (micturition, defecation), or if there is acute haematoma expansion.6