1. Interesting Case Rounds
Rebecca Burton-MacLeod
R4, Emerg Med
June 28th, 2007

2. 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

3. History
Any other questions you wish to ask?

4. 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

5. Physical exam

6. Vulvar hematomas

7. Vulvar hematoma Blood supply: Pudendal artery Posterior rectal artery
Transverse perineal artery
Posterior labial artery

8. Causes of injury Straddle injuries (75% of cases in peds) Sexual abuse
Kicks
Self-inflicted wounds

9. Vulvar hematoma
Mgmt ?

10. Mgmt No further rapid expanse of hematoma Pain control
Ice packs to groin
Observe for ability to void
D/W Gyne

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

12. Mgmt Conservative Surgical Small hematomas No rapid expanse
Patient able to void
Surgical
Large, rapidly expanding hematomas
Inability to void due to swelling
Infective complications

13. Mgmt Conservative mgmt: Observation Ice packs Ice Sitz baths
Tetanus (if appropriate…)

14. Surgical mgmt I + D Ligation of bleeding arteries
If suspected retroperitoneal hematoma:
Laparoscopy
Exploratory celiotomy

15. 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

16. U/S

17. CT

18. Summary Conservative mgmt if small, nonexpanding hematoma
Involve Gyne if rapidly expanding, unable to urinate
No role for imaging at this time…

19. Questions ?