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Lower Genital Tract Trauma: DR Izzni Adilah Binti Dzulkifli 17th October 2022

The document discusses lower genital tract trauma including vaginal and perineal tears, vulva hematomas, cervical injuries, and obstetric fistulas. It describes the causes, signs and symptoms, risk factors, and management approaches for each condition. Conservative treatments for vulva hematomas include ice, compression, and analgesics for small hematomas. Larger hematomas require surgical evacuation and hemostasis. Cervical injuries from prolonged labor or instrumentation require examination and suturing. Obstetric fistulas are abnormal connections between cavities that cause incontinence.

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50 views28 pages

Lower Genital Tract Trauma: DR Izzni Adilah Binti Dzulkifli 17th October 2022

The document discusses lower genital tract trauma including vaginal and perineal tears, vulva hematomas, cervical injuries, and obstetric fistulas. It describes the causes, signs and symptoms, risk factors, and management approaches for each condition. Conservative treatments for vulva hematomas include ice, compression, and analgesics for small hematomas. Larger hematomas require surgical evacuation and hemostasis. Cervical injuries from prolonged labor or instrumentation require examination and suturing. Obstetric fistulas are abnormal connections between cavities that cause incontinence.

Uploaded by

miss_izzni
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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LOWER GENITAL TRACT

TRAUMA

Dr Izzni Adilah binti Dzulkifli 17th October 2022


CONTENT

1) Vagina and perineal tears


2) Vulva hematoma
3)Cervical injuries
4) Periuretheral tears
5) Fistula
Vulva Hematoma
Infralevator hematoma in rectal triangle
Coronal section through hematoma
Paravaginal /supralevator hematoma ;common in
episiotomy
Vessel injury

• Branches of pudendal artery


• : inferior rectal ,
• :transverse perineal and
• : posterior labial artery
• Direct cause : episiotomy , vaginal • Sexual assault
laceration repairs , instrumental delivery
• Post coital injury 9most common)
• Indirect cause : extensive stretching of
birth canal during vaginal delivery
• Risk factors : Instrumental deliveries ,
prolonged second stage ,macro
Sonia ,use of anticoagulant,
vulvovaginal varicosities
• Non obstetric cause :
• Trauma to perineum -saddle injury
• Falling from height
Hx & Physical examination

• Perineal ,buttock Pain is the most common symptoms


• Disrupt mobility
• Urinary retention : due to mechanical urethral obstruction
• Haemodynamically unstable
• Tender fluctuations lump of variable size >15cm
Imaging

• US, CT, MRI


• -> to diagnose hematomas above pelvic diaphragm
• -> to assess any extension into pelvis

• MRI
• ->location ,size and extend of haematoma, monitoring progress or resolution
• -> DDX : other causes of pelvic mass : Abscess or Endometrioma
MANAGEMENT

• Aim :
• - to prevent further blood loss
• -minimize tissue damage
• Relieve pain
• Reduce risk of infection and scarring

• Prompt assessment to vulva vagina and perineum :


• identify site of haematoma and assess expansion
• Estimate blood loss
1) Resuscitative measures

• Fluid replacement
• Assess coagulation status -essential of heavy bleeding or signs of hypovolaemia
• GXM
• Urinary Catheter :
• -> for fluid balance
• -> avoidance of possible urinary retention d/t pain , edema or pressure from vaginal pack
COnservative Treatment

• if small (<5 cm) : ice packs , local compression , analgesics


• Ensure bleeding has settled and hematoma has resolves
• Avoid rectal administration of analgesics
• NOt suitable for large hematomas : longer hospital stays ,greater subsequent operative
intervention
Surgical Treatment

• For large vulvovaginal hematoma > 5cm


• Haemodynamically unstable

• Evacuation : incisions should be place medically to minimize scarring


• Clots should be evacuated
• Ligate any bleeding points
• 1)Primary Closure : rarely can identify
site of bleeding
• Space should be closed with deep
mattress sutures , skin apples without
tension
• beware of ureters bowel and bladder
• COmpression : vagina packing 12 - 24
hours

• Drains : to highlight ongoing /recurrent


bleeding but defeat the purpose of
vaginal packing which is to tamponade
bleeding vessels
Pelvis arteriography and arterial embolization

• Success rate 90%


• Through femoral artery ->access to pelvic circulation
• Angiography is used to identify bleeding vessels before selective embolization
• Complication :
• Fever, pelvic infection
• Ischaemia buttock pain/ groin hematoma ,
• Vessel perforation
• Temporary foot drop
Prevention

• Haematomas are unavoidable , HOWEVER


• Good surgical technique , with attention to haemostasis during laceration repair of
episiotomies is important
Cervical injuries

• Minor lacerations extremely common but does not cause symptoms


• Deep lacerations particularly those involve vaginal vault causing excessive bleeding need to be managed in
OT under good anesthesia
• Bleeding which continues despite of. Contracted uterus after birth is an indication for examining the cervix to
exclude cervical injury
• Risk factors :
• Precipitate/ Prolonged labour
• Trapped cervical tissue during vacuum or forceps
• rapid delivery of head in breech presentation
• Cervical scars
Management

• Prompt recognition is key to prevent


further bleeding
• Good light for proper visualization
• Inspect whole cervix circumferential
using 2 pairs of sponge forceps “cervical
walk”
• Identify the apex
• Suture through whole thickness of its wall
by running locking /interrupted sutures
Obstetrics Fistula
• Abnormal communication between 2 cavities with different epithelial types either vesicovaginal
or rectovaginal fistula
• Diagnosis : patient presented of urinary leakage 1 week pos delivery
• Estimates of 2-7 million women affected mostly in developing countries
• Most common in young women result in chronic incontinence or faeces in vagina
• A Psychosocial injury
• Most cases are unreported due to stigma and lack of knowledge
Sign & Symptoms

• Flatulence
• Pain during sexual activity
• Foul smelling vaginal discharge
• Recurrent vaginal /urinary tract infections
• Irritation or pain in the vaginal surrounding areas
• Urinary /faecal incontinence
Risk factors

• Pelvic fracture
• Obstructed labor
• Teenage pregnancy
• Early marriage before pelvic growth is complete
• Sexual violence , rape ,trauma
• Inflammatory bowel disease
• Malnourished
Thank you

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