Because of the rich vascular supply, trauma to the perineum can produce bleeding, commonly resulting in a vulvar hematoma. It is important to ascertain the mechanism and to examine for internal injuries, which are more difficult to detect. A common mechanism is a straddle injury, but this can also be a result of forceful consensual or nonconsensual sexual activity. Patients are often reluctant to reveal the nature of the mechanism, making those at risk harder to identify. The accumulation of the hematoma is usually rapid and painful. If there is an associate laceration, bleeding can be brisk.
Management and Disposition
Large or expanding hematomas require urgent consultation for further management to include examination under anesthesia for internal injury, further observation, pain control, and rarely, incision and drainage, which is best avoided due to the risk of introducing bacteria and difficult hemorrhage control. Minor hematomas can be managed as an outpatient providing pain is controlled (ice packs and analgesics) and follow-up arranged. Disposition to a short-stay observation unit may be appropriate.
Sexual abuse or assault should be considered in cases that do not have a straight forward history or mechanism.
Vulvar hematomas are the most common sequelae of vulvar trauma.
Translabial ultrasound may be useful to discern between hematoma and soft tissue swelling.
Place a foley catheter early to prevent bladder obstruction for large or expanding hematomas.
Vulvar Hematoma. This large vulvar hematoma from coitus-related activity required surgical drainage. A laceration is noted at the 6-o’clock position of the labia. (Photo contributor: Zachary Wohlgemuth, MD.)