NEW YORK — A vulvar injury in a child is likely to heal without major intervention, even if a large hematoma is present and the patient complains of severe pain, David Muram, M.D., said at a gynecology conference sponsored by Mount Sinai School of Medicine.
Typical vulvar injuries are accidental deceleration injuries, occurring when the child falls on the crossbar of a bicycle or while climbing fences or playground equipment. The vagina, urethra, and hymen are usually spared because of the protection provided by the overlying labia, Dr. Muram said.
If there is no evidence of hymeneal injury—which is unlikely to result from an accident—the main concern is ensuring the child can void. If not, she should be kept for observation, and a suprapubic catheter should be placed, he said.
It's also a good idea to check whether there is a fracture of the pubic bone. “Tell her to stand up and raise one foot at a time. If this causes pain, get an x-ray. Not that you are going to do anything about it, but you won't be sued for missing it,” said Dr. Muram of the department of obstetrics and gynecology at the University of Tennessee, Memphis, and consultant to Eli Lilly & Co., Indianapolis.
In most cases, contusion of the vulva does not require special treatment, other than cold packs. Drainage is required only if bleeding persists and there is a large hematoma that continues to grow. Any clotted blood should be removed and the bleeding points identified and ligated, he said.
If the source of the bleeding in a large hematoma cannot be identified, pack the cavity with gauze and apply a firm pressure dressing. The pack can be removed the next day, but watch for possible renewed bleeding, he said.
It's also wise to prescribe a broad-spectrum antibiotic prophylactically, particularly if the hematoma is incised.
“Sitz baths are wonderful in this situation, and make sure the child lies on an air-filled doughnut to prevent pressure necrosis of the external genitalia,” he said.