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Miss D.C. is a 9 year old who was standing on top of a fire hydrant when she slipped and fell, landing with her pubic area striking the fire hydrant. She had immediate pain and was brought to the emergency room by her mom.
When I saw her, the emergency room physician had already given her an icepack to place over the swelling of her left labia majora and minora. She had already had an AP and Lateral xray of her pelvis to demonstrate that there were no fractures.
Vulvar Hematoma
This presentation is fairly representative of straddle injuries among women. There is a branch of the pudendal artery and vein that run along each side of the clitoral shaft and hood. In the event of a sudden blunt traumatic injury to that area, it is relatively easy for one or the other branch to be torn by crushing against the pubic bone, or shearing of the vessel. Either way, a hematoma will rapidly form, involving the labia majora and minora on that side.
Initial treatment is to place an icepack to reduce swelling and slow hematoma formation. Frequently, you will want to place a Foley catheter early in this process, because if you wait until the hematoma is huge, the distortion of the normal anatomy may be so great that it will become difficult to place an indwelling urinary catheter.
Next, I reassured the patient and her mother that I did not believe she had any kind of permanent injury to the area. I pointed out that the orange-sized swelling was mostly from soft tissue edema and not from the hematoma. I admitted her for further observation (with serial tape measurements of the hematoma) and continuing icepacks.
If the hematoma were smaller, I would have tried just the ice pack, without the Foley. If it were larger when first seen, a suprapubic catheter might have been needed.
After the first 24 hours, ice packs can be discontinued and warm soaking in the tub substituted, three or four times a day. This helps keep the area clean and helps avoid urinary retention as the woman can urinate directly into the tub.
Sometimes, these hematomas will need to be drained, but usually not. Remember that most of the size of the lump the patient sees is made up of soft tissue swelling and not the hematoma. Given time to stabilized, the soft tissue swelling will gradually resolve and the hematoma will become reabsorbed if small and spontaneously decompress if large. Should you try to operate on the hematoma, you usually never find the bleeding point, and their recovery is now complicated by surgical recovery and risk of infection. Should the hematoma become infected, it will of course need to be drained.
But you infrequently need to surgically drain these as they will either reabsorb or spontaneously drain, usually fairly soon after the accident.
