Evacuation of a large traumatic vulvar haematoma with an intravaginal cosmetic approach

Abstract

A healthy youngwoman presented 3 days after a jet ski accident with a large left vulvar haematoma measuring 12 cm. Immediately postinjury, she was managed conservatively in the emergency room of another hospital. However, the haematoma continued to slowly expand. She presented to our clinic with difficulty walking and severe discomfort. Decision was made to drain the haematoma surgically. The patient was sceptical to have scarring on her vulva. Thus, the haematoma was evacuated by a vertical incision on the left vaginal sidewall. After evacuation and achieving haemostasis, the was closed with two interrupted sutures. Edges of the incision were secured similar to marsupialisation with five interrupted sutures to allow continual drainage. Her discomfort resolved immediately postsurgery and she had an uncomplicated postoperative course. The intravaginal approach yielded superior aesthetic result with no scarring on the external vulva.

Background

The anatomical location and rich vascular supply by the internal pudendal artery make the vulvar region susceptible to haematomas.¹ Due to the rarity of non-obstetrical vulvar haematomas, there is a paucity of the literature and standardised practice guidelines pertaining to their management. Few cases report conservative management to be sufficient and there are fewer cases where surgical management was warranted.^{1 2} Our patient was concerned about scarring her vulva and affecting its aesthetic appearance. To the best of our knowledge, there is no previous literature describing evacuation of a large non-obstetrical vulvar haematoma through an incision on the vaginal sidewall. In addition to effective evacuation, this approach provides superior cosmetic result. Self-perception of body image, beauty and physique influence a person’s mental and social well-being.^1–3 In this case report, our experience reiterates that timely surgical management can lower morbidity, and this can be achieved in an aesthetically sound manner.

Case presentation

A healthy 25-year-old woman, with no significant medical history, presented 3 days after a jet ski accident. She lost control while she was on the jet ski. She was tossed in the air and landed on her perineum over the handlebars. She subsequently developed a left vulvar haematoma measuring 12 cm along with a 3 cm area of overlying skin necrosis (figure 1). Immediately after the incident, she presented to the emergency room of another hospital. After establishing haemodynamic stability and ruling out pelvic fracture by CT scan, she was discharged home with pain medications and conservative management with ice packs. However, the haematoma continued to expand. Eventually, the patient started experiencing severe discomfort and difficulty walking. At that time, she presented to our outpatient clinic. On examination, there was necrosis of the skin overlying the haematoma along with severe erythema. The skin over the haematoma was very tense. Her vitals were normal and stable. Laboratory investigations revealed a normal complete blood count and absence of any bleeding or coagulation disorders.

Figure 1.

Twelve-centimetre large left vulvar haematoma with tense overlying erythematous skin.

Investigations

The patient underwent a CT scan at another hospital during her emergency room visit to rule out a pelvic fracture. In the clinic, her complete blood count, serum fibrinogen, prothrombin time, partial thromboplastin time and international normalised ratio were within normal limits. Preoperatively, we did a bedside ultrasound to determine the size and extent of the haematoma.

Treatment

Failure of conservative management warranted surgical evacuation of the haematoma. The patient was concerned about scarring and the subsequent cosmetic appearance of her vulva. Hence, decision was taken to drain the haematoma through an incision inside the vagina on the left vaginal sidewall (figure 2). A preoperative ultrasound was performed to better understand the extent of the haematoma. She was taken to the operating room, prepped and draped in the usual sterile manner. A 4 cm vertical incision was made at the thinnest point overlying the haematoma. As 72 hours had elapsed from the occurrence of the injury, the accumulated clotted blood in the haematoma provided pressure haemostasis. Little active bleeding was noted due to the tamponade effect. After the evacuation of the haematoma, haemostasis was achieved with pressure and extremely judicious use of electrocautery. The cavity was irrigated with normal saline. Thedead-space was closed with two interrupted sutures using 3-0 vicryl. To prevent early closure, the edges of the vaginal incision were secured with five interrupted sutures, similar to marsupialisation. Marsupialisation is a surgical technique wherein the cut edges of the incision are sutured from the external surface to the internal surface.⁴ This left an open area that facilitated drainage and minimised chances of recurrence. She was administered on a 5-day course of amoxicillin–clavulanic acid postoperatively. The patient reported an immediate sense of relief after surgery. After observation in postoperative recovery room for 4 hours, she was discharged home with precautions and instructions. She was counselled about complete pelvic rest for 6 weeks, using clean sanitary pads for vaginal spotting, rinsing the vagina once daily with normal saline using a squeeze bottle, keeping the area clean and dry at all times. She was also prescribed acetaminophen and ibuprofen for pain relief, as required. She was instructed to return to the clinic if she experienced excessive vaginal bleeding, fever, recurrent swelling or foul-smelling discharge.

Figure 2.

Intravaginal incision on the left sidewall. Edges were sutured to avoid early closure and allow continual drainage.

Outcome and follow-up

A 1-week postoperative follow-up appointment was made to ensure that there was no recurrence and infection. She reported moderate amount of serosanguineous discharge and some pain, which was resolved by acetaminophen. On visualisation, the incision on the vaginal sidewall was clean, dry and intact. There was no overlying skin erythema and necrosis. The patient was counselled to continue pelvic rest until 6 weeks. Her subsequent follow-up appointment was at 10 weeks. Complete healing of the vaginal incision was noted (figure 3). She reported no difficulty in sexual intercourse. The patient was extremely satisfied for having no external scars and a splendid cosmetic result (figure 4).

Figure 3.

Complete healing of the vaginal incision at 10-week postoperative visit.

Figure 4.

Haematoma resolved with no external scarring seen.

Discussion

Non-obstetrical causes of vulvar haematoma are uncommon. Their incidence is about 3.7% and overall they account for 0.8% of gynaecological admissions.^{5 6} Although most vulvar haematomas cause local symptoms, large vulvar haematomas might even lead to haemodynamic instability.^{2 5} There is no clear guideline or consensus about management of vulvar haematomas. Selective arterial embolisation, ligation of bleeding points and primary drainage of the haematoma cavity have been previously described in the literature.^{1 2 7} Transperineal ultrasound has also been utilised to assist in expectant management.⁸ Timely surgical management has proven to be superior than conservative management in case of large, expanding, symptomatic haematomas.^{2 9} To the best of our knowledge, there are few descriptions of surgical techniques for evacuation of large vulvar haematomas. These mainly comprise of making overlying incisions on the skin in the vulvar region. Although this approach is effective functionally, it is associated with scarring. In today’s world, people are becoming increasingly self-conscious about their bodies and cosmetic interventions are now becoming increasingly popular even in gynaecology.¹⁰ With changing times and trends, it is becoming imperative for surgeons to improvise on surgical techniques to achieve better cosmetic results. Another point worthy of discussion is the timing of surgery to drain large haematomas. As 72 hours had elapsed before we evacuated the haematoma, the accumulated blood clot resulted in a tamponade effect, and there was little active bleeding noted during surgery. This suggests that timing of surgery may have some correlation with bleeding encountered during surgery. In an era, where perception of self-body image has increasingly become a part of our lives, this surgical technique is effective and provides superlative cosmetic result. Given the scarcity of the literature about management of non-obstetrical vulvar haematomas, there is a pressing need for more comprehensive studies and guidelines.

Patient’s perspective.

When I noticed the swelling outside my vagina, I was scared. I was concerned if my vagina would ever look the same again. The pain, pressure and discomfort were excruciating and so I sought a second opinion. With the failure of conservative treatment, I felt that I was heading towards surgery, which made me increasingly anxious. I was worried about scarring my private parts permanently. The physician understood my concern of external scarring and reassured me that he would attempt to drain the haematoma from inside the vagina. Postsurgery, I felt immediate relief and the healing process was uneventful. I was pleasantly surprised as my vagina looked like nothing had ever happened. I am grateful to my physician for being mindful about the cosmetic outcome of his surgical approach and I am glad to not live with a scarred vagina for the rest of my life.

Learning points.

• Surgical management is more effective than conservative management of large vulvar haematomas.

• In today’s era of increasing consciousness of one’s own body image, a cosmetically sound intravaginal approach could be used to drain vulvar haematomas.

• Draining a vulvar haematoma through an incision on the vaginal sidewall provides superlative cosmetic results.

• Waiting for 48–72 hours from haematoma formation to surgical management can provide added benefit of decreased bleeding due to tamponade effect of the haematoma.

• Technique similar to marsupialisation can be utilised for continual drainage of haematoma to prevent recurrence.