TRAUMA
Nonobstetric lacerations of the vaginal wall or introitus are most often the result of sexual trauma (consensual or otherwise). This may occur from intercourse (80%), saddle or water-skiing injury, sexual assault, or penetration by foreign objects. A rape injury, in particular, may be a potentially serious one, because it is often associated with psychological trauma (rape trauma syndrome), damage to adjacent vital organs, and even surgical shock. This is especially true when the injury occurs in a child. Inspection of the vestibule and vagina in such a case often reveals a jagged laceration, which has ruptured the hymen, torn the labia minora, and extended down the perineum toward the anus. Usually, the external genitalia are also badly damaged, with contusions and abrasions as far as the medial surfaces of the thighs. In more severely traumatized victims, the tears may compromise the integrity of the urethra, bladder, and rectum or breach the peritoneum. Such individuals may be brought into the hospital in a state of profound shock requiring immediate blood and fluid replacement before definitive surgical treatment can be instituted. In adults, common sites of lacerations are the vaginal wall, the lateral fornices, and the cul-de-sac. Rape injuries are dangerous in elderly, postmenopausal women who, because of vulvar and vaginal atrophy and the attendant increased fragility of the vaginal wall, are predisposed to more extensive damage. In younger women, the trauma to the vagina from rape is usually not so grave, although during pregnancy and in the immediate post-partum period, the tissues are vascular, delicate, and liable to injury.
Vigorous self-instrumentation during masturbation occasionally causes
vaginal lacerations in children or older women, especially when a sharp or
breakable object is used. Similarly, some practices in association with a
sexual partner may result in accidental injury. Because of its relatively
protected position between the thighs and inside the external genitalia, the
vagina is seldom subject to trauma by other than sexual means. When it does
occur, it is most frequently the so-called picket fence injury caused by
falling astride a sharp object that penetrates the vagina. This type of
impalement, like a rape injury, may produce a dangerous surgical condition,
depending upon the extent of the damage to the adjacent pelvic viscera. In the
lower picture, the arrows indicate the various possible lines of perforation,
and it must be remembered that the lesions may be multiple. The spike of the
metal fence has passed upward through the vagina, lacerating the posterior wall
and piercing the peritoneum of the posterior cul-de-sac. Such a wound may cause
peritonitis, intestinal injury, or prolapse of the small intestine into the
vagina. The external genitalia are usually torn and bruised, and not
infrequently hematomas propagate upward in the
loose connective tissue between the pelvic viscera and especially within the
leaves of the broad ligament, where suppuration may ensue.
There are three basic responsibilities in the care of someone who may have been raped or abused: the detection and treatment of serious injuries, the preservation of evidence, and protection against sequelae. Treatment of all types of vaginal trauma is governed by the following cardinal surgical principles: improving the patient’s general condition, controlling the local hemorrhage, and repairing the laceration. The latter may involve several different stages, depending on which organs are involved, but the steps can be taken in logical sequence once the patient has been made safe for surgery. Any time there is a suspicion that the abdominal cavity has been entered, exploratory laparoscopy or laparotomy should be carried out to assess the possibility and perform any needed repairs.
