Sarah H. Milton and Elisabeth McGaw
History of present illness
A four-year-old girl presented to the emergency department after slipping while getting out of the bathtub. She was accom- panied by her mother who witnessed the fall. Both reported that she fell in a manner that she straddled the edge of the bathtub. After the fall she immediately began to cry and complain of pain. Her mother then noted bleeding from
“between her legs”and was able to see what she thought looked like a“cut.”The patient’s mother was able to apply pressure to the area which slowed the bleeding, and then brought her immediately to the emergency department for evaluation.
Upon questioning, the patient is tearful and nods that she is in pain. She points to her genitals when asked where she hurts.
She denies any other source of pain. She is unable to answer any further questions. The mother adds that she and her daughter were the only two people home at the time of the accident, that her daughter does not have any known medical problems, has never had surgery, and has never been hospital- ized. When questioned separately, both the patient and her mother deny any history of physical or sexual abuse directed toward the patient.
Physical examination
General appearance:Tearful child, clinging to her mother Vital signs:
Temperature: 37.0°C Pulse: 85 beats/min
Blood pressure: 107/68 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 100% on room air Neurologic:Nonfocal
HEENT:Normocephalic, atraumatic Cardiovascular:Regular, rate, and rhythm Respiratory:Chest clear to auscultation bilaterally Abdomen:Soft, nontender, nondistended, normal bowel sounds
Extremities: No other bruises or injuries noted Genitourinary: The examination is limited by patient discomfort (Fig. 73.1). Dried blood is noted on the medial thighs and external genitalia. There is Tanner stage I pubic hair development. There is a laceration of the left labia majora extending from just below the level of the clitoris down to the perineal body, approximately 3 cm in length with minimal active bleeding. There is minimal ecchymosis
on left labia majora, minora and perineal body adjacent to laceration. The depth of laceration is difficult to discern due to patient cooperation
Laboratory studies:CBC was normal
What is your diagnosis?
The patient has an accidental straddle injury with a perineal laceration. The recognition of active bleeding and the size of the laceration warrant surgical intervention.
How would you manage this patient?
The inability to adequately perform a genitourinary examin- ation further substantiates the need for examination under anesthesia. The patient was taken to the operating room where an examination revealed a 3 cm laceration that was 1 cm in depth and extended from the left labia majora down the perineal body to 1 cm anterior to the anus. The laceration was repaired with a 3–0 synthetic absorbable suture with excellent anatomic reapproximation and hemostasis. The patient was able to be discharged from the hospital the next day at which time she was able to void and ambulate comfort- ably while taking only oral pain medications. At a two-week follow-up visit, the area was well healed with only a faint visible scar.
Fig. 73.1 A four-year-old girl after falling while exiting the bath tub.
(Photograph courtesy of Shalon Nienow, MD.)
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Straddle injuries
Pediatric patients presenting with genital trauma pose a par- ticular challenge to the provider. While these injuries are relatively rare, their evaluation and management can provoke significant anxiety in the patient and their caregivers. Genital trauma may be accidental or may be the result of sexual abuse.
A careful history and physical examination to rule out abuse is warranted in any patient who has sustained genital trauma.
Providers should place particular emphasis on creating a safe environment for the interview and physical examination as children who have sustained perineal trauma are often particu- larly frightened and vulnerable.
Accidental genital trauma can occur as the result of straddle injuries, motor vehicle accidents, animal bites, burns, falls, and penetrating injuries [1]. By far the most common mechanism of accidental injury to the genital tract in pediatric females is straddle injury, accounting for over 80% of cases [2].
Straddle injuries, which can result in lacerations or hematoma formation, occur as a result of blunt trauma to the genital region incurred during an accidental fall where the patient straddles an object, railing or other obstacle. Although less common, vaginal insufflation injury is also reported in which rapid distension of the vagina results in tearing of the vaginal walls with resultant bleeding. This mechanism of injury has been reported in association with falls while water or jet skiing and in association with water slides [3]. While the majority of accidental trauma occurs in the home, outdoor and sports- related activities are also commonly implicated [4]. The aver- age age of patients sustaining an accidental genital tract injury is 5.5–6.5 years of age [3,4,5].
The presentation of traumatic injury to the genital tract is variable. Accidental injury may result in ecchymoses, abra- sions, hematomas, or lacerations [1]. Penetrating trauma is more likely to result in laceration of the hymen or vagina [3].
Conversely, blunt trauma commonly results in vulvar damage including ecchymoses, abrasions, hematomas, and lacerations [3]. In straddle injuries specifically, the most common injury sustained is a laceration and the most commonly involved area is the posterior vulva as was the case in this patient [2]. While most patients with a history of sexual abuse will have normal or nonspecific physical examination findings, these patients may also present with any combination of the aforementioned findings [6]. Because of the significant variability in physical examination following sexual abuse, providers must be vigilant in their assessment of history and risk factors to aid in identi- fication of patients who have been the victims of assault [6,7].
Evaluating a child who has sustained a traumatic genital injury is particularly challenging. Careful attention to the history is necessary to assess the severity of injury as well as to screen for abuse. History should be obtained from the patient alone whenever possible with collateral information obtained from the caregiver and/or witnesses to the injury [1,7]. As in any trauma patient, initial evaluation should focus on vital signs and a primary survey to identify any
hemodynamic instability that would warrant emergent inter- vention. Laboratory evaluation varies based on severity of injury. A complete blood count should be ordered if bleeding has been significant or is persistent. Once the primary survey is performed, it is followed by a complete physical examin- ation, including a targeted genitourinary examination [3].
Positioning the child for examination of the genitalia can be accomplished with the patient frog-legged or supine, or with the child in knee-chest position. If examination reveals active bleeding, a laceration, or a hematoma, it is critical to fully assess the extent of the injury. If assessment is limited by patient cooperation, pain or bleeding, force, or coercion should never be used. Sedation can be used in the emergency department to obtain better visualization or the patient may require an examination under anesthesia to evaluate the extent of the injury [3]. Speculum examination is usually not necessary and is reserved for evaluation of significant vaginal lacerations or unidentified bleeding. If the use of a speculum is needed in a prepubertal patient, sedation or anesthesia should be used [1]. In addition, depending on the extent of injury and the age of the patient, the pediatric gynecologist can consider utilizing cystoscopy or vaginoscopy to better visualize genital injuries [3].
Genital trauma is commonly managed conservatively [2].
Abrasions that are bleeding can be treated with cold com- presses and pressure. In most cases, vulvar hematomas also respond favorably to conservative management [3]. The mass effect of a large hematoma can compress the urethra and render the patient incapable of voiding. Therefore, if any urinary retention is noted, a Foley catheter should be placed until the hematoma decreases in size. A nonexpanding hema- toma in a hemodynamically stable patient should be managed with cold compresses, analgesia, and rest [1,3]. These conser- vative measures commonly result in resolution of the hema- toma over several weeks without surgical intervention [8].
Rapid expansion of a hematoma or hemodynamic instability warrant surgical evacuation [3].
Small, hemostatic genital lacerations, particularly in prepubertal girls, generally respond favorably to conservative management [3], commonly healing in a matter of days [8].
Application of nightly topical estrogen cream to lacerations in prepubertal girls facilitates healing [3]. Moderately sized lacer- ations or those with bleeding may be amenable to repair in the emergency department with local anesthesia in appropriately selected patients. Lacerations that are bleeding persistently, are large, or potentially involve the urethra, vagina, or anal region require surgical exploration and management. Intrao- peratively the extent of the injury should be carefully delin- eated and the laceration should be repaired in layers (when of significant depth) with a synthetic absorbable suture [3]. Any patient who has sustained genital trauma should have an appropriate plan for analgesia, should be voiding (spontan- eously or in the case of large vulvar hematomas via indwelling catheter), and should have close pediatric or gynecologic follow-up [1,3].
Key teaching points
In pediatric patients who have sustained genital trauma, providers must screen for sexual assault with a careful history and physical examination.
Initial evaluation of a patient with genital trauma involves assessment of vital signs and hemodynamic stability, followed by a complete physical examination including a targeted genitourinary examination.
If examination of the genitalia in a pediatric patient is limited by patient cooperation, pain or bleeding, an examination with sedation or under anesthesia in the
operating room should be performed. Care should be taken to avoid using force or coercion to facilitate examination.
Vulvar lacerations are the most common injury resulting from accidental genital trauma in pediatric patients. If hemostatic, lacerations may be managed conservatively with a plan for analgesia and close follow-up.
Vulvar hematomas should be managed conservatively unless they are expanding rapidly or the patient is hemodynamically unstable.
References
1. Benjamins LJ. Genital trauma in pediatric and adolescent females.
J Pediatr Adolesc Gynecol2009;22:
129–33.
2. Spitzer RF, Kives S, Caccia N, et al.
Retrospective review of unintentional female genital trauma at a pediatric referral center.Pediatr Emerg Care 2008;24:831–5.
3. Emans SJ, Laufer MR.Pediatric and Adolescent Gynecology, 6th edn.
Philadelphia, PA, Lippincott Williams &
Wilkins, 2012.
4. Saxena AK, Steiner M, Hollwarth ME.
Straddle injuries in female children and adolescents: 10-year accident and management analysis.Indian J Pediatr2013; Jul 4 [Epub ahead of print].
5. Bond GR, Dowd MD, Landsman I, Rimza M. Unintentional perineal injury in prepubescent girls: a multicenter prospective report of 56 girls.Pediatrics 1995;95:628–31.
6. Adams JA, Harper K, Knudson S, et al. Examinationfindings in legally confirmed child sexual abuse: It’s normal to be normal.Pediatrics 1994;94:310–17.
7. Kellog N. The evaluation of sexual abuse in children.Pediatrics 2005;116:506–12.
8. Mcann J, Miyamoto S, Boyle C, et al.
Healing of non-hymenyl genital injuries in prepubertal and adolescent girls:
a descriptive study.Pediatrics 2007;120:1000–11.
Case 73: A four-year-old girl falls while exiting the bathtub