Vulvar-Vaginal Reconstruction Workup
- Author: Stephen A Metz, MD, PhD; Chief Editor: Richard Scott Lucidi, MD, FACOG more...
In general, assessment of vulvovaginal trauma does not require extensive laboratory testing.
Hemoglobin and hematocrit: If the injury is associated with significant overt hemorrhage (eg, as during parturition) or if extensive occult bleeding is suspected, hemoglobin and hematocrit levels may be significantly decreased. These values take time to equilibrate following acute blood loss, so the acute values may not reflect ultimate levels.
Urinalysis: Should deep organ injury be suspected, a urinalysis should be obtained to determine whether the patient has developed hematuria.
Sexually transmitted disease screening: A woman who has been the victim of sexual assault should be tested for sexually transmitted diseases (STDs), including serologic testing for syphilis. Recombinant hybridization techniques are available to permit evaluation for gonorrhea and chlamydia. She should also be offered the option of testing for exposure to HIV.
Packed red blood cells: Used in patients found to be or are at risk of becoming hemodynamically unstable.
The decision to obtain imaging studies, as well as the specific studies chosen, should be guided by the nature of the injury, as indicated by history and physical examination findings. Further evaluation is certainly indicated if lower urinary tract (eg, urethral, bladder, ureteral) injury or occult hemorrhage is suspected. Severe perineal trauma may raise the question of skeletal damage, which should be evaluated appropriately.
Transvaginal ultrasonography: If the patient is able to tolerate it, transvaginal ultrasonography is the most specific imaging study to detect free fluid in the pelvis and abnormalities of the internal genitalia. A transabdominal study is a second choice.
Abdominal plain film radiography: If preliminary evaluation of vaginal trauma raises the possibility of intraperitoneal extension, addressing this concern definitively is important. The presence of free air in the peritoneal cavity can result either from penetrating injury to the proximal posterior vaginal wall, which extends through the peritoneum, or from gastrointestinal perforation. A radiograph of the patient's abdomen while she is erect or, alternatively, a lateral radiograph while she is lying on her side, reveals the presence of free air under the superior aspect of the peritoneal cavity (eg, the diaphragm in the case of an upright radiograph).
A note of caution: In the setting of perineal or vaginal trauma, should intraperitoneal pathology be suspected, imaging may prove helpful. The objective of such an evaluation is not to construct a detailed analysis of the intraperitoneal anatomy, but rather to rapidly determine the presence of intraperitoneal free air or fluid. Such findings, especially in the setting of hemodynamic instablity, should prompt a decision for operative exploration.
If disruption of the bony pelvis is suspected, a CT scan of the pelvis and lower abdomen can provide detailed information regarding not only the skeletal integrity, but also the existence of large retroperitoneal fluid collections such as hematomata. Use of intravenous contrast material during such a study, provided the patient is not sensitive to the contrast, adds additional information regarding the integrity and position of the ureters.
Voiding cystourethrography: Urethral injury can usually be detected during physical examination. The finding of urethral trauma should prompt further evaluation of possible bladder insult. One very useful imaging study in this situation is the voiding cystourethrogram, in which contrast fluid is instilled into the bladder via transurethral catheter. Subsequent lateral and anteroposterior images allow for excellent visualization of the bladder lumen. Fluoroscopic images of the urethra during subsequent voiding provide further information regarding urethral integrity.
Transurethral cystoscopy: Another option for lower urinary tract evaluation is transurethral cystoscopy, which permits direct visualization of the urethral and bladder lumen, urethrovesical junction, and ureteral orifices.
Retrograde urograms: Performed under fluoroscopic guidance, these provide information regarding ureteral integrity. This alternative is especially appropriate if the patient otherwise requires anesthesia for evaluation or therapy.
Propst AM, Thorp JM Jr. Traumatic vulvar hematomas: conservative versus surgical management. South Med J. 1998 Feb. 91(2):144-6. [Medline].
DeLancey JOL. Surgical anatomy of the female pelvis. Rock JA, Jones HW III, eds. TeLinde's Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. 82-112.
Gianini GD, Method MW, Christman JE. Traumatic vulvar hematomas. Assessing and treating nonobstetric patients. Postgrad Med. 1991 Mar. 89(4):115-8. [Medline].
Shafik A, Mostafa RM, Shafik AA, El-Sibai O. Study of the effect of straining on the bulbocavernosus muscle with evidence of a straining-bulbocavernosus reflex and its clinical significance. Int Urogynecol J Pelvic Floor Dysfunct. 2002. 13(5):294-8. [Medline].
Suh DD, Yang CC, Cao Y, Garland PA, Maravilla KR. Magnetic resonance imaging anatomy of the female genitalia in premenopausal and postmenopausal women. J Urol. 2003 Jul. 170(1):138-44. [Medline].
Brandon CJ, Lewicky-Gaupp C, Larson KA, Delancey JO. Anatomy of the perineal membrane as seen in magnetic resonance images of nulliparous women. Am J Obstet Gynecol. 2009 May. 200(5):583.e1-6. [Medline]. [Full Text].
Shafik A, Sibai OE, Shafik AA, Shafik IA. A novel concept for the surgical anatomy of the perineal body. Dis Colon Rectum. 2007 Dec. 50(12):2120-5. [Medline].
Rab M, Ebmer And J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001 Nov. 108(6):1618-23. [Medline].
Iglesia CB, Yurteri-Kaplan L, Alinsod R. Female genital cosmetic surgery: a review of techniques and outcomes. Int Urogynecol J. 2013 May 22. [Medline].
Ostrzenski A. Selecting aesthetic gynecologic procedures for plastic surgeons: a review of target methodology. Aesthetic Plast Surg. 2013 Apr. 37(2):256-65. [Medline].
Marchitelli CE, Sluga MC, Perrotta M, Testa R. Initial experience in a vulvovaginal aesthetic surgery unit within a general gynecology department. J Low Genit Tract Dis. 2010 Oct. 14(4):295-300. [Medline].
Netter FH. The CIBA Collection of Medical Illustrations. 1965. 2:90-104.
Saxena AK, Steiner M, Hollwarth ME. Straddle injuries in female children and adolescents: 10-year accident and management analysis. Indian J Pediatr. 2014 Aug. 81(8):766-9. [Medline].
Bachoo P, Brazzelli M, Grant A. Surgery for faecal incontinence in adults. Cochrane Database Syst Rev. 2000. (2):CD001757. [Medline].
Goldman HB, Idom CB, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol. 1998 Mar. 159(3):956-9. [Medline].
Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2016 Jul. 128 (1):e1-e15. [Medline].
Haelle T. ACOG: New Recommendations on Obstetric Lacerations. Medscape Medical News. Available at http://www.medscape.com/viewarticle/865296. June 24, 2016; Accessed: June 24, 2016.
Grant JCB. Grant's Atlas of Anatomy. 6th ed. Philadelphia: Williams & Wilkins Co; 1972. 225.
Grisoni ER, Hahn E, Marsh E, et al. Pediatric perineal impalement injuries. J Pediatr Surg. 2000 May. 35(5):702-4. [Medline].
Negosanti L, Sgarzani R, Fabbri E, et al. Vulvar reconstruction by perforator flaps: algorithm for flap choice based on the topography of the defect. Int J Gynecol Cancer. 2015 Sep. 25(7):1322-7. [Medline].
Kim SW, Lee WM, Kim JT, Kim YH. Vulvar and vaginal reconstruction using the "angel wing" perforator-based island flap. Gynecol Oncol. 2015 Jun. 137(3):380-5. [Medline].