Introduction```

A vulvar hematoma is a collection of blood in the vulva. The vulva is soft tissue
mainly composed of smooth muscle and loose connective tissue and is supplied by
branches of the pudendal artery.[1] Although it is a common obstetric
complication, a vulvar hematoma can occur in non-obstetric settings too. Perineal
pain is the hallmark genital hematoma.[2] Early recognition is paramount in
reducing the associated morb
 Etiology
• During labor, a vulvar hematoma can result from either direct or indirect
injury to the soft tissue.
• Examples of causes of direct injuries include
1. episiotomy, vaginal
2. laceration repairs
3. instrumental deliveries,
• while indirect injury can result from
1. extensive stretching of the birth canal during vaginal delivery.[4]
 Interestingly, most vulvar hematomas are formed after a normal delivery
instead of complicated deliveries.[2][5]
Vulva heamatoma
:Dr. Abeer Elzwie presention
Risk factors for developing vulvar hematoma include
1. instrumental delivery, episiotomy
2. , primiparity, prolonged second stage of labor
3. , macrosomia,
4. use of anticoagulants, coagulopathy,
5. hypertensive disorders of pregnancy,
6. and vulvovaginal varicosity.[6][7]
• 1]
Non-obstetric vulvar hematomas can arise from any form of
1. trauma to the perineum, such as a saddle injury,[8]
2.  falling from a height,[3]
3.  insertion of a foreign body,
4. sexual assault,[9] 
5. consensual coitus,[1] surgery of the vulva.[10][11] If there is no associated
trauma, spontaneous vessel rupture is a possible cause.[12] It is reported that
post-coital injury is the most common non-obstetric cause of vulvar hematoma.[
• Epidemiology
Vulvar hematomas are more common in the obstetric population, with an
incidence ranging from 1:300 to 1:1000 deliveries.[12] Outside the obstetric
population, it can make up about 0.8% of gynecological problems.[1]
Non-obstetric vulvar hematoma follows a bimodal age distribution. It is more •
common during childhood or early adolescence because the labia majora, which
is composed of fat for its protective functionality, is less developed in young
pre-pubertal females.[3] At the other end of the spectrum, hypoestrogenism in
postmenopausal women results in atrophy and loss of elasticity of the vulva and
vagina epithelium. The increased friability of the tissue makes the vulva more
[3].prone to injury, hence, vulvar hematoma formation
Pathophysiology
• A hematoma is described as a collection of blood beneath an intact
epidermis that presents as a swollen fluctuant lump. It can be
extremely tender on palpation.[3] Due to its rich blood supply, the
vulva is highly vulnerable and prone to hematoma formation.
Although venous bleeding is possible, arterial bleeds mainly originate
from one of the branches of the pudendal artery.[1] Vulvar hematoma,
rarely, might be secondary to operative laparoscopy (especially
adnexal surgery), spontaneous rupture of the internal iliac artery, or
spontaneous rupture of a pseudoaneurysm of the pudendal artery
History and Physical
Pain is the most common symptom of a vulvar hematoma. Patients can describe it as perineal, •
abdominal, or buttock pain.[12] The intensity of the pain can be severe enough to interfere with
mobility.[3] There may also be intermittent bleeding. Depending on the size and location of the vulvar
hematoma, urological or neurological signs and symptoms may be present. Due to mechanical urethral
obstruction, patients may present with urinary retention or micturition difficulties.[12] In severe cases,
the patient can be hemodynamically unstable and will require urgent fluid resuscitation or blood
transfusion. Symptoms usually develop within a few hours to days of delivery, depending on the
.severity of the condition
If a vulvar hematoma is suspected, a detailed history should be taken to elicit possible causes associated •
with it. They include preceding coitus, accidents involving injury to their perineum, and recent
 .deliveries or operations. It is also important to inquire about sexual assault in a sensitive manner
As bleeding into the vulva is largely restricted only by the Colles fascia and the urogenital diaphragm, a •
hematoma in this area will be visible on physical examination.[12] This is seen as a tender fluctuant
lump of variable size. Since the Colles fascia exerts little resistance, vulvar hematomas can grow to
become 15cm in diameter or more.[14] The observation of a lump or swelling in the groin may be
offered by the patient if asked during the consultation. Although there is no anatomical explanation, it
[3][15].is discovered that the right side appears to be more commonly affected
During the examination, a thorough inspection should be performed for pelvic fractures and genital •
Evaluation
Complete blood count (CBC), type and screen, and if deemed necessary, coagulation •
screening should be performed. If there is a likelihood of the need for a blood
.transfusion, blood should also be taken for cross-matching
Ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) of the •
pelvis can be done to evaluate the size, site, and growth of the hematoma. MRI
angiography of the pelvis may help in the detection of any aneurysms. Transperineal
sonography is also a simple, non-invasive technique that can be useful for the follow-up
[8].and monitoring of patients undergoing expectant management of a vulvar hematoma
In addition, further investigations can be done to evaluate for causes of hematoma •
formation, such as the presence of connective tissue disorders or coagulopathies. In cases
associated with severe trauma or sexual assault, the extent of injury to the perineum and
pelvis must also be assessed adequately. Additional investigations, such as a pelvic X-ray
[9].for pelvic bone fractures in cases of pelvic trauma, should be done
Treatment / Management
The majority of vulvar hematomas are small and can be managed conservatively. However, large (>10 cm in diameter) or •
progressively enlarging hematomas causing intense pain and distress to the patient require surgical intervention. Urgent surgical
management is also warranted if the hematoma is large enough to cause hemodynamic instability, or urological or neurological signs
.and symptoms.[3][13] A catheter may be inserted if the patient experiences difficulty urinating
Conservative management usually involves the use of ice packs, local compressions, bed rest, and analgesics. In the event that •
conservative management has not been effective, surgery may be performed. In fact, conservative management of large hematomas has
been found to be associated with a longer period of hospitalization, greater need for antibiotics, and blood transfusion[14]. A
[16].conservative approach is also not advisable for hematomas that are expanding acutely
Surgical management includes surgical drainage of the hematoma, evacuation of any clots present, ligation of bleeding points, and the •
assessment for signs of pressure necrosis (a complication of vulva hematoma).[1] These can be done under local anesthesia. As further
blood loss during surgery is anticipated, the necessary investigations such as cross-matching and preparations for a possible blood
[17].transfusion should be done. An intravaginal approach for incision and evacuation of hematoma produces better cosmetic results
Alternatively, selective arterial embolization may be performed. This procedure was first described by Brown et al. for the treatment of •
postpartum hemorrhage.[18] Subsequently, this approach has been used successfully for the treatment of bleeding in several obstetric
and gynecological conditions.[19] Pelvic angiography is done prior to selective embolization to investigate and locate bleeding vessels.
Surgeons may choose angiographic embolization if bleeding continues post-operatively, or if the vulvar hematoma reforms after
surgical management. It may also be the choice of treatment in situations where surgery is not possible, such as in patients who are
hemodynamically unstable and not fit for surgical ligation procedures.[20] A case of successful transarterial embolization after a failed
[21].conservative treatment for an expanding non-obstetrical vulvar hematoma has also been reported
Differential Diagnosis
There are a few more frequently diagnosed vulvar conditions that can present similarly to a vulvar hematoma. These include Bartholin’s gland •
cysts and abscesses, vulvar varicosities, and folliculitis.[1][22] In addition, as with any conditions presenting as a growth, vulvar cancer must
.also be considered on the list of differential diagnoses
The Bartholin’s glands are two pea-sized glands located symmetrically at the vaginal opening. These glands function by lubricating the vagina •
through mucus production.[23] A Bartholin’s gland cyst forms as a result of a blocked duct, which leads to a collection of secretions. This can
subsequently develop into a Bartholin’s gland abscess when infected. While the former can be asymptomatic, Bartholin’s gland abscesses
usually present with surrounding cellulitis.[23] A non-obstetric vulvar hematoma has been reported to be misdiagnosed as a Bartholin’s gland
duct abscess.[15] Such a misdiagnosis is possible as extravasated blood of a vulvar hematoma can trigger an inflammatory reaction similar to an
.abscess
Vulvar varicosities can also be a differential diagnosis. However, it is important to note that there have been case reports of postoperative vulvar •
hematoma following surgical management for vulvar varicose veins.[10] Unlike vulvar hematomas, vulvar varicosities are much more common,
[24].especially in multigravid females. In addition, they are often asymptomatic, with only a minority of cases causing mild discomfort
Vulvar folliculitis arises due to inflammation of the hair follicles and often resembles acne in the genital region. Patients with vulvar folliculitis •
may present to the clinic with genital pain or itchiness. However, on examination, it is usually seen as small papules or pustules uniformly
[25].distributed over the vulva
Finally, although vulvar carcinoma can present as a fleshy lump or mass, most cases have a history of pruritus and do not usually present with •
pain. In addition, vulvar carcinoma can also be described as ulcerated, leukoplakic, or warty.[26] Metastatic choriocarcinoma is a highly
vascularized trophoblastic tumor which should also be suspected in patients with trophoblastic disease. In a case report by Bhattacharyya SK et
[27].al., vulvovaginal metastasis of choriocarcinoma was initially misdiagnosed and managed as an old infected vulvar hematoma
Prognosis
• Vulvar hematomas may cause serious morbidity but rarely leads to
mortality. A complete recovery is often seen. For small vulvar
hematomas, most resolve spontaneously under conservative
management.[28] Management with surgical intervention or selective
arterial embolization is also effective, with most patients being able to
mobilize within a day or two, and discharged home without any
complication.[13][21]
Complications
Necrosis is a complication that will necessitate surgical debridement. This complication arises •
due to the pressure applied by the large or growing hematoma on surrounding tissues.[1]
 Pressure necrosis can be prevented with the prompt surgical evacuation of blood clots.
[12][29] In situations where there is increasing pain and necrosis on presentation, urgent
.surgical intervention will be necessary
As with any condition managed operatively, the risk of infection is a potential complication, •
and patients should follow up shortly after discharge from the hospital to check for recurrence
.of hematoma or infection. Prophylactic antibiotics may be prescribed if clinically indicated
Selective pelvic arterial embolization, although not readily available, is an effective procedure •
in competent hands.[30] Reported post-procedural complications include muscle pain,
guidewire perforation, and vaginal fistula.[31] Low-grade fever, pelvic infection, and
temporary foot drop are also possible. Pelvic arterial embolization means some degree of
[32].exposure to ionizing radiation
Postoperative and Rehabilitation Care
• Early mobilization has been shown to have inherent benefits in
minimizing the risk of venous thromboembolism.[33] However, there
remains much controversy over the recommended period of bed rest
before encouraging mobilization after vulvar surgery.[34] Other
routine postoperative care relevant to patients receiving vulvar
operations include attentive wound care, postoperative analgesics, and
antibiotics if indicated. In addition, as hematomas can recur after
surgery, continued monitoring of the patient’s vital signs is important