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Paper text:
vulvar hematomas are usually seen in the obstetric population following repair of episiotomies and birthrelated soft tissue injury . however , traumatic nonobstetric vulva hematomas are rare
. they may arise secondary to blunt trauma sustained during a fall from height 1 , 2 , 3 , sexual assault , foreign body insertion , and coitus 4 , 5 , 6 , 7 .
although most are small and pose little threat to the patient , nonobstetric hematomas may become large enough to cause hemodynamic instability . while conservative management is often the mainstay of treatment
we detail the presentation and management of a young woman with a significant vulva hematoma following accidental blunt trauma .
a healthy 16yearold female , with no known comorbidities , presented to the outpatient department with severe perineal pain .
the mechanism of injury was a fall from height in which the patient sustained blunt trauma to the perineum .
the patient reported immediate onset of severe pain associated with a progressive swelling of the vulva and the presence of blood .
this was associated with the gradual onset of headache and symptoms of presyncope , including generalized weakness , nausea , and lightheadedness .
the past medical history was noncontributory and the patient reported no known allergies or current medications . on physical examination
the heart rate was 115 bpm with a manual blood pressure of 100/60 mmhg and an oral temperature of 37.1c .
examination of the perineum revealed a 10  8 cm swelling of the left vulva with right deviation of the right labia and clotted blood over the left labia minora ( fig .
basic laboratory investigations revealed a hb of 10.2 g / dl , with a normal wbc and platelet count .
initial resuscitation consisted of 1500 ml iv bolus of crystalloid solution . despite the infusion , the patient remained hypotensive and tachycardic .
given the degree of swelling and accompanying hemodynamic instability , the patient was consented for surgical intervention .
intraoperative , a large hematoma was evacuated through a medial incision of the left labia majora . a single , actively bleeding vessel was identified and suture ligated .
the cavity was irrigated and inspected for hemostasis , which was subsequently closed with 10 chromic catgut ( fig .
the patient had an uneventful postoperative course with prompt removal of urinary catheter and discharge on postoperative day three .
the patient was seen in followup at 4 weeks and the vulva appeared symmetric with the swelling completely resolved .
preoperative : swollen vulva with a clotted blood mass on left labia minora and lateral deviation of right labia majora .
the vulva consist mostly of loose connective tissue and smooth muscle that is richly supplied by branches of the pudendal artery ; a significant branch of the internal iliac artery 8 .
the venous drainage consists of labial veins , which are tributaries of the internal pudendal vein and venae comitantes .
the injury to labial branches of the internal pudendal artery , which is located in the superficial fascia of the anterior and posterior pelvic triangle , can cause significant vulvar hematomas 9 .
blunt trauma to the vulva may occur secondary to reflex adduction of the thighs immediately preceding trauma .
its anatomical position and rich vascular supply make it susceptible to hematoma formation during perineal injury . in the case of a fall ,
a patient falls astride an object compressing the soft tissue of the vulva on the underlying pelvic girdle , which leads to laceration and hematoma formation .
it is imperative to elicit the nature of the trauma in order to provide the most appropriate pre and postoperative care .
social and cultural barriers to a thorough sexual history must be addressed to provide appropriate management .
the true incidence of nonobstetric vulvar hematoma is unknown but is likely underreported in the available literature .
there are no consensus statements or best practice guidelines for the necessity or timing of surgical intervention .
10 observed that in the absence of acute hematoma expansion , nonoperative conservative management can yield good results .
however , benrubi et al . 11 found that conservative management of hematomas was associated with longer stays in hospital , an increased need for antibiotics and blood transfusion and greater subsequent operative intervention .
. this may be particularly useful in the highrisk operative candidate with prohibitive comorbidities , as the procedure does not require a general anesthetic .
it may also be advantageous in the situation where the degree of soft tissue trauma makes careful delineation of the anatomy difficult 2 , 14 , 15 , 16 .
however , this approach requires unique institutional resources that are often not available at the community or district level facility .
reported complications include groin hematoma , muscle pain , puncture site infection , guide wire perforation , and vagina fistula 16 . in the case
presented , early surgical intervention is offered because of the enlarging hematoma and associated hemodynamic instability . for small , nonexpanding hematomas a conservative approach consisting of appropriate analgesia , cold compression , and close observation is appropriate .
surgical intervention is essential in the patient with a rapidly expanding hematoma or associated hemodynamic instability that does not immediately respond to crystalloid infusion .
in cases of severe nonobstetric blunt trauma to the perineum , hematoma of the vulva can represent a potentially lifethreatening hemorrhage that requires urgent surgical intervention . while conservative management plays an important role in minor perineal injuries ,
surgical hematoma evacuation and hemostasis is often desirable to minimize hospital stay and diminish the impact of longterm complications .
written informed consent was obtained from the patient for publication of this case report and any accompanying images .
a copy of the written consent is available for review by the editor of this journal on request .
key clinical messagenonobstetric hematomas of the vulva are rare and not extensively reported in literature . 
 there are no consensus guidelines and a paucity of literature to guide best practices with regard to management . 
 we present a case of vulva hematoma in a teenage girl . 
 our experience highlights the importance of prompt surgical intervention to reduce associated morbidity and minimize hospital stay .