What is Vulvar Hematoma?
A vulvar hematoma is a condition where blood collects in the vulva, the soft tissue area of a woman’s body found outside the vagina. The vulva is mainly made up of smooth muscle and loose connective tissue and gets its blood supply from the pudendal artery. Even though it’s a common complication during childbirth, a vulvar hematoma can also happen in situations not related to childbirth.
There are other kinds of similar conditions, known as puerperal genital hematomas, which include paravaginal, vulvovaginal, or subperitoneal hematomas. The key symptom that a person suffering from a puerperal genital hematoma may experience is pain in the perineum, the area between the genitals and anus. This pain should signal to healthcare providers to check a patient for a suspected puerperal genital hematoma.
Recognizing this condition early is extremely important in reducing related health risks, enhancing patient recovery, and minimizing the time a patient needs to stay in the hospital.
What Causes Vulvar Hematoma?
During childbirth, a bruise or blood-filled swelling on the external part of a woman’s genitalia, known as a vulvar hematoma, can occur due to either direct or indirect harm to the soft tissue. Direct injuries could occur because of surgical incisions made during childbirth (episiotomy), repairs of vaginal tears, or deliveries involving instruments like forceps or vacuum extraction. On the other hand, indirect injury can result from the intense stretching of the birth canal during a vaginal birth.
Interestingly, most vulvar hematomas happen after a normal delivery, not complicated ones.
Certain factors can increase the risk of developing this condition, like the use of instruments during childbirth, surgical incisions, being a first-time mother, a labor phase that’s long, having a large baby, using blood-thinning medications, clotting disorders, high blood pressure conditions during pregnancy, and varicose veins in the genital area.
Vulvar hematomas can also happen outside of childbirth due to any trauma to the perineum (the area between the anus and the genitals). This could happen due to a sports injury (like from cycling), falling from a height, insertion of a foreign object, sexual assault, consensual sex, or surgery on the outer part of the female genitalia. If there’s no related trauma, it’s possible that a blood vessel just breaks spontaneously. However, it’s reported that the most common non-childbirth related cause is injury after sexual activity.
Risk Factors and Frequency for Vulvar Hematoma
Vulvar hematomas, which are blood-filled swellings, commonly occur in women who are pregnant or have recently given birth, with incidents ranging from 1 in 300 to 1 in 1000 deliveries. They constitute about 0.8% of women’s health issues outside of pregnancy.
These hematomas also occur in two specific age groups. Younger girls and teenagers are more susceptible because the protective fatty tissue in the outer part of the genitals, or the labia majora, is still developing. On the other hand, postmenopausal women produce less estrogen, which results in a more fragile and less able to stretch vulva and vaginal tissue. This makes them more prone to injuries that can lead to vulvar hematomas.
Signs and Symptoms of Vulvar Hematoma
A vulvar hematoma is a condition that involves bleeding into the vulva area. The most common symptom is pain, which could feel as though it is coming from the perineum (area between the vagina and anus), stomach, or buttocks. Some patients find this pain intense enough to affect their movement. It may also present with irregular bleeding. Depending on the position and size of the hematoma, there could be urological or neurological signs like difficulties urinating due to urethral blockage. In severe cases, patients might need urgent fluid replacement or blood transfusion due to unstable blood circulation (hemodynamic instability). Symptoms usually come on within hours or days of delivery, with the exact timing depending on how severe the condition is.
If a doctor suspects a vulvar hematoma, they will ask detailed questions to figure out potential causes. These might include recent sexual intercourse, any accidents injuring the perineal area, and recent births or surgeries. Doctors should also sensitively inquire about potential sexual assault.
During an examination, doctors will observe a tender lump of varying size in the vulva due to the hematoma’s visible nature. Surprisingly, these hematomas can grow quite large, more than 15cm in diameter. An interesting observation is that the right side seems to be affected more often, although there is no clear anatomical reason for this. A patient might also report noticing a lump or swelling in the groin during her consultation.
In the examination, the doctor should make sure to also look for pelvic fractures and genital cuts, especially if there has been significant trauma. Vital signs like heart rate, breathing rate, and blood pressure should be recorded as a baseline for monitoring. If needed, a urinary catheter might be inserted.
Testing for Vulvar Hematoma
Your doctor may do a complete blood count test to check your overall health and detect a range of disorders. They may also test your blood type and screen for any blood disorders or unusual antibodies that might affect your transfusion. If your doctor thinks you may need a blood transfusion, they will take blood to do a “cross-match” test to ensure the blood you receive is safe and compatible with your own.
To evaluate a hematoma (a collection of blood outside of a blood vessel) in the pelvic area, your doctor might use imaging tests like an ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI). An MRI may also help spot any aneurysms (abnormal bulges in the walls of your blood vessels). The doctor might also use a transperineal sonography (an imaging test that uses high-frequency sound waves to create images of the inside of your body). This is a simple, non-invasive test that can be beneficial when regularly monitoring patients with a vulvar hematoma, without needing surgical intervention.
If your doctor sees the need for more examinations, these could look for causes of the hematoma, such as the presence of disorders in connective tissue or problems with blood clotting. If you’ve experienced severe trauma or sexual assault, a detailed examination of any injuries in your pelvic area or perineum (the area between the anus and the genitals) will be necessary. If the trauma involves the pelvis, additional tests like a pelvic X-ray may be done to check for any fractures in the pelvic bones.
Treatment Options for Vulvar Hematoma
Most hematomas (which are collections of clotted blood) in the vulva, the external part of the female genitalia, are small and can be treated without surgery. However, larger ones, especially those over 10 cm wide or those that keep growing, may cause a lot of pain and distress. It becomes necessary to perform surgery on these hematomas if they’re big enough to disrupt the body’s normal functions, prompt urinary or neurological symptoms, or result in unstable vital signs. If a patient has trouble urinating, they might have to use a catheter, which is a flexible tube placed in the bladder to drain urine.
Non-surgical treatment usually involves the use of ice packs, local compression (putting pressure on the area), staying in bed and using pain relief medications. If these methods aren’t effective, it might be necessary to resort to surgery. In fact, treatment without surgery for large hematomas has actually been linked to longer hospital stays, increased need for blood transfusions and antibiotics. For hematomas that grow quickly, avoiding surgery isn’t recommended.
Surgery generally involves draining the hematoma, removing any clots, stopping the bleeding, and checking for signs of tissue death due to pressure (a complication of vulva hematoma). This can be done using local anesthesia, meaning that the patient is awake but the area is numbed. Since there could be more blood loss during the operation, preparations for a possible blood transfusion should be made, such as ensuring that there is compatible blood available. A procedure which approaches the hematoma from inside the vagina could give better cosmetic results.
An alternative option is selective arterial embolization, a procedure that involves blocking a blood vessel to stop bleeding. This procedure is used for various conditions involving bleeding in obstetrics and gynecology. Prior to embolization, an examination known as pelvic angiography is done to identify and locate any bleeding vessels. This method might be chosen if bleeding continues after surgery, if the hematoma reappears following surgery, or if the patient’s condition makes surgery too risky. Successful use of embolization after failed non-surgical treatment for a growing vulvar hematoma that isn’t related to childbirth has been reported.
What else can Vulvar Hematoma be?
Vulvar hematoma, a condition which usually results in a painful lump in the vulvar area, can sometimes be confused with other health conditions that present similar symptoms. These conditions include Bartholin’s gland cysts and abscesses, vulvar varicosities (varicose veins in the vulva), folliculitis (inflammation of hair follicles), and vulvar cancer. Understanding the underlying symptoms and causes of these conditions helps doctors to properly diagnose a vulvar hematoma.
- Bartholin’s gland cysts and abscesses: Bartholin’s glands are tiny glands on each side of the vaginal opening that produce fluid for vaginal lubrication. If one of these glands gets blocked, it can create a painless cyst or a painful abscess if the fluid-filled lump gets infected. These cysts or abscesses may look similar to a vulvar hematoma.
- Vulvar varicosities: Just like you can get varicose veins on your leg, you can get them on your vulva, particularly in women who’ve been pregnant multiple times. These are usually painless but can sometimes cause discomfort. Sometimes, these varicose veins might be confused with a vulvar hematoma, especially after a woman has had surgery to treat the varicose veins.
- Folliculitis: This involves the inflammation of hair follicles on the vulva, giving the appearance of pimples. This could cause itching or pain in the genital region which can be confused with symptoms of a vulvar hematoma.
- Vulvar cancer: While it’s a rather rare condition, vulvar cancer often presents as a lump or growth, usually accompanied by itching, which might lead doctors to consider it as a potential diagnosis. Additionally, metastatic choriocarcinoma, a type of cancer that can reach the vulva, should be considered if the patient has a history of this cancer.
In order to arrive at a correct diagnosis, doctors need to conduct detailed physical examinations and carefully consider patient history and symptoms.
What to expect with Vulvar Hematoma
Vulvar hematomas, or blood-filled swellings on the vulva, can be serious but rarely cause death. In many cases, a full recovery is usual. For small hematomas, they often go away on their own under careful observation and simple treatments. With surgical intervention or a procedure called selective arterial embolization, most patients can usually move around within a day or two and go back home without any complications.
Possible Complications When Diagnosed with Vulvar Hematoma
Necrosis, or the death of tissue, can be a problem that might need surgery for removal. This issue often happens when a large or growing blood clot puts too much pressure on the nearby tissues. Swift surgical intervention can help dodge such complications by removing these clots. If pain and necrosis are increasing, an urgent surgery is typically necessary.
As with any surgical treatment, there’s always a risk of getting an infection. After being discharged from the hospital, it is crucial patients check in again soon to make sure they haven’t developed an infection or if their blood clot has returned. Doctors may give preventive antibiotics if it seems necessary.
Another approach, called selective pelvic arterial embolization, can also be quite beneficial, even though it’s not always achieved easily. After the procedure, patients may experience some issues like muscle pain, the accidental piercing of the guidewire, and the creation of an abnormal connection between the vagina and an adjacent organ, known as a vaginal fistula. They might also encounter low-grade fever, pelvic infection, and temporary loss of movement or sensation in the foot, known as foot drop. Finally, because pelvic arterial embolization process uses ionizing radiation, it does expose patients to a certain level of radiation.
Common complications:
- Necrosis
- Pressure from large or growing blood clots
- Infection after surgery
- Recurrence of a blood clot
- Complications post pelvic arterial embolization procedure (muscle pain, guidewire perforation, vaginal fistula, low-grade fever, pelvic infection, temporary foot drop)
- Exposure to ionizing radiation from pelvic arterial embolization
Recovery from Vulvar Hematoma
Moving around early after surgery is known to have the advantage of reducing the risk of blood clots in veins. However, the exact time a patient should stay in bed and rest after surgery on the vulva is still a topic of debate. Medical professionals also focus on the detailed care of the surgical wound, management of pain after surgery and use of antibiotics if necessary.
It is also important to be aware that blood clots can come back after surgery. Therefore, constantly checking the patient’s blood pressure, heart rate, respiratory rate, and temperature remains a key part of care.
Preventing Vulvar Hematoma
Vulvar hematoma, which is a collection of blood outside the blood vessels in the vulvar area, can often be prevented by taking certain precautions. One of the ways to prevent it is by making changes to avoid the common causes. For instance, keeping a safe environment at home can be beneficial. This could involve using non-slip materials on the floor and making sure the house is well lit, especially during the night.
In the case of postmenopausal women who have fragile skin in the vulvar area, reducing potential for injury is also important. For such cases, doctors may prescribe estrogen gels and other treatments for vulvar and vaginal dryness. The use of these treatments can lessen the chances of damaging the skin which could potentially lead to a vulvar hematoma.
For women during childbirth, there can also be potential for a vulvar hematoma. To lessen this risk, healthcare professionals may opt to decrease the use of episiotomy (a surgical cut made during childbirth) and operational vaginal procedures. Fewer of these procedures mean a lower chance of a vulvar hematoma occurring.
