Genital trauma in girls are injuries to the external and internal genitals that have arisen as a result of mechanical, thermal, chemical, electrical, radiation and other influences. They are manifested by pain, bleeding, hematomas, edema, deformity of organs. To make a diagnosis, examination data, vaginoscopy, pelvic radiography are used, supplemented with microbiological examination if necessary. The treatment regimen includes primary treatment of the wound area, surgical restoration of injured organs with the appointment of infusion therapy, hemostatic, antibacterial, anti-inflammatory, sedative drugs.
Traumatism of internal and external genitalia is detected in 0.8% of girls under the age of 6-7 years and in 4.7% of schoolgirls. In the general structure of gynecological diseases of childhood, genital injuries account for at least 6%, while most authors note that such traumatic injuries occur 2-4 times less often in girls than in boys. Most often, as a result of direct blows, falls on sharp or blunt objects, the pubis, labia majora and labia minora, the vestibule of the vagina, perineum, hymen, clitoris are injured. Up to 75% of the damage is open. Injuries to the internal organs of the reproductive system are diagnosed less often, usually they are the result of sexual violence, transport accidents, iatrogenic effects.
Causes of genital trauma in girls
Traumatic genital injuries in childhood are usually associated with careless behavior of the child and others, adverse external influences, intentional actions of adults or other children. Specialists in the field of pediatric gynecology and traumatology distinguish the following main causes of injuries of the reproductive organs in girls:
- Accidents and accidents. Up to 5-6 years of age, injuries in the genital area are usually of a domestic nature and occur at home, sometimes in preschool institutions. Girls after the age of 6 often get injured outside the home, and the frequency of sports injuries increases in children over the age of 11. The most common causes of injury are falls on sharp or blunt objects, blows, less often — the influence of chemical and thermal factors.
- Sexual acts. The internal and external genitals of a girl can be damaged as a result of rape, including with the use of piercing and cutting objects. Such injuries are massive, often accompanied by significant blood loss and psychological shock. Injury of the vagina, labia, hymen, perineum is also possible when large, piercing or sharp objects are inserted into the genitals, urethra, rectum for the purpose of masturbation.
- Birth trauma in adolescent girls. Childbirth in adolescence is associated with a high risk of damage to the birth canal — ruptures of the cervix, vagina, perineum. Almost half of young women in labor have anatomical narrowing of the pelvis, which in combination with frequent rapid or rapid childbirth increases the likelihood of soft tissue destruction. Disorders associated with genital trauma during childbirth are often aggravated by hypotonic postpartum bleeding.
- Iatrogenia. Extremely rarely, the genitals of girls are damaged due to careless performance of diagnostic and therapeutic manipulations. Injuries are the result of general surgical, gynecological, and urological procedures. Genital injuries occur with the rough introduction of a probe, endoscope, other equipment, violation of the technique of performing invasive interventions, radiation therapy. With iatrogenic traumatism, the formation of fistulas between the hollow organs is possible.
There are a number of predisposing anatomical, physiological and psychological factors that increase the likelihood of injury to the genital area of the child. In girls, subcutaneous fat is insufficiently expressed, the integumentary epithelium is loosely connected to the underlying tissues, the epidermal layer is thin and does not cope well with the function of protection from mechanical influences. Children are inquisitive, mobile, impulsive, prone to pranks, they do not have enough coordinated movements, some important household skills are missing. An important role is played by insufficiency or lack of supervision.
The mechanism of occurrence of clinical manifestations in genital injuries depends on the type of damaging factor, time and direction of its action. As a rule, maximum damage is noted in the central part of the injured area — destruction of soft tissues, blood vessels, nerve fibers. In the area adjacent to the injury site, inflammatory mediators are actively released, due to a short-term reflex spasm with subsequent paretic vasodilation, microcirculation is disrupted, stagnant hyperemia and traumatic edema (serous tissue impregnation) occur. With more massive injuries, hemorrhages, hematomas are formed, tissues are imbibed with blood.
During the repair period, the damaged areas are cleared of necrotic masses, blood supply and innervation are restored in them, epithelialization or scarring occurs. There are some differences between the individual links of pathogenesis in mechanical damage to the genitals (bruise, cut, puncture, rupture), their radiation, chemical or thermal burn.
The systematization of genital trauma in girls takes into account the cause of damage, localization and type of disorders, the degree of involvement of adjacent organs in the process. The correct definition of the clinical form of pathology allows you to choose the optimal medical tactics. Genital trauma in girls are classified based on criteria such as:
- Damaging factor. The most common are mechanical injuries to the organs of the reproductive system. Thermal, chemical, and radiation damage are less common.
- Type of injury. Depending on the mechanism of action of the damaging agent and the features of tissue destruction, bruises, tears, crushing, cuts, punctures, burns, frostbite of the genitals are distinguished.
- Localization of damage. External genitals (vulva, perineum, clitoris, hymen), internal genitals (vagina, uterus, appendages) can be injured. Combined injuries are possible.
- Involvement of related organs. With massive impacts, damage to the bones of the pelvis, urethra, bladder, ureters, peritoneum, rectum, and other parts of the small and large intestines is likely.
Symptoms of genital trauma in girls
The child usually complains of intense pain in the damaged area. In 30% of girls with external genital trauma and with a significant part of internal injuries, bleeding occurs. It becomes especially massive with the rupture of cavernous formations and venous plexuses of the clitoris, injury of large vessels of the perineum. If the integrity of the skin or mucous membranes is preserved, hematomas are formed. Their sizes can be stable, gradually or rapidly increase (if the arterial vessel is damaged).
In some girls, there is a spread of large hematomas from the vulva and perineum to the front wall of the abdomen, buttocks, inner thighs. Traumatic edema is detected in the surrounding tissues. When the vagina and uterus are injured, blood is released from the genital tract, internal bleeding is possible, less often — the formation of a hematoma with its spread to the external genitals and pelvic tissue. The increase in internal hematoma is indicated by the appearance of complaints of bursting pain.
With combined injuries of the genital and adjacent organs, hematuria, pain or difficulty urinating, tenesmus, involuntary discharge of gases and feces occur. Injuries in girls are often accompanied by general malaise and resorptive fever. Thermal and chemical burns of the genitals are characterized by pronounced hyperemia, the appearance of blisters on the skin, rapid formation of erosions and deeper necrotic destruction of tissues. Radiation injuries develop slowly, their consequences in the form of necrosis and tissue fibrosis are detected some time after exposure.
Injuries with bleeding from the genitals are complicated by anemia, in severe cases — hemorrhagic shock, hematocolpos formation, hematometers. Usually, the wound is accompanied by primary microbial contamination, which increases the likelihood of purulent-inflammatory processes — suppuration of wounds, burns, hematomas, the development of pyokolpos, pyometra, pyosalpinx, pelvioperitonitis and peritonitis. During rape, the development of genital infections (gonorrhea, syphilis, genital herpes, chlamydia, trichomoniasis, mycoplasmosis, ureaplasmosis, etc.) is possible.
The long-term consequences of genital injuries suffered by girls are scarring of the perineum, vulvar ring, vagina, which complicate the course of labor in the future. A serious consequence of combined damage to the genital and nearby organs is the formation of rectal-vaginal, urethrovagal and vesicovaginal fistulas. Most girls in the post—traumatic period have neurosis-like disorders – depression with a sense of their own inferiority, depression, anxiety-phobic states, obsessions.
When examining girls with genital injuries, it is important to quickly assess the nature and extent of the injuries in order to quickly begin the necessary treatment. The accuracy of the diagnosis allows you to determine the correct medical tactics and minimize the likelihood of complications. The examination plan includes such physical, instrumental and laboratory methods as:
- Examination on the chair. Linear or lacerations, abrasions, bruises are detected on the surface of the labia, perineum, and blood may be released from the vagina. In the presence of an external hematoma, the vulva is deformed with the displacement of the genital slit to the intact side. Rectal-abdominal examination and careful probing of the vagina are preferable.
- Vaginoscopy for a child. To detect foreign bodies and internal injuries of the organs of the reproductive sphere, a vaginoscope (combined urethroscope) or children’s vaginal mirrors with removable illuminators that can be inserted through the natural openings of the hymen are used. When choosing a vaginoscope tube and mirrors, the age of the girl and the characteristics of the hymen are taken into account.
- Radiography of the pelvis. X-ray examination is indicated if a combination of genital trauma with fractures of the pelvic bones or the presence of a foreign body in the vagina is suspected. Filling the vagina with a contrast agent allows you to visualize objects made of X-ray negative materials. Contrasting is not carried out with possible internal breaks.
- A smear on the flora. In the case of rape, it is mandatory to take material for the possible detection of gonococci and spermatozoa. Subsequently, the girl was recommended laboratory tests to detect pathogens of genital infections: inoculation on flora with an antibioticogram, PCR diagnostics, RIF, ELISA, an extended version of the TORCH complex.
As additional techniques, cystoscopy, rectoromanoscopy, finger examination of the rectum, radiography of the abdominal organs can be prescribed. Differential diagnosis is made between different types of injuries. According to the testimony of the injured girl, in addition to a pediatric gynecologist, a traumatologist, a surgeon, a urologist, a proctologist, a psychologist, a psychotherapist consult.
Treatment of genital trauma in girls
The main therapeutic tasks in cases of injuries to the genital organs of children are rehabilitation of the injured area, restoration of tissue integrity, prevention of possible complications. According to statistics, up to 50% of girls with injured genitals are hospitalized for hospital care. Almost all children need tetanus prevention. Taking into account the age of the patient, most manipulations are performed under local or general anesthesia. The scheme of management of a child with a trauma of the genital organs includes the following stages:
- Primary surgical treatment. Fragments of necrotic tissues, blood clots, foreign bodies, and particles of contamination are removed from the lesion. Wounds are treated with sterile and aseptic solutions. When the tissues are crushed, they provide an outflow from the destruction zone. Pressure bandages are applied to hematomas and cold is applied. If the bruise continues to grow, it is dissected to remove clots, ligate the bleeding vessel and, if necessary, install drainage.
- Suturing of damaged genitals. The application of primary sutures in compliance with the topography of the tissues is allowed in the absence of crushing, contamination, assistance no later than 12-24 hours after injury. In other cases, it is recommended to apply early secondary sutures for 7-14 days after complete cleansing of the wound and the formation of granulations. In the presence of inflammatory processes, antibacterial drugs are additionally prescribed. During the operation, if possible, the integrity of the hymen is restored.
The volume of drug therapy is determined by possible complications. According to the indications, the girl may be prescribed analgesics, blood transfusion, infusion therapy, hemostatics, sedatives. Massive injuries with penetrating wounds of the abdominal cavity, damage to the intestines, urinary organs are indications for emergency abdominal operations, cystostomy, drainage installation. In the long-term period, in the presence of fistulous passages between individual organs, reconstructive interventions are performed. To reduce the possible excessive scarring, courses of resorption therapy are used.
Prognosis and prevention
Due to timely adequate treatment, 91.2% of traumatized girls achieve positive results with the creation of prerequisites for the preservation of menstrual and reproductive functions, sufficient social adaptation. Primary prevention is aimed at providing supervision of children, teaching them the rules of safe behavior in everyday life, children’s institutions, sections, on the street, protection from possible sexual harassment. An important preventive measure is the creation of conditions that exclude the possibility of domestic, school, sports child injuries.