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Genital tract injuries1

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VANITASharma19

The document discusses various genital tract injuries in women including those occurring during childbirth such as vaginal, cervical, and perineal lacerations as well as injuries from sexual assault or insertion of foreign objects. It provides details on the clinical presentation and management of these injuries, emphasizing prompt repair of lacerations to prevent long term complications. Prevention strategies are also outlined such as recognizing disproportion during pregnancy and treating with caesarean section when needed.

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GENITAL TRACT INJURIES
GENITAL TRACT INJURIES • The genital tract and the adjacent pelvic organs are subjected to strain of vaginal delivery either spontaneous or assisted. • The injury is more in areas of inadequate antenatal or intranatal care. • The patients may have full recovery from the injuries but a substantial number may produce permanent legacies which lead to major gynecological problems.
OBSTETRIC INJURIES Injuries during normal delivery Vagina become patulous superficia l laceration of the perineal skin carunculae myrtiformes . first degree perineal tear
CONTINUED….. Extensive vaginal laceration Severe lacerations of the perineum Severe lacerations of the cervix Rectovaginal fistula Vesicovaginal fistula Tears of the vagina
PREVENTION & MANAGEMENT • The majority of obstetric injuries are theoretically preventable. • A case of disproportion should be recognized antenatally and be treated in time by caesarean section. • Lacerations of the cervix and extensive tears of the perineum, although avoidable, should be treated by immediate suturing.
COITAL INJURIES • Tearing of the hymen or bruising of the vagina or urethra. • Tear spreads to involve the vestibule or the region of the clitoris. • Rupture of the vault of the vagina usually occurs in: –rape –very young girls –postmenopausal atrophy –following vaginal/abdominal hysterectomy.
MANAGEMENT • Small tears - pressure application • Larger lacerations need to be repaired. • Ruptured vault - laparotomy and repair the vault and to tackle any associated pathology. • Bowel prolapsed – Abdomen is opened so that a complete inspection of the genital tract (GIT) from the jejunum to the rectum can be made. The correct treatment performed under direct vision.
RAPE VICTIMS The very young, mentally and physically handicappe d and the very old are the common victims. The victims may be of any age groups— pre- menar- chal, childbeari ng or even postmeno pausal.
FORENSIC CONSIDERATIONS • The medico-legal issues should be seriously considered even if the victim does not wish to report the case or press for prosecution. • Rape is a legal diagnosis. The medical evidences and examinations are of value only to the court. • Referral may be through police, hospital, doctor or by self referral. • The physician should examine her as early as possible following rape.
CONTINUED….. • Due consent is to be taken from the victim and the examination is made in presence of a third party or chaperone. Confidentiality is to be maintained. • Detailed statement from the victim, examination findings are recorded. Collected materials are labeled properly and should be submitted for expert examination. • Sperm are rarely detected in the vagina later than 72 hours and motile sperm later than 4 hours. Rarely non-motile sperm may be present in vagina even after 12-20 hours of the attack.
M A N A G E M E N T Examination with clinical and evidential protocols. To treat any local injury. To perform appropriate tests. To prevent infection and STD. To prevent pregnancy (emergency contraception). To provide emotional support to the victim. Follow-up
DIRECT TRAUMA AND VULVAL HEMATOMA • Accident, as falling astride on any sharp or pointed object • Bruising of the vulva or at times give rise to vulval hematoma • Fracture of pelvic of bones causing injuries to pelvic viscera like bladder or rectum apart from vagina. There may be supralevator hematoma. • Large hematoma may develop in the labia majora, and the effused blood spreads widely in the lax connective tissues.
CONTINUED…. • Comparable hematomas of the vulva are sometimes caused by the rupture of varicose veins of the labia majora during pregnancy, and the large swelling may obstruct the delivery. • One of the common cause could be inadequate hemostasis during suturing of an episiotomy or a perineal tear.
CONTINUED…. COMPLICATIONS • Subsequent anemia • Local infection CLINICAL FEATURES • Painful tender swelling, bluish black in appearance. • Patient may look pale and may be in condition of shock which is out of proportion to the clinical blood loss.
M A N A G E M E N T Small hematoma Rest in bed Sitz bath Magnesium sulphate fomentation Antibiotic Large hematoma Incise the swelling under anesthesia packing with drainage may be required Deep penetrating injuries Operations, suture and repair of the injured structure. Laparotomy and suturing of perforated bowel or bladder Temporary colostomy
INJURIES DUE TO FOREIGN BODIES In the vagina • Coins, toys, small stones either introduced out of curiosity by children or perversion in adults. • Forgotten menstrual tampon or diaphragm, cervical cap or condom used as contraceptives • Articles introduced to procure abortion. • Packs, swabs or dressings. • Forgotten pessary. In the uterus • Retained IUCD for a long time. • Old gauze packs. • Articles inserted for procuring abortion.
EFFECTS • The effects depend upon the nature of the foreign body, duration of its existence and amount of tissue damage. • Infection • Foul smelling discharge • Retained and forgotten pessary may cause vaginitis, sloughing and ulceration. It may produce vesico-vaginal fistula and may be a precursor of vaginal carcinoma. • Prolonged retention of IUD may cause menorrhagia, irregular bleeding and if left even in postmenopausal period, may produce pyometra or postmenopausal bleeding.
MANAGEMENT • Remove the foreign body. • Local antiseptic douches after-treatment into vagina. • If the vagina is perforated, chemotherapy is indicated. • Adnexal involvement (not responding to chemotherapy) laparotomy and their surgical removal is required. • If there are signs of peritoneal infection or bowel damage, as with abortion, laparotomy is needed. • When the pelvic organs are grossly disorganized
INJURIES DUE TO INSTRUMENTS • Cervical injuries may be inflicted by the vulsellum or by a dilator especially in nulliparous cervix. • Body of the uterus is commonly injured by sound, dilator or curette or during insertion of IUD. • Susceptible conditions are : –Small and soft uterus during lactation –Postmenopausal uterus –Infected uterus –Pyometra
CONTINUED…. Dangers Brisk hemorrhage either intraperitoneal or revealed Spreading infection (peritonitis) Injury to the gut.
MANAGEMENT NON-INFECTIVE/NON- MALIGNANT Observation: • Pulse and blood pressure. • Administer antibiotics. • Evidences of peritonitis • Laparoscopy Interference • Deteriorating general condition • Suspected gut injury • Features of developing peritonitis. INFECTIVE/MALIGNANT • Risk of spreading peritonitis. • Observation may be done under cover of antibiotics but if unresponsive, laparotomy is preferred. • In malignancy or pyometra, laparotomy and definitive surgery have to be seriously considered.
CHEMICAL AND OTHER BURNS OF THE VAGINA • Cause: – Use of strong chemicals such as Lysol, permanganate or corrosive sublimate. – Douches administered at too high a temperature – Cauterization – Radium inserted into the vagina – Laser therapy • Complication: – Extensive vaginal adhesions and fibrosis will obliterate the canal and prevent coitus – Retention of menstrual discharge with hematometra and pyometra. – Vaginitis
TREATMENT Plastic surgery Expectant treatment
OLD-STANDING COMPLETE PERINEAL TEARS (CPT) Definition • Tear of the perineal body involving the sphincter ani externus with or without involvement of the anorectal mucosa is called complete perineal tear. • It is called old when passed beyond an arbitrary period of 3 months following the injury.
ETI0LOGY Risk factors for third degree tears (RCOG-2007) – Primigravida – Big baby (>3 kg) – Face to pubis delivery – Midline episiotomy – Forceps delivery – Outlet contraction with narrow pubic arch – Shoulder dystocia – Precipitate labor – Scar in the perineum – Prolonged second stage Obstetrical Over stretching or sudden stretching of the perineum during child birth. Gynecological Direct injury on the perineum by fall may lead to trauma on the perineum to the extent of CPT.
CLINICAL FEATURES Patient profile: Primiparous with a history suggestive of inadequate care during childbirth. Symptom: Inability to hold the flatus and feces Soreness over the perianal region Signs: Absence of perineum Visible dimple on the skin on either side of the fused mucosa Radial wrinkling of the skin of anal opening Palpation: Absence of the sphincteric grip Anal canal is separated from the vagina only by a septum Differential diagnosis: Rectovaginal fistula
TREATMENT PREVENTIVE • Delivery of the head by early extension is to be avoided. • Controlled delivery of the flexed head in between uterine contractions. • Timely and judicious medio-lateral episiotomy OPERATIVE • Repair of anal sphincter complex (sphincteroplasty) • Restoration of the perineal body (perineorrhaphy) • Preferably be done between 3–6 months following the injury, best within 24 hours of the injury
Special Postoperative Care: • Non-residual diet is given from 3rd day onwards; the full diet is given on 6th day. • Bowel should not be moved for about 4-5 days. • Lactulose 10 ml twice daily beginning on the second day and increasing the dose upto 30 ml on the 3rd day • Compound enema • Antibiotics • Intestinal antiseptics should be CONTINUED….. Preoperative Preparations: • Admission at least 3 days prior • Low residual diet 2 days prior • Intestinal antiseptics 2 days prior • Enema and bowel wash are given daily, for two days prior
Complications Complete dehiscence Incomplete dehiscence Difficulty in defecation Dyspareunia Peristence of incontinence of flatus or feces
VAGINAL LACERATIONS • Vaginal lacerations commonly occur following assisted instrumental vaginal deliveries, difficult breech extractions, or following shoulder dystocia. • It is good practice to inspect the lower genital tract after the expulsion of the placenta, indentify all tears and suture them meticulously. • It may extend to the vault of the vagina and cause profuse bleeding. Suturing must be done with great care to avoid injury to the ureter. • Tear to a broad ligament may lead to a broad ligament hematoma which may require to a laparotomy for its evacuation.
CERVICAL LACERATIONS • Minor injuries are common and need no treatment. • Bilateral transverse tears of the cervix end up as ectropions. • Extensive tears involving the sphincter of the cervix may lead to preterm deliveries or habitual painless mid-trimester abortions.
CONTINUED….. • In women with flat pelvis, the anterior lip of the cervix may get caught between the fetal head and symphysis pubis resulting in an anterior bucket handle tear. • Rarely, in women with the small gynaecoid pelvis, a trial of labour may result in circumferential ischaemic necrosis of the lower part of the cervix and end up with annular detachment of the cervix.
PERFORATION OF THE UTERUS Definition • Perforation of the uterus is a condition resulting from the accidental piercing of the full thickness of the uterine wall, usually by one of the instruments used while performing any uterine procedure. Uterine perforation is an uncommon but potentially serious complication of uterine manipulation, evacuation of retained products of conception or termination of pregnancy (TOP), hysteroscopic procedures and during coil insertion.
UTERINE & CERVICAL FACTORS THAT INCREASE THE RISK OF PERFORATION • Advanced gestation when termination of pregnancy is performed • Evacuation of Retained Product of Conception for postpartum hemorrhage • Parous uterus • Recent pregnancy in the past 6 months • Small postmenopausal uterus • Tight postmenopausal cervix
CONTINUED…. • Uterine cavity distorted by fibroids • Intrauterine synechiae or adhesions • Pyometra • Infection • Position and attitude of the uterus • Retroverted, acutely anteverted or retroflexed uterus • Uterine anomalies • The scarred uterus (previous uterine surgery)
MANAGEMENT
Genital tract injuries1
Genital tract injuries1
Genital tract injuries1

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Genital tract injuries1

  • 2. GENITAL TRACT INJURIES • The genital tract and the adjacent pelvic organs are subjected to strain of vaginal delivery either spontaneous or assisted. • The injury is more in areas of inadequate antenatal or intranatal care. • The patients may have full recovery from the injuries but a substantial number may produce permanent legacies which lead to major gynecological problems.
  • 4. CONTINUED….. Extensive vaginal laceration Severe lacerations of the perineum Severe lacerations of the cervix Rectovaginal fistula Vesicovaginal fistula Tears of the vagina
  • 5. PREVENTION & MANAGEMENT • The majority of obstetric injuries are theoretically preventable. • A case of disproportion should be recognized antenatally and be treated in time by caesarean section. • Lacerations of the cervix and extensive tears of the perineum, although avoidable, should be treated by immediate suturing.
  • 6. COITAL INJURIES • Tearing of the hymen or bruising of the vagina or urethra. • Tear spreads to involve the vestibule or the region of the clitoris. • Rupture of the vault of the vagina usually occurs in: –rape –very young girls –postmenopausal atrophy –following vaginal/abdominal hysterectomy.
  • 7. MANAGEMENT • Small tears - pressure application • Larger lacerations need to be repaired. • Ruptured vault - laparotomy and repair the vault and to tackle any associated pathology. • Bowel prolapsed – Abdomen is opened so that a complete inspection of the genital tract (GIT) from the jejunum to the rectum can be made. The correct treatment performed under direct vision.
  • 8. RAPE VICTIMS The very young, mentally and physically handicappe d and the very old are the common victims. The victims may be of any age groups— pre- menar- chal, childbeari ng or even postmeno pausal.
  • 9. FORENSIC CONSIDERATIONS • The medico-legal issues should be seriously considered even if the victim does not wish to report the case or press for prosecution. • Rape is a legal diagnosis. The medical evidences and examinations are of value only to the court. • Referral may be through police, hospital, doctor or by self referral. • The physician should examine her as early as possible following rape.
  • 10. CONTINUED….. • Due consent is to be taken from the victim and the examination is made in presence of a third party or chaperone. Confidentiality is to be maintained. • Detailed statement from the victim, examination findings are recorded. Collected materials are labeled properly and should be submitted for expert examination. • Sperm are rarely detected in the vagina later than 72 hours and motile sperm later than 4 hours. Rarely non-motile sperm may be present in vagina even after 12-20 hours of the attack.
  • 11. M A N A G E M E N T Examination with clinical and evidential protocols. To treat any local injury. To perform appropriate tests. To prevent infection and STD. To prevent pregnancy (emergency contraception). To provide emotional support to the victim. Follow-up
  • 12. DIRECT TRAUMA AND VULVAL HEMATOMA • Accident, as falling astride on any sharp or pointed object • Bruising of the vulva or at times give rise to vulval hematoma • Fracture of pelvic of bones causing injuries to pelvic viscera like bladder or rectum apart from vagina. There may be supralevator hematoma. • Large hematoma may develop in the labia majora, and the effused blood spreads widely in the lax connective tissues.
  • 13. CONTINUED…. • Comparable hematomas of the vulva are sometimes caused by the rupture of varicose veins of the labia majora during pregnancy, and the large swelling may obstruct the delivery. • One of the common cause could be inadequate hemostasis during suturing of an episiotomy or a perineal tear.
  • 14. CONTINUED…. COMPLICATIONS • Subsequent anemia • Local infection CLINICAL FEATURES • Painful tender swelling, bluish black in appearance. • Patient may look pale and may be in condition of shock which is out of proportion to the clinical blood loss.
  • 15. M A N A G E M E N T Small hematoma Rest in bed Sitz bath Magnesium sulphate fomentation Antibiotic Large hematoma Incise the swelling under anesthesia packing with drainage may be required Deep penetrating injuries Operations, suture and repair of the injured structure. Laparotomy and suturing of perforated bowel or bladder Temporary colostomy
  • 16. INJURIES DUE TO FOREIGN BODIES In the vagina • Coins, toys, small stones either introduced out of curiosity by children or perversion in adults. • Forgotten menstrual tampon or diaphragm, cervical cap or condom used as contraceptives • Articles introduced to procure abortion. • Packs, swabs or dressings. • Forgotten pessary. In the uterus • Retained IUCD for a long time. • Old gauze packs. • Articles inserted for procuring abortion.
  • 17. EFFECTS • The effects depend upon the nature of the foreign body, duration of its existence and amount of tissue damage. • Infection • Foul smelling discharge • Retained and forgotten pessary may cause vaginitis, sloughing and ulceration. It may produce vesico-vaginal fistula and may be a precursor of vaginal carcinoma. • Prolonged retention of IUD may cause menorrhagia, irregular bleeding and if left even in postmenopausal period, may produce pyometra or postmenopausal bleeding.
  • 18. MANAGEMENT • Remove the foreign body. • Local antiseptic douches after-treatment into vagina. • If the vagina is perforated, chemotherapy is indicated. • Adnexal involvement (not responding to chemotherapy) laparotomy and their surgical removal is required. • If there are signs of peritoneal infection or bowel damage, as with abortion, laparotomy is needed. • When the pelvic organs are grossly disorganized
  • 19. INJURIES DUE TO INSTRUMENTS • Cervical injuries may be inflicted by the vulsellum or by a dilator especially in nulliparous cervix. • Body of the uterus is commonly injured by sound, dilator or curette or during insertion of IUD. • Susceptible conditions are : –Small and soft uterus during lactation –Postmenopausal uterus –Infected uterus –Pyometra
  • 21. MANAGEMENT NON-INFECTIVE/NON- MALIGNANT Observation: • Pulse and blood pressure. • Administer antibiotics. • Evidences of peritonitis • Laparoscopy Interference • Deteriorating general condition • Suspected gut injury • Features of developing peritonitis. INFECTIVE/MALIGNANT • Risk of spreading peritonitis. • Observation may be done under cover of antibiotics but if unresponsive, laparotomy is preferred. • In malignancy or pyometra, laparotomy and definitive surgery have to be seriously considered.
  • 22. CHEMICAL AND OTHER BURNS OF THE VAGINA • Cause: – Use of strong chemicals such as Lysol, permanganate or corrosive sublimate. – Douches administered at too high a temperature – Cauterization – Radium inserted into the vagina – Laser therapy • Complication: – Extensive vaginal adhesions and fibrosis will obliterate the canal and prevent coitus – Retention of menstrual discharge with hematometra and pyometra. – Vaginitis
  • 24. OLD-STANDING COMPLETE PERINEAL TEARS (CPT) Definition • Tear of the perineal body involving the sphincter ani externus with or without involvement of the anorectal mucosa is called complete perineal tear. • It is called old when passed beyond an arbitrary period of 3 months following the injury.
  • 25. ETI0LOGY Risk factors for third degree tears (RCOG-2007) – Primigravida – Big baby (>3 kg) – Face to pubis delivery – Midline episiotomy – Forceps delivery – Outlet contraction with narrow pubic arch – Shoulder dystocia – Precipitate labor – Scar in the perineum – Prolonged second stage Obstetrical Over stretching or sudden stretching of the perineum during child birth. Gynecological Direct injury on the perineum by fall may lead to trauma on the perineum to the extent of CPT.
  • 26. CLINICAL FEATURES Patient profile: Primiparous with a history suggestive of inadequate care during childbirth. Symptom: Inability to hold the flatus and feces Soreness over the perianal region Signs: Absence of perineum Visible dimple on the skin on either side of the fused mucosa Radial wrinkling of the skin of anal opening Palpation: Absence of the sphincteric grip Anal canal is separated from the vagina only by a septum Differential diagnosis: Rectovaginal fistula
  • 27. TREATMENT PREVENTIVE • Delivery of the head by early extension is to be avoided. • Controlled delivery of the flexed head in between uterine contractions. • Timely and judicious medio-lateral episiotomy OPERATIVE • Repair of anal sphincter complex (sphincteroplasty) • Restoration of the perineal body (perineorrhaphy) • Preferably be done between 3–6 months following the injury, best within 24 hours of the injury
  • 28. Special Postoperative Care: • Non-residual diet is given from 3rd day onwards; the full diet is given on 6th day. • Bowel should not be moved for about 4-5 days. • Lactulose 10 ml twice daily beginning on the second day and increasing the dose upto 30 ml on the 3rd day • Compound enema • Antibiotics • Intestinal antiseptics should be CONTINUED….. Preoperative Preparations: • Admission at least 3 days prior • Low residual diet 2 days prior • Intestinal antiseptics 2 days prior • Enema and bowel wash are given daily, for two days prior
  • 30. VAGINAL LACERATIONS • Vaginal lacerations commonly occur following assisted instrumental vaginal deliveries, difficult breech extractions, or following shoulder dystocia. • It is good practice to inspect the lower genital tract after the expulsion of the placenta, indentify all tears and suture them meticulously. • It may extend to the vault of the vagina and cause profuse bleeding. Suturing must be done with great care to avoid injury to the ureter. • Tear to a broad ligament may lead to a broad ligament hematoma which may require to a laparotomy for its evacuation.
  • 31. CERVICAL LACERATIONS • Minor injuries are common and need no treatment. • Bilateral transverse tears of the cervix end up as ectropions. • Extensive tears involving the sphincter of the cervix may lead to preterm deliveries or habitual painless mid-trimester abortions.
  • 32. CONTINUED….. • In women with flat pelvis, the anterior lip of the cervix may get caught between the fetal head and symphysis pubis resulting in an anterior bucket handle tear. • Rarely, in women with the small gynaecoid pelvis, a trial of labour may result in circumferential ischaemic necrosis of the lower part of the cervix and end up with annular detachment of the cervix.
  • 33. PERFORATION OF THE UTERUS Definition • Perforation of the uterus is a condition resulting from the accidental piercing of the full thickness of the uterine wall, usually by one of the instruments used while performing any uterine procedure. Uterine perforation is an uncommon but potentially serious complication of uterine manipulation, evacuation of retained products of conception or termination of pregnancy (TOP), hysteroscopic procedures and during coil insertion.
  • 34. UTERINE & CERVICAL FACTORS THAT INCREASE THE RISK OF PERFORATION • Advanced gestation when termination of pregnancy is performed • Evacuation of Retained Product of Conception for postpartum hemorrhage • Parous uterus • Recent pregnancy in the past 6 months • Small postmenopausal uterus • Tight postmenopausal cervix
  • 35. CONTINUED…. • Uterine cavity distorted by fibroids • Intrauterine synechiae or adhesions • Pyometra • Infection • Position and attitude of the uterus • Retroverted, acutely anteverted or retroflexed uterus • Uterine anomalies • The scarred uterus (previous uterine surgery)