J Pediatr Adolesc Gynecol (2009) 22:e156ee158

Case Report
Management of Vulvar Hematomas: Use of a Word Catheter
Evelyn Y. Mok-Lin, MD and Marc R. Laufer, MD
Division of Gynecology, Department of Surgery, Childrens Hospital Boston, Boston, Massachusetts; Department of Obstetrics and Gynecology, Brigham and Womens Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts

Abstract. Background: Large vulvar hematomas in the pediatric population resulting from straddle-type injuries often require surgical incision and drainage. We report an innovative use of a Word catheter to facilitate recovery following hematoma evacuation. Case: A 14-year-old female presented with a 6-cm right labial hematoma and was initially treated with ice packs and analgesia. The hematoma did not resolve over the following weeks, and she subsequently underwent incision, drainage, and placement of a Word catheter. It was removed painlessly on postoperative day 8, and follow-up revealed no signs of reaccumulation, infection, or scar tissue formation. Summary and Conclusion: Placement of a Word catheter following evacuation of vulvar hematomas is a comfortable alternative to traditional drains to prevent reaccumulation and facilitate recovery.

evacuation of the hematoma, ligation of identiable bleeders, and placement of a suction drain to prevent reaccumulation of uid and blood.2,4 Placement of these drains often eases pain and facilitates recovery; however, stitches are required to secure the drain to the skin. We report a case in which an innovative use of a Word catheter allowed for successful surgical management of a vulvar hematoma. A Word catheter is a 6-cm long, 10- or 12-French latex rubber catheter with a 3 cc balloon at its tip that is typically used for treatment of Bartholins gland cysts or abscesses. In this case, a Word catheter was easily placed without sutures and removed painlessly, effectively treating a vulvar hematoma in an adolescent patient. Case

Key Words. VulvarHematomaAdolescent ManagementWord catheter

Introduction Nonpuerperal vulvar hematomas in the pediatric and adolescent population often result from blunt trauma associated with straddle-type injuries. The rich vascular network of the vulva, combined with the loose subcutaneous tissues, allow for the accumulation of a large amount of blood.1 Most authors advocate for conservative management in the absence of a rapidly enlarging lesion to prevent the introduction of infection.1-4 However, surgical intervention is recommended for complicated cases involving a large or rapidly expanding hematoma. This surgery consists of an
EYM has nothing to disclose. MRL has nothing to disclose.

Address correspondence to: Marc R. Laufer, MD, Division of Gynecology, 300 Longwood Ave, Boston, MA 02115; Phone: (617) 355-5785; Fax: (617) 730-0186.; E-mail: marc.laufer@childrens. harvard.edu
2009 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.

A 14-year-old Caucasian female presented with a large right labial hematoma after she sustained a straddle injury from tripping and falling on top of a seatbelt at an amusement park. At the time of presentation, she denied any signicant pain, vaginal bleeding, or difculty voiding. The initial physical examination revealed a 6 5 3-cm hematoma of the right labia majora, with intact skin overlying the mass (Fig. 1). She showed no signs of active bleeding, infection, or urinary dysfunction. The decision was made to treat conservatively with ice packs to the perineum, oral analgesia, and restrictions on physical activity. The patient returned to the ofce 2 weeks later with a hematoma that had not decreased in size. She continued to have no vaginal bleeding or voiding difculties, but she reported increasing vulvar discomfort from the persistent mass. She also reported signicant emotional distress, as she had been unable to participate in many of her school sporting events or enjoy her active lifestyle. The patient strongly desired surgical management at this point. She was brought to the operating room, where the hematoma was incised and evacuated, and a Word catheter was placed through a separate
1083-3188/09/$36.00 doi:10.1016/j.jpag.2009.02.002

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Fig. 1. A vulvar hematoma of the right labia majora resulting from a straddle injury in an adolescent female.

incision (Fig. 2). The catheter was held in place by the inated balloon at its tip. No additional sutures were required to secure the Word catheter. The patient resumed her usual activities, and the Word catheter remained intact until its removal in the ofce on postoperative day 8. Examination at that time revealed a non-tender right labia with a wellhealed incision and no signs of uid or hematoma reaccumulation. The balloon of the Word catheter was deated and the catheter removed painlessly. The patient was very pleased with her management and continued to do well. At her 3-month follow-up visit, a physical examination revealed normal-appearing bilateral labia. Discussion Conservative management, which includes ice packs to the perineum, adequate analgesia, and bed rest, is generally favored for small, nonexpanding vulvar hematomas.1e3 Surgical treatment should be avoided in these cases to prevent infection.3 However, large or expanding hematomas should be incised and drained to limit their dissection and prevent necrosis of the overlying skin.2,4 This procedure should be performed in an operating room setting for adequate exposure and anesthesia. An incision is made, and clot and devitalized tissue are removed. Active bleeders that are seen are clamped and suture-ligated. If a specic bleeder is not identied and complete hemostasis cannot be

Fig. 2. Word catheter placement after incision and drainage of the vulvar hematoma.

achieved, packing of the hematoma cavity for 24 hours followed by placement of a suction drain should be considered.4 Continuous drainage of a hematoma may help to evacuate blood and secretions, as well as eliminate dead space in the cavity, thereby reducing pressure, pain, and risk for tissue necrosis and infection.1 The Word catheter, traditionally used for Bartholins cysts, was a successful alternative in this case to both the traditional drains and packing. It allowed for passive drainage of the evacuated hematoma cavity without necessitating the use of sutures to secure the catheter to the skin, thereby sparing our young patient from suture removal at her postoperative visit. In addition, the balloon of the Word catheter, while serving to keep the catheter in place, may also have a tamponade effect on small bleeders. In situations in which packing of the cavity is considered, this may be a more comfortable alternative, as the traditional gauze pack often causes the pediatric and adolescent patient notable pain upon removal. Conclusion Small, stable vulvar hematomas commonly resolve with conservative management. Surgical intervention should be considered in large or expanding hematomas, or in those who failed initial treatment. Placement of a Word

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Mok-Lin and Laufer:Word Catheter for Management of Vulvar Hematomas

2. Adams Hillard PJ: The 5-minute Obstetrics and Gynecology Consult. Philadelphia, Lippincott Williams & Wilkins, 2008, pp 612e13. 3. Emans SJ, Laufer MR, Goldstein DP: Pediatric and Adolescent Gynecology, (5th ed.), Philadelphia, Lippincott Williams & Wilkins, 2005, pp 551e52. 4. Bieber EJ, Sanlippo JS, Horowitz IR: Clinical Gynecology. Philadelphia, Churchill Livingstone, 2006, pp 517-18.

catheter following incision and drainage is a safe, effective, and comfortable alternative to wound packing and traditional suction drains to prevent uid and hematoma reaccumulation and to facilitate recovery. References
1. Gilstrap LC, Cunningham FG, Van Dorsten JP: Operative Obstetrics, (2nd ed.), New York, McGraw-Hill, 2002. pp 226e30.