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FEMALE GENITAL INJURY
Injuries result from unintentional trauma, sexual assault and,
in some regions, female genital mutilation.
Technique
| 1 |
Conduct
a local examination of the genital area. Check for associated
injuries.
Obtain information about the nature of the object causing injury; sharp objects
may have penetrated adjacent organs. |
| 2 |
Catheterize
the bladder if the patient has urinary retention. Repair
all lacerations
unless they are very superficial. Anaesthesia may be required to perform a thorough
examination and repair of severe injuries. |
| 3 |
Check
for tears of the hymen then introduce a speculum and
examine all the vaginal walls, fornices and the cervix. |
| 4 |
Thoroughly
clean the skin with soap and water, irrigate lacerations
with saline and ligate bleeding vessels. Excise only devitalized
tissues. |
| 5 |
Repair
deep lacerations with absorbable suture without tension
and the skin with non-absorbable suture. |
| 6 |
Perform
a laparotomy if the peritoneum is penetrated. For vulval
haematomas, infiltrate the area with local anaesthesia
and evacuate the clots. |
Complications
Complications include:
| 1 |
Infection |
| 2 |
Haematoma
in the parametrium |
| 3 |
Rectovaginal
fistula |
| 4 |
Dyspareunia. |
These
can be prevented by proper haemostatis and laceration repair.
Rape
If there is allegation of rape, make detailed records of your findings and
comply fully with local legal requirements. Give a dose of penicillin to protect
the patient against bacterial infection. Protect the patient against pregnancy;
use an IUD or emergency contraception with two birth control pills immediately
and two more in 12 hours. Give an anti-emetic with the birth control pills. Arrange
psychological counselling.
FEMALE GENITAL MUTILATION
Female genital mutilation (FGM) continues to be performed in some parts of
the world. The majority of cases are performed with non-sterile razors by untrained
personnel. Tradition rather than religion is the reason for these acts. There
is no health indication for FGM.
The procedure varies from amputation of the clitoris (type I), excision of
the clitoris and labia minor (type II), and complete excision of the clitoris,
labia minora and portions of the labia majora (type III). Type III is very
destructive and healing creates an epidermal cover over the urethra and the
vagina.
Treatment
| 1 |
Treat
as other genital injuries with wound debridement, saline
irrigation and removal of all foreign material. |
| 2 |
Remove
minimal tissue and drain abscesses. Administer antibiotics
for infected wounds, cellulitis or abscesses. |
| 3 |
Catheterize
the bladder to provide adequate drainage and administer tetanus
prophylaxis to non-immune patients. |
| 4 |
Excise
the epidermal tissue to permit urine flow and sexual
intercourse. |
| 5 |
For
childbirth, consider Caesarean section in severe cases.
Healed mutilation wounds with vaginal or perineal stenosis
may need specialized gynaecology care. |
PERINEAL ABSCESSES
Bartholin’s abscess
The patient complains of a painful, throbbing and tender swelling
in the vulva on the posterior and middle parts of the labia
majora. Differential diagnosis of labial masses includes:
| :: |
Cysts
of the vaginal process |
| :: |
Labial
hernia. |
These
conditions are lateral to Bartholin’s gland. Take a
smear of vaginal discharge to examine for gonococci and other
bacteria. Treat Bartholin’s cysts
with marsupialization but, if an abscess is present, incision and drainage
is sufficient. Interference with sleep is an indication for
urgent intervention.
An abscess is diagnosed by evidence of:
| :: |
Localized
pus |
| :: |
Throbbing
pain |
| :: |
Marked
tenderness |
| :: |
Fluctuation. |
Technique
Incision and drainage is easy to perform, almost bloodless and provides the best
chance of a cure.
| 1 |
Place
the patient in the lithotomy position and clean and drape
the
perineum. |
| 2 |
Make
a longitudinal incision in the most prominent part of
the abscess at
the junction of the vulva and vagina (Figure 9.60). |
|
| 3 |
Deepen
the incision and open the abscess widely. Drain the pus
and take
a specimen for bacteriological examination. Pack the cavity with petroleum
or saline soaked gauze and apply an external gauze dressing. |
HAEMATOCOLPOS
Haematocolpos occurs in cases of imperforate hymen, but may also present
in cases of vulval stenosis resulting from exposure to irritant substances
or from infection, trauma or dystrophy. The latter are best referred for
specialized treatment.
The patient complains of amenorrhoea with cyclical abdominal pain or acute
retention of urine. Examination reveals a mass in the lower abdomen that
is dull to percussion. This is the distended vagina with the uterus on top.
Differential diagnosis includes:
| :: |
Pregnancy |
| :: |
Tuberculous
peritonitis |
| :: |
Pelvic
kidney |
| :: |
Ovarian
cyst. |
Technique
Treat haematocolpos due to imperforate hymen surgically with
incision and drainage under a general or regional anaesthetic.
| 1 |
With
the patient in the lithotomy position, clean and drape
the perineum. |
| 2 |
Make
an incision over the bulging membrane. Evert the edges
of the wound and stitch them to the adjacent vaginal
tissue with interrupted sutures of 2/0 absorbable suture
(Figures 9.61, 9.62). |
|
|
| 3 |
Allow
the blood to drain and apply a sterile pad. Administer
antibiotics for 48 hours. |
| 4 |
Avoid
vaginal examination for 1–2 months after the operation. |
Complications
Complications include:
| :: |
Salpingitis |
| :: |
Peritonitis. |
MALE PERINEAL INFECTIONS
Fournier’s gangrene
Fournier’s gangrene is a necrotizing fasciitis of perineal areas most
commonly affecting the scrotum of adults. The source of infection is the
genitourinary or gastrointestinal tract with E. coli as the predominant aerobe
and Bacteroides as the predominant anaerobe.
Urethral obstruction is a frequently associated urinary sepsis. Patients
present with scrotal swelling and with pain out of proportion to the physical
findings. A feculant odour may be present. The scrotal skin may be normal
but is
usually discoloured and oedematous. If black areas develop, trans-scrotal
necrosis may ensue. Gas gangrene is unusual. Systemic findings are fever, dehydration
and tachycardia.
Treatment
Treat with systemic broad spectrum antibiotics, fluid resuscitation, tetanus
prophylaxis and complete surgical debridement, which may need to be extensive.
Perform multiple daily debridements, as required, to remove all necrotic tissue.
Uncontrolled sepsis may lead to death, but the prognosis is generally good.
The scrotum has a great ability to heal by secondary intention. Use skin
grafts to cover healthy granulation tissue.
Periurethral abscesses
Infections of the male periurethral glands secondary to gonococcal urethritis or
urethral stricture may lead to abscess formation.
Treatment
Treat with antibiotics and drainage. Needle aspiration may be sufficient
in small gonococcal abscesses. Use suprapubic urinary diversion for large
abscesses and for urinary fistula.
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Female genital mutilation:
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Acute
complications include:
– Haemorrhage
– Shock
– Urinary retention
– Damage to the urethra and anus
– Cellulitis
– Abscesses
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Chronic
complications include:
– Sexual dysfunction
– Psychological disturbance
– Urinary obstruction
– Keloids
– Large epidermal inclusion
cysts
– Difficult micturation
– Vaginal stenosis, which can cause obstructed labour,
often complicated by vesical
or rectal vaginal fistulae.
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