Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Stomac and duodenum
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
The Perineum


Injuries result from unintentional trauma, sexual assault and, in some regions, female genital mutilation.


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 include:

1 Infection
2 Haematoma in the parametrium
3 Rectovaginal fistula
4 Dyspareunia.

These can be prevented by proper haemostatis and laceration repair.

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 (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.


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.


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.


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
2 Make a longitudinal incision in the most prominent part of the abscess at
the junction of the vulva and vagina (Figure 9.60).
Figure 9.60
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 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.


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).
Figure 9.61
Figure 9.61

Figure 9.62
Figure 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 include:

:: Salpingitis
:: Peritonitis.


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.


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.


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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  Kep Points  
Female genital mutilation:
Acute complications include:
– Haemorrhage
– Shock
– Urinary retention
– Damage to the urethra and anus
– Cellulitis
– Abscesses

Chronic complications include:
– Sexual dysfunction
– Psychological disturbance
– Urinary obstruction
– Keloids
– Large epidermal inclusion
– Difficult micturation
– Vaginal stenosis, which can cause obstructed labour,
often complicated by vesical
or rectal vaginal fistulae.