A

Project on

Injuries of Vaginal Tract

Submitted by

Muhammad Abdul Saquib

for the partial fulfillment of practical exams of

BUMS Final Prof. Gynaecology

Under the guidance of

DR. AYSHA RAZA (MD)

Associate professor, Maternity Incharge

Head of Department of Gynaecology and obstetrics
 GOVT. OF NCT OF DELHI
DEPARTMENT OF GYNAECOLOGY AND OBSTETRICS
AYURVEDIC & UNANI TIBBIA COLLEGE & HOSPITAL
AJMAL KHAN ROAD, KAROL BAGH, NEW DELHI-110005

CERTIFICATE

This is to certify that this assignment entitled “Injuries of Vaginal

tract” prepared by Muhammad abdul Saquib is a bonafide work done by him

under my supervision for the partial fulfillment of practical exams of BUMS

final Prof. in the subject of Gynaecology.

Signature

(Dr. Aysha Raza )

HOD
Dept. of gynae & Obs
A & & Tibbia College & Hospital,
Karol Bagh, New Delhi 110005
 GOVT. OF NCT OF DELHI
DEPARTMENT OF GYNAECOLOGY AND OBSTETRICS
AYURVEDIC & UNANI TIBBIA COLLEGE & HOSPITAL
AJMAL KHAN ROAD, KAROL BAGH, NEW DELHI-110005

CERTIFICATE

This is to certify that this assignment entitled “Injuries of vaginal tract” prepared by
me is under the supervision of Dr. Aysha raza (HOD) for the partial fulfillment
of practical exams of BUMS Final Prof. in the subject of Gynaecologyt.

Muhammad Abdul Saquib

Student
BUMS final Prof.
A & & Tibbia College &
Hospital, Karol Bagh, New
Delhi 110005
 Injuries Of Vaginal Tract
History of studying genital trauma
Doctors and nurses have been conducting sexual assault

examinations and have been collecting evidence for victims of assault for 20

years. But the amount of scientific data collected on genital injuries

post-sexual assault are still minimal. Therefore, there is no available

evidence to show specific patterns of injury resulting from sexual assault. The

motivation for investigating and collecting data on genital injuries has

primarily been within the context of the legal system, such as proving or

d i s p r o vi n g s e xu a l a s s a u l t , r a t h e r t h a n f o r m e d i c a l p u r p o s e s .

The studies that have been done in the past 25 years in relation to

sexual assault cases in the judicial system has laid the groundwork for

interpreting sexual assault injuries. It is important for there to research on

genital injuries more broadly relating to sexual activity (and not just sexual

assault) to improve medical knowledge on the subject. Methods of studying

and documenting genital injury has greatly improved through the use of

tissue staining dyes and colposcopy. The first studies that used newer

methods were retrospective chart reviews done in a hospital by a doctor or

nurse. These studies used several different methods to identify and

document injuries, such as direct visualization, colposcopy, and/or tissue

staining dyes. Earlier studies only used direct visualization for their data
Vaginal trauma from consensual and

non-consensual intercourse

Vaginal trauma is possible during and after consensual and

non-consensual intercourse so it is difficult to determine the circumstances in

which the trauma occurs only based on a physical examination. It can be

difficult to differentiate between injuries from consensual sex and injuries

f r o m s e x u a l a s s a u l t i n a d o l e s c e n t s .

Women are three times more likely to have vaginal injuries

and intercourse-related injuries from a forced assault than from a consensual

s e x u a l e x p e r i e n c e .

Vaginal lacerations that happen during consensual or non consensual

intercourse might need surgery, but victims of a forced assault will need

additional services such as police intervention and trauma counseling.[2]

There is little research on minor injuries in adult, pre-menopausal women,

adolescent girls, and post-menopausal women that do not require surgery or

t r e a t m e n t .

Why does vaginal trauma occur?

There are factors that can predispose women to vaginal injury during

consensual sex. These things include: first sexual experience, pregnancy,

vigorous penetration, vaginal atrophy and spasm, previous operation or

radiation therapy, disproportionate genitalia, penile ornamentation, and

congenital anomalies.

During vaginal intercourse in the missionary position with legs tilted all

the way back, the penis reaches its deepest penetration and the extreme

rotation of the uterus leads to hyper distention of the vaginal wall, which in

some cases can cause it to rupture.

This position is the most likely position for vaginal laceration. The

vaginal wall on the right side is the most commonly torn site in this

position.Vaginal lengthening and lubrication usually occurs naturally in a

consensual sexual situation.

Vaginal tearing can occur in rape victims because those two things will

not occur. This is consistent with the fact that more injuries result from sexual

assault than from consensual intercourse.An inability to produce adequate

vaginal lubrication and dilatation is thought to be an underlying cause of

severe tears in the upper area of the vagina

.

Types of vaginal trauma:

Intercourse-related lacerations can range from superficial tears to

more severe lacerations, tears rarely extend into the rectal lumen and the

peritoneal cavity.

Recto-vaginal injuries are usually a result of assault with a foreign

object, rape, or accidental gynecologic injury. Injuries of this severity that

resulted from consensual sex are very rare.

Posterior and right vaginal fornix lacerations have been known to

occur during consensual vaginal intercourse. The location of these

lacerations is usually based on a woman's reproductive anatomy. It is

common for women to have a uterus that lies slightly to the right, this

exposes the right fornix and makes it easier for some type of tearing or

trauma to occur.

Lacerations to the posterior peri-cervical vagina tend to occur in the

missionary position, hips and legs hyperflexed. Other positions can also

expose the posterior vaginal wall that usually protected by the cervix, this

allows for posterior fornix tears. Tears in the upper area of the vagina are

more often reported in consensual intercourse than forced intercourse.

Complications from severe vaginal lacerations, such as from an

as s a u lt , can in c lud e h e m o p e ri to n e u m , p n e u m o p e rit o n e u m , and

retroperitoneal hematoma with or without vaginal perforation. Tears along the

long axis of the vagina or the posterior fourchette lacerations are more likely

to occur from rape. Lacerations or tears of the hymen are common but are

not indicative of consensual or non-consensual intercourse

.

EXAMNINATION:
A pelvic examination is the physical examination of the external and

internal female pelvic organs.It is frequently used in gynecology for the

evaluation of symptoms affecting the female reproductive and urinary tract,

such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g.

sexual assault).

It can also be used to assess a woman's anatomy in preparation for

procedures. The exam can be done awake in the clinic and emergency

department, or under anesthesia in the operating room.

The most commonly performed components of the exam are

1) the external exam, to evaluate the vulva

2) the internal exam with palpation (commonly called the bimanual exam) to

examine the uterus, ovaries, and structures adjacent to the uterus (adnexae)

3) the internal exam using a speculum to visualize the vaginal walls and

cervix.

4) During the pelvic exam, sample of cells and fluids may be collected to

screen for sexually transmitted infections or cancer (the Pap test)

.

Preparation, communication, and trauma-informed care

The examination can be emotionally and physically uncomfortable for

women. Preparation, good communication, thoughtful technique, and

trauma-informed care can help mitigate this discomfort.

Prior to the exam, before the patient is undressed and lying on the

examination table or chair, examiners should ask the patient if she has had a

pelvic exam in the past and whether she has any questions or concerns
about the exam.

Women may be concerned about pain, or they may be

embarrassed about the examination of sensitive areas of the body. They may

have experienced sexual assault or negative experiences with pelvic

examination in the past, which may lead to the exam triggering strong

emotional and physical symptoms.Additionally, patients may have concern

about odor or menstruation during exam, neither of which should impact the

examiner's ability to perform a thorough, respectful exam.

Patients generally

prefer to be asked about past experiences and are often helpful in suggesting

ways to mitigate the discomfort of the exam.Prior to the exam, the examiner

should offer to show the patient models or diagrams of the pelvic anatomy

and any instruments that will be used during the exam.

Careful preparation is helpful for an efficient and comfortable exam.

Prior to asking the patient to position herself on the exam table or chair for

examination, the examiner should collect all the instruments needed for the

exam and any planned procedures, including the speculum, light source,

lubricant, gloves, drapes, and specimen collection media. Warming the

speculum with warm tap water or keeping the speculum in a warmer will also

increase comfort. The patient should be given the opportunity to have a

chaperone or support person in the room during the exam. In general, male

examiners should always be accompanied by a female chaperone.

The examiner should explain each step of the exam and its

purpose, should address and normalize any concerns, should assert that the
patient has full control over the exam, and should ask permission before

each step of the exam. The examiner should keep as much of the patient's

body covered as possible during the exam. Relaxation of the pelvic muscles

can reduce discomfort during the exam. Rather than telling the patient to

"relax", which can trigger strong emotions for women who are survivors of

assault, patients can be told to breathe slowly and deeply into their

abdomens, or which is a more instructive way of describing how to relax the

pelvic muscles.

The patient should be informed that she can stop the procedure at

any time. If the patient does not want to continue the exam, the examiner

should stop, speak with the patient about her concerns and how to mitigate

them, and only continue when the patient is ready to do so. However, in all

but seven states in the United States, it is legal for pelvic exams to be done

under anesthesia without the patient's consent.

External Examination:
The pelvic exam begins with a discussion as described above, and an

explanation of the procedure. The patient is asked to put on an examination

gown, get on the examination table, and lie on her back with her feet in

footrests. Sliding down toward the end of the table is the best position for the

clinician to do a visual examination. A pelvic exam begins with an

assessment of the reproductive organs that can be seen without the use of a

speculum. Many women may want to 'prepare' for the procedure. One

possible reason for delaying an exam is if it is to be done during

menstruation, but this is a preference of some patients and not a requirement

of the clinician. The clinician may want to perform pelvic examination and

assessment of the vagina because there are unexplained symptoms of

vaginal discharge, pelvic pain, unexpected bleeding, or urinary problems.

The typical external examination begins with making sure that the patient is

in a comfortable position and her privacy respected.

In some instances, different positioning and assistance may be

required to keep tissue from blocking the view of the perineal area.

The pubic hair is inspected for pubic lice and hair growth patterns.

Sparse hair patterns can exist in older and in some Asian patients.

The labia majora are evaluated. Their position and symmetry are assessed.

The expected finding in older patients is that the labia majora can be thinner

and smaller.

The examiner is looking for ulcers, inflammation, warts and rashes.

If drainage is present from these structures, its color, location and other

characteristics are noted. Infection control is accomplished by frequent glove

changes.

The labia minora are then evaluated. They should appear moist,

smooth in texture and pink. The presence of tearing, inflammation and

swelling is noted. Thinner and smaller labia minora are an expected finding in

older patients.
 The clitoris is assessed for size, position, symmetry, and

inflammation.The urethral opening is inspected. No urine should leak when

the patient is asked to cough. Urine leakage may indicate stress incontinence

and the weakening of pelvic structures. The opening should be midline, pink,

and smooth. The presence of inflammation or discharge may indicate an

infection. Excoriation can be present in obese patients due to urinary

incontinence.

The vaginal opening is inspected for position, presence of the

hymen, and shape. The examiner should look for the presence of bruising,

tearing, inflammation and discharge. Pelvic examinations are usually

procedures that are designed to obtain objective, measurable descriptions of

what is observed. If sexual abuse is suspected, questions regarding this are

discussed after the examination and not during it. When the patient is

requested to 'bear down', the presence of prolapsed structures such as the

bladder (cystocele), rectum (rectocele) or uterus are documented. Prolapsed

structures can appear when abdominal pressure increases or they can

protrude without bearing down.

The perineum, the space between the vagina and the anus, is

inspected. It should be smooth, firm, and free of disease. Scars from

episiotomies are visible on women who have had the procedure during

childbirth.

The anus is assessed for lesions, inflammation or trauma. It should

appear dark, continuous and moist. In some patients, excoriation may be

present, and can be a sign of fecal incontinence.

Internal examination
Before inserting the speculum, the vaginal wall, urethra, Skene's

glands and Bartholin's glands are palpated through the vaginal wall. During

the internal exam, the examiner describes the procedure while doing the

assessment, making sure that the patient can anticipate where she will feel

the palpations.

The patient is first informed that the examiner will insert their finger

into the vagina. The palpation of the vagina is done by evaluating the

condition of the vaginal walls. These should feel smooth, consistent and soft.

The rugae can also be assessed by palpation.

The patient is again asked to bear down while the examiner

continues the internal examination. The presence of bulging is assessed.[20]

The position of the urethra is assessed by palpation with a finger through the

vaginal wall.

The Skene's glands, located on each side of the urethra, are

palpated to produce secretion from the glands.

The Bartholin glands are also

assessed internally by gently squeezing them with one finger placed

externally, on the posterior labia majora and the other finger in the vagina.

At this point of the pelvic exam, the examiner will insert the speculum to

visualize other internal structures: the cervix, uterus, and ovaries.[20][21] If

this is the first pelvic exam of the patient, the examiner will show the

speculum to the patient, explain its use and answer any questions.

The appropriate sized speculum is selected.

The speculum is slowly inserted in its collapsed state at a 45

degree angle to match the slope of the vagina. The blades are then

expanded until the cervix comes into view.

If the speculum is transparent, the

vaginal walls can be seen.

The cervix is then assessed. It should look moist, round, pink, and

centered to the middle. The secretions of the cervix should be clear or whitish

with no odor. The presence or absence of polyps, ulcers, and inflammation

are noted.

A swab or cytobrush will be used to collect or scrape cervical cells off

of the surface of the cervix to be evaluated for changes. Other vaginal swabs

can be taken at this time to test for sexually transmitted infections.

Bimanual examination
The bimanual component of the pelvic examination allows the

examiner to feel ("palpate" in medical terms) the structures of the pelvis,

including the vagina, cervix, uterus, and adnexae (structures adjacent to the

uterus, which include the ovaries and any adnexal masses).

The bimanual

exam traditionally occurs after the speculum is removed. The examiner

explains this part of the exam.

From a standing position, the examiner typically applies lubricant to

the fingers of the glove of their dominant hand, and the index finger or index

finger and middle finger are gently inserted into the vagina. The examiner's

opposite hand is place on the patient's abdomen to allow palpation of the

pelvic structures; thus the exam is termed a "bimanual: examination".

A systematic exam of the pelvic structures allows an assessment of

the vaginal introitus (opening), pelvic floor muscles, bladder, rectum, cervix,

and the area posterior to the uterus; this portion of the exam is particularly

helpful for individuals with pelvic pain, as it allows an assessment of

tenderness and an anatomic source of pain.

In assessing the uterus,

elevation of cervix with the vaginal hand allows palpation of the uterus above

the pubic symphysis with the opposite hand, and the size, shape, mobility,

contour, consistency, and position of the uterus can be determined.

Observing the patient's face during this exam can provide

information about the additional characteristic of uterine tenderness, and the

patient can also provide verbal feedback. The adnexal structures are similarly

palpated, noting any enlargement of the ovaries and if present, the size,

shape, mobility, consistency, and tenderness of ovarian/adnexal masses.

Normally Fallopian tubes are not palpable.

An additional component of the pelvic examination may include recto-vaginal

examination.The examiner puts on a clean glove, and using sufficient

lubricant, places the index finger within the vagina and the middle finger

within the rectum. This component of the exam assesses rectal tone and

lesions such as hemorrhoids, anal fissures, rectal polyps, or masses

including carcinoma. It also allows palpation of the recto-vaginal septum, the

intra-abdominal area posterior to the uterus (the cul-de-sac or pouch of

Douglas), and the adnexal.Nodularity posterior to the uterus along the

uterosacral ligaments has been associated with pelvic endometriosis as well

as implants of ovarian cancer.

After completion of the exam, the examiner discards their gloves, washes

their hands, assists the patient in sitting up, and describes their findings on

the examination.

Treatment of vaginal trauma

Diagnosing and treating vaginal trauma can often be difficult and

delayed due to the sensitive and personal nature of these types of injuries;

this also may be enhanced if the patient is young in age. The repair of most

genital injuries require suture and the bleeding from the area is usually

m inima l. The bleeding that results from extreme vaginal tears can be

copious, leading to hemorrhagic shock, and the patient may need a blood

transfusion. Treatment of these lacerations could warrant surgical repair.

Vulvar trauma
 Vulvar trauma is more common in prepubertal children due to small

labial fat pads and more physical activity. Adults are more protected. Though

some injuries are serious, most are accidental minor blunt traumas. The most

common type of injury is a straddle injury, which can be incurred through

normal activities like bicycle riding.

Due to the vascularity of the vulva, it may form a large hematoma

when injured. The vulva can also be injured through sexual assault. Vulvar

trauma can occur concurrently with vaginal trauma, especially if a sharp

object is involved
.

Vaginal trauma
Vaginal trauma can occur when something is inserted into the

vagina, for example, a sharp object, causing penetrating trauma. Vaginal

trauma can occur as a result as an initial painful sexual experience or sexual

abuse. Vaginal trauma can occur in children as a result of a straddle injury.

Most of these, though distressing, are not serious injuries.

In some instances a severe injury occurs and requires immediate

medical attention especially if the bleeding will not stop. Vaginal trauma

occurs during an episiotomy.