Pediatric Vulvar Hematoma: Surgical Management and Developmental Considerations: Two Case Reports

Hye Mi Lee; Ryang Woo Lee; Eun Jung Jang; Young Cheon Na

doi:10.22467/jwmr.2026.03496

Abstract

Pediatric vulvar hematoma typically results from straddle-type injuries and is usually managed with nonoperative measures. However, rapid progression and the risk of complications in some cases, including tissue necrosis, infection, and urinary retention, necessitate surgical intervention. The highly vascularized anatomy of the vulva allows for rapid hematoma expansion, requiring careful assessment of hematoma size, progression, functional impairment, and hemodynamic stability when determining the treatment strategy. In addition, genital trauma during developmental periods can influence self-perception and psychosexual development, making timely intervention important to prevent aesthetic and functional sequelae. We present two pediatric patients with vulvar hematoma who underwent successful surgical treatment following careful evaluation of both physical and psychological factors. This report emphasizes the importance of a comprehensive, multifaceted approach to the management of pediatric vulvar hematomas.

Key Words: Hematoma; Pediatrics; Psychosexual development; Vulva; Case reports

Introduction

Vulvar hematoma is commonly observed following accidental genital trauma resulting from straddle-type injuries in children and adolescents and is managed conservatively in most cases [1,2]. Clinical manifestations vary depending on hematoma size. Perineal pain is the most common symptom, but abdominal or buttock pain, a rapidly enlarging vulvar mass, difficulty in walking, and urinary symptoms such as urinary retention may also arise [1,2]. Rapidly progressing hematomas can lead to complications including hemodynamic instability, soft tissue necrosis, and secondary infection [2,3].

The female external genitalia serve important functional, aesthetic, and psychological roles [4-8]. When complications emerge during adolescence, they may negatively affect genital self-image and psychosexual adaptation [4-7]. Accordingly, injuries to this region during childhood or adolescence—and the resulting morphological or functional changes—can significantly influence long-term quality of life [4-9]. Given these considerations, careful evaluation of hematoma size, progression, associated functional impairment, and the patient’s overall condition is essential when determining the optimal management strategy [2]. This report describes the successful surgical treatment of two pediatric patients with vulvar hematomas following straddle-type injury and highlights key considerations in the management of vulvar hematomas in children with accidental genital trauma.

This study was approved by the Institutional Review Board of Wonkwang University Hospital (IRB No. 2025-12-034), and informed consent for publication was obtained from the patients and their guardians in both cases.

Cases

Case 1: a large, rapidly expanding vulvar hematoma

A 12-year-old girl with no significant medical history presented to the emergency department with genital trauma after sustaining a straddle-type injury while using exercise equipment. She was initially examined at a local hospital, where swelling on the left labia majora was noted. Vulvar hematoma was diagnosed, and incision and drainage were performed. Persistent bleeding and progressive swelling at the incision site made subsequent Foley catheter insertion difficult. Computed tomography (CT) displayed a hematoma measuring 9.5×5.4×

5.5 cm (Fig. 1). Laboratory evaluation displayed a hemoglobin level of 11.0 g/dL. Emergent hematoma evacuation was performed under general anesthesia. TachoSil (human fibrinogen/thrombin; Takeda) and an M-vac (Hemovac; Moohan) drain were applied to achieve hemostasis, and layered closure was performed using #4-0 Vicryl and #4-0 Ethilon sutures. The operation was completed successfully. Topical ointment (Fucidin, fusidic acid; Dongwha) and foam dressing (Renofoam; T&L) were applied to the surgical site (Fig. 2). In the postoperative hospitalization period, the patient maintained a frog-leg position as instructed to prevent postoperative maceration. By postoperative day (POD) 8, vulvar swelling had gradually improved and the wound discharge had become clear, allowing transition to open dressings with topical ointment only. The Foley catheter was removed on the same day. Prophylactic antibiotics were administered until POD 10 (Fig. 3). Sutures were removed on POD 14 and the patient was discharged without complications. At follow-up on POD 19, the postoperative wound demonstrated satisfactory healing without signs of recurrence, infection, or necrosis.

Case 2: a case presenting with hemodynamic instability

A 10-year-old girl with a history of attention deficit hyperactivity disorder presented to a local hospital with labia majora swelling after falling approximately 3 m from a jungle gym. The patient was initially managed conservatively with Foley catheter insertion, however, she developed hypotension accompanied by mental status deterioration (systolic blood pressure 75 mmHg, diastolic blood pressure 41 mmHg; heart rate 70 beats/min) during hospitalization, and her hemoglobin level decreased to 8.3 g/dL. CT imaging demonstrated a hematoma measuring 8.1×5.2×2.5 cm. The patient received one unit of packed red blood cells. Ten hours after transfusion, her mental status improved to “alert” and her vital signs stabilized (blood pressure 110/80 mmHg, heart rate 95 beats/min). However, despite stabilization of her general status, the vulvar lesion showed no clinical improvement (Fig. 4). Discoloration of the overlying skin with clot protrusion was noted, suggesting a pressure-induced compartment effect. The patient was therefore transferred to the department of plastic and reconstructive surgery for further evaluation and management. Emergent hematoma evacuation under general anesthesia was planned. During surgery, TachoSil and an M-vac drain were applied to the wound to achieve hemostasis, and layered suturing was performed using #5-0 Vicryl and #5-0 Nylon sutures. Surgical evacuation was completed without complications (Fig. 5). Postoperative dressings were maintained with topical ointment and foam (Medifoam; Genewel) dressings. After confirmation of adequate hemostasis, adjuvant alprostadil was administered (Alostin; DongKook) to promote tissue perfusion and reduce risk of flap necrosis and wound dehiscence. A total daily dose of 5 μg was diluted in 100 mL of normal saline and infused at a rate of 50 mL/hr for 2 hours. Postoperatively, the patient was able to maintain the frog-leg position as instructed. However, she showed limited engagement during rounds and exhibited avoidant behavior during clinical consultations. By POD 6, swelling had subsided and wound discharge decreased, allowing transition to open dressings with topical ointment only. The Foley catheter was removed on the same day. Prophylactic antibiotics were administered until POD 12, and suture removal was performed on POD 13. At a 1-month follow-up, the patient demonstrated improved participation in clinical care compared to during hospitalization and responded appropriately during clinical interviews. The postoperative wound showed complete healing without evidence of recurrence, surgical site infection, or wound necrosis (Fig. 6).

Discussion

Vulvar hematomas can arise from various etiologies, including accidental straddle injuries, foreign-body or penetrating trauma, sexual assault, postoperative complications, and spontaneous rupture of a vulvar vessel [1-3]. Anatomically, the female external genitalia consist of multiple structures embedded within a confined space [10]. The rich pudendal arterial supply and the loose connective tissue of the perineum facilitate rapid hematoma expansion after trauma, allowing blood to dissect along soft tissue planes and increase hematoma size [11]. Therefore, an expanding vulvar hematoma may compress adjacent tissues, leading to skin and soft tissue ischemia or necrosis, wound infection, and urologic complications [9,12].

Physical examination should include an evaluation for vulvar swelling, bleeding, associated genital lacerations, and in cases of high-energy trauma, an evaluation for pelvic fractures [1,12]. Checking vital signs and complete blood count are essential to detect concealed bleeding or hemodynamic instability [2,12]. Ultrasonography, CT, and magnetic resonance imaging can be used to evaluate the size of the hematoma and associated injuries [2,8]. Past medical history should include evaluation for underlying bleeding tendencies, such as von Willebrand disease, platelet dysfunction, connective tissue disorders, and anticoagulant use [12].

Management depends on the size of the hematoma and the severity of functional impairment [2,8]. Most stable hematomas improve with conservative treatment, including ice packs, compression, and analgesics [2]. Large hematomas may require long-term observation, blood transfusion or intravenous antibiotics. Surgical intervention is indicated if the hematoma is rapidly growing, larger than 4 cm, or is accompanied by hemodynamic instability or urological or neurological symptoms [2,8]. Surgical treatment includes incision and drainage, evacuation of the hematoma, ligation of the bleeding vessels, and exploratory examination for combined injuries.

Complications of vulvar hematoma include pressure-induced ischemia, soft tissue necrosis, chronic pain, and adhesions [4-7,9]. Alprostadil (prostaglandin E₁, PGE₁) has vasodilatory and microcirculatory effects that may support tissue perfusion in ischemic conditions. It is therefore expected to have a preventive effect against skin necrosis in cases of pressure-induced ischemia of the skin after hematoma evacuation. Owing to the anatomical characteristics of the vulva, surgical site infection may also occur following hematoma evacuation [2,4-7]. In addition, the perineal anatomy predisposes this region to wound infection, which may result in secondary complications such as excessive scarring, adhesions, and sexual dysfunction [2,3,5,12]. Early debridement of infected or necrotic tissue and appropriate reconstruction are necessary to prevent these sequelae. Preservation of labial contour and prevention of deformation of the urethral and vaginal openings are essential surgical objectives.

Pediatric vulvar trauma is not solely a physical injury; it also requires careful consideration of developmental and psychological factors unique to children and adolescents [4-7,12]. Body self-image begins to form in late childhood and becomes particularly sensitive during puberty, when gender identity, autonomy, and awareness of genital appearance further develop [4,6,7]. Genital trauma during this period may therefore result in psychological distress, and the examination process itself can exacerbate patient anxiety [4,6,7,12].

Given these potential psychological consequences, current recommendations emphasize a multifaceted approach to the evaluation of pediatric genital trauma. Age-appropriate explanations should be provided, and assent or consent obtained when possible, with examinations following a systematic, stepwise protocol, minimizing bodily exposure. Physical restraint should be avoided during assessment [12-14]. When significant anxiety or limited cooperation is anticipated, conscious sedation or general anesthesia may be appropriate [15]. Psychologically non-threatening positions, such as the frog-leg or knee–chest position with gentle labial traction, can allow adequate visualization while minimizing discomfort [12]. To reduce psychological stress associated with repeated examinations, assessment by a single experienced clinician is recommended whenever feasible [12,14].

The two cases presented here demonstrated favorable clinical outcomes following appropriate surgical management and an approach that considered the psychological characteristics of pediatric patients. Nevertheless, several limitations were identified during the evaluation and follow-up process [5,7]. Notably, no systematic assessment of genital body image was performed at key clinical time points from the initial injury to the postoperative outpatient follow-up. As a result, systemic education and formal evaluation aimed at promoting a healthy genital body image were not possible. Neither were psychological stressors before and after treatment formally assessed. Furthermore, the lack of a control cohort managed via conservative treatment precluded an objective assessment of the long-term, multifaceted sequelae associated with this injury. Future studies should incorporate structured assessment tools, targeted sexual self-image education, and formal psychological support [4,5,7]. Despite these limitations, the present cases illustrate the clinical presentation and course of vulvar hematomas requiring surgical intervention while underscoring the importance of careful examination and vigilant monitoring. These findings suggest that clinicians should consider the multifaceted aspects of pediatric vulvar trauma, particularly factors that may be overlooked during routine clinical evaluation.

These cases also demonstrate that while the majority of pediatric vulvar hematomas respond well to conservative management, rapidly expanding lesions or those complicated by hemodynamic compromise necessitate prompt surgical intervention [1,2]. Early intervention can limit hematoma progression, reduce the risk of complications, and mitigate potential long-term psychosocial sequelae [4-7,12]. Optimal management of pediatric vulvar trauma therefore requires a comprehensive approach that integrates careful physical and psychological assessment, appropriate imaging, and an individualized treatment strategy.