Nonobstetric vaginal trauma can span a continuum of severity from minor trauma resulting from normal sexual intercourse to major vaginal lacerations. The true incidences of such injuries are difficult to ascertain, especially because the nature of vaginal injury usually remains undisclosed. Many cases resolve without medical intervention, but severe lacerations sometimes require hospitalization and may be fatal.
2 Geist
3 reported that up to 75% of women in the emergency department with vaginal lacerations require repair. According to Geist's review,
3 these patients usually have marked vaginal bleeding (80%) and perineal and/or lower abdominal pain (10%–20%). Hemorrhagic shock may be present in up to 15% of the cases. The lacerations tend to be 3 to 5 cm long and are usually located in the distal vagina. They are more commonly located posteriorly and to the right. Lacerations extending into the peritoneal cavity occur in less than 1% of patients.
3
The most common mechanism of nonobstetric injury to the vagina is coitus.
4 Predisposing and etiologic factors that can account for such injuries include virginity, disproportion of male and female genitalia, atrophic vagina in post-menopausal women, friability of tissues, stenosis and scarring of the vagina because of congenital abnormalities, previous surgery, or pelvic radiation therapy. Other factors include rough and violent thrusting of the penis during intercourse, insertion of foreign bodies, and sexual assault. Coital positioning, especially in cases of dorsal decubitus, with hyper-flexion of the thighs and sitting positions have also been suggested as predisposing factors.
1,5–7 Women with significant coital injuries may present late and with significant blood loss. This delay may be due to embarrassment because of the nature and cause of injuries or fear of spousal or parental knowledge. Partner abuse should be considered as a cause of injury and appropriately evaluated.
1
Noncoital reproductive tract injuries often occur in the setting of multiple severe injuries and usually require operative intervention.
4,5 Vaginal lacerations may be a consequence of blunt or penetrating abdominal trauma, particularly as a result of pelvic fractures.
5 Vaginal lacerations have also been reported in association with injuries sustained while in straddle and astride positions.
4,5 Straddle injuries are more common in small children and are usually limited to the lower vagina.
4 Genital tract injuries have been reported in association with water sports such as water-skiing and jet-skiing.
8 These injuries can range from vulvar hematomas to minor vaginal lacerations to life-threatening vaginal bleeding. Such injuries are also usually limited to the lower vagina.
5
The spatial orientation of the cervix to the long axis of the vagina predisposes the posterior fornix to injuries, especially during coitus.
1,2,9,10 Dickinson
9 pointed out the relative weakness in the structure of the posterior fornix, which is supported by only a few bundles of connective tissue. The right fornix is also prone to injury because of slight variations of the uterocervical axis.
1,10 One report even suggests the possibility of tears in these structures resulting from levator muscle spasms in addition to direct injury.
6