Abstract

Although obstetrically related trauma remains the most common cause of injury to the female
genital tract, trauma of nonobstetric origin is not uncommon. Reports of traumatic injuries to the
vagina, especially lacerations, have been infrequent in the literature and offer only a generalized
approach to this problem. Severe vaginal lacerations may result in life-threatening blood loss.
The authors report their recent experience with treating patients who have this type of trauma,
review mechanisms of injury, and provide an organized treatment protocol for the nonobstetric
patient with suspected vaginal laceration. Preparation for these emergencies circumvents
dangerous delays and inadequate examination and treatment.
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Nonobstetric vaginal lacerations differ greatly from lacerations sustained during childbirth and
are generally classified into two types. The first type is relatively minor and is associated with
normal sexual intercourse or the first experience of sexual intercourse.1 These lacerations usually
resolve with minimal treatment. The second type of laceration is deeper and more extensive,
often resulting in copious vaginal bleeding. This condition can be life threatening and requires
immediate intervention.
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Case Series
While severe vaginal lacerations are commonly encountered by physicians, they are infrequently
reported in the literature. In addition, there is a lack of an organized treatment protocol for such
patients. During the past few years, we have treated four patients with severe vaginal injury with
profuse bleeding, and two of these patients had severe hypovolemic shock on initial examination.
After obtaining institutional review board approval, we reviewed the cases and developed an
organized treatment protocol for the nonobstetric patient with suspected vaginal laceration.

Case 1
A 28-year-old, gravida (G) 2, para (P) 2 woman had a deep right sulcus laceration that extended
from the right lateral fornix all the way to the hymenal ring. The laceration was about 6 cm long
and extended deep into the ischiorectal fossa. The patient also had a deep left sulcus laceration
about 4 cm long, extending from the hymenal ring to three quarters of the way toward the left
fornix. She had a few minor lacerations and abrasions as well. It was later discovered that her
husband had physically and sexually abused her.

Case 2
A 20-year-old woman (G0) had a spiral-shaped laceration that extended from the cervix at the 3o'clock position to the posterior fornix on the right and spiraled distally to terminate at the 10o'clock position, about 1 cm proximal to the hymenal ring. It was later determined that her

boyfriend had abused her by repeatedly inserting a metal pipe into her vagina. She revealed a
history of sexual and physical abuse by the same boyfriend.

Case 3
The third patient was a 20-year-old woman (G3, P3) who had sustained a right posterolateral
laceration approximately 3 cm long. She stated that she and her partner had regular sexual
intercourse earlier that night and that she woke up with the bed full of blood.

Case 4
Our fourth patient, a 20-year-old woman (G2, P2), had a posterior fornix laceration that was
approximately 4 cm long and toward the right, with an underlying hematoma. Her injury had
reportedly occurred immediately after intercourse.
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 Geist3 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.1,57 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
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 Dickinson9 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

Although legal and medical definitions vary, rape is typically defined as oral, anal, or vaginal
penetration that involves threats or force against an unwilling person. Such penetration, whether
wanted or not, is considered statutory rape if victims are younger than the age of consent. Sexual
assault is rape or any other sexual contact that results from coercion, including seduction of a
child through offers of affection or bribes; it also includes being touched, grabbed, kissed, or
shown genitals. Rape and sexual assault, including childhood sexual assault, are common; the
lifetime prevalence estimates for both ranges from 2 to 30% but tends to be about 15 to 20%.
However, actual prevalence may be higher because rape and sexual assault tend to be
underreported.
Typically, rape is an expression of aggression, anger, or need for power; psychologically, it is
more violent than sexual. Nongenital or genital injury occurs in about 50% of rapes of females.
Females are raped and sexually assaulted more often than males. Male rape is often committed
by another man, often in prison. Males who are raped are more likely than females to be
physically injured, to be unwilling to report the crime, and to have multiple assailants.

Symptoms and Signs

Rape may result in the following:

Extragenital injury
Genital injury

Psychologic symptoms

Sexually transmitted diseases (STDseg, hepatitis, syphilis, gonorrhea,

chlamydial infection, trichomoniasis, HIV infection [rarely])

Pregnancy (uncommonly)

Most physical injuries are relatively minor, but some lacerations of the upper vagina are severe.
Additional injuries may result from being struck, pushed, stabbed, or shot.

Psychologic symptoms of rape are potentially the most prominent. In the short term, most
patients experience fear, nightmares, sleep problems, anger, embarrassment, shame, guilt, or a
combination. Immediately after an assault, patient behavior can range from talkativeness,
tenseness, crying, and trembling to shock and disbelief with dispassion, quiescence, and smiling.
The latter responses rarely indicate lack of concern; rather, they reflect avoidance reactions,
physical exhaustion, or coping mechanisms that require control of emotion. Anger may be
displaced onto hospital staff members.
Friends, family members, and officials often react judgmentally, derisively, or in another
negative way. Such reactions can impede recovery after an assault.
Eventually, most patients recover; however, long-range effects of rape may include posttraumatic
stress disorder (PTSDsee Posttraumatic Stress Disorder), particularly among women. PTSD is
an anxiety disorder; symptoms include re-experiencing (eg, flashbacks, intrusive upsetting
thoughts or images), avoidance (eg, of trauma-related situations, thoughts, and feelings), and
hyperarousal (eg, sleep difficulties, irritability, concentration problems). Symptoms last for > 1
mo and significantly impair social and occupational functioning.

Evaluation
Goals of rape evaluation are

Medical assessment and treatment of injuries and assessment, treatment,

and prevention of pregnancy and STDs
Collection of forensic evidence

Psychologic evaluation

Psychologic support

If patients seek advice before medical evaluation, they are told not to throw out or change
clothing, wash, shower, douche, brush their teeth, or use mouthwash; doing so may destroy
evidence.
Whenever possible, all people who are raped are referred to a local rape center, often a hospital
emergency department; such centers are staffed by specially trained practitioners (eg, sexual
assault nurse examiners [SANE]). Benefits of a rape evaluation are explained, but patients are
free to consent to or decline the evaluation. The police are notified if patients consent. Most
patients are greatly traumatized, and their care requires sensitivity, empathy, and compassion.
Females may feel more comfortable with a female physician; a female staff member should
accompany all males evaluating a female. Patients are provided privacy and quiet whenever
possible.
A form (sometimes part of a rape kit) is used to record legal evidence and medical findings (for
typical elements in the form, see Table 1: Typical Examination for Alleged Rape ); it should be
adapted to local requirements. Because the medical record may be used in court, results should

be written legibly and in nontechnical language that can be understood by a jury.

Open table in new window

Table 1

Typical Examination for Alleged Rape

Category

Specifics
Demographic data about the patient

General information
Name, address, and phone number of the guardian if the patient
is under age
Name of police officer, badge number, and department
Date, time, and location of examination
Circumstances of attack, including
History

Date, time, and location (familiar to patient?)

Information about assailants (number, name if
known, description)

Use of threats, restraints, or weapon

Type of sexual contact (vaginal, oral, rectal; use

of condom?)

Types of extragenital injuries sustained

Occurrence of bleeding (patient or assailant)

Occurrence and location of ejaculation by the

assailant

Activities of the patient after the attack, such as

Douching or bathing
Use of a tampon or sanitary napkin

Urination or defecation

Changing of clothing

Eating or drinking

Use of toothpaste, mouthwash, enemas, or

drugs

Last menstrual period

Date of previous coitus and time, if recent
Contraceptive history (eg, oral contraceptives, intrauterine
device)
General (extragenital) trauma to any area
Physical examination
Genital trauma to the perineum, hymen, vulva, vagina, cervix,
or anus
Foreign material on the body (eg, stains, hair, dirt, twigs)

Data collection

Examination with Wood's lamp or colposcopy when available

Condition of clothing (eg, damaged, stained, foreign material
adhering)
Small samples of clothing, including an unstained sample,
given to the police or laboratory
Hair samples, including loose hairs adhering to the patient or
clothing, semen-encrusted pubic hair, and clipped scalp and
pubic hairs of the patient (at least 10 of each for comparison)
Semen taken from the cervix, vagina, rectum, mouth, and
thighs
Blood taken from the patient
Dried samples of the assailant's blood taken from the patient's
body and clothing
Urine
Saliva
Smears of buccal mucosa
Fingernail clippings and scrapings
Other specimens, as indicated by the history or physical
examination

Acid phosphatase to detect presence of sperm*

Laboratory testing
Saline suspension from the vagina (for sperm motility)
Semen analysis for sperm morphology and presence of A, B, or
H blood group substances
Baseline serologic test for syphilis in the patient
Baseline testing for sexually transmitted diseases in the patient
Blood typing (using blood from the patient and dried samples
of the assailant's blood)
Urine testing, including drug screen|| and pregnancy tests
Other tests, as indicated by the history or physical examination
Treatment, referral,
physician's clinical
comments

Specify

Witness to
examination

Signature

Disposition of
evidence

Name of the person who delivered the evidence and the person
who received it
Date and time of delivery and receipt

*This test is particularly useful if the assailant had a vasectomy, is oligospermic, or

used a condom, which may cause sperm to be absent. If the test cannot be done
immediately, a specimen should be placed in a freezer.

This test should be done by the examining physician if it can be done in time to
detect motile sperm.

In 80% of cases, blood group substances are found in semen.

This test is not recommended by all authorities because evidence of preexisting

sexually transmitted diseases may be used to discredit the patient in court.
||

Many authorities recommend not including comments or tests regarding the

presence of alcohol or drugs in the patient because evidence of intoxication may be
used to discredit the patient in court.
History and examination:

Before beginning, the examiner asks the patient's permission. Because recounting the events
often frightens or embarrasses the patient, the examiner must be reassuring, empathetic, and
nonjudgmental and should not rush the patient. Privacy should be ensured. The examiner elicits
specific details, including

Type of injuries sustained (particularly to the mouth, breasts, vagina, and

rectum)
Any bleeding from or abrasions on the patient or assailant (to help assess the
risk of transmission of HIV and hepatitis)

Description of the attack (eg, which orifices were penetrated, whether

ejaculation occurred or a condom was used)

Assailant's use of aggression, threats, weapons, and violent behavior

Description of the assailant

Many rape forms include most or all of these questions (see Table 1: Typical Examination for
Alleged Rape ). The patient should be told why questions are being asked (eg, information
about contraceptive use helps determine risk of pregnancy after rape; information about previous
coitus helps determine validity of sperm testing).

The examination should be explained step by step as it proceeds. Results should be reviewed
with the patient. When feasible, photographs of possible injuries are taken. The mouth, breasts,
genitals, and rectum are examined closely. Common sites of injury include the labia minora and
posterior vagina. Examination using a Wood's lamp may detect semen or foreign debris on the
skin. Colposcopy is particularly sensitive for subtle genital injuries. Some colposcopes have
cameras attached, making it possible to detect and photograph injuries simultaneously. Whether
use of toluidine blue to highlight areas of injury is accepted as evidence varies by jurisdiction.

Testing and evidence collection:

Routine testing includes a pregnancy test and serologic tests for syphilis, hepatitis B, and HIV; if
done within a few hours of rape, these tests provide information about pregnancy or infections
present before the rape but not those that develop after the rape. Vaginal discharge is examined
to check for trichomonal vaginitis and bacterial vaginosis; samples from every penetrated orifice
(vaginal, oral, or rectal) are obtained for gonorrheal and chlamydial testing. If the patient has
amnesia for events around the time of rape, drug screening for flunitrazepam (the date rape drug)
and gamma hydroxybutyrate should be considered. Testing for drugs of abuse and alcohol is
controversial because evidence of intoxication may be used to discredit the patient.

Follow-up tests for the following are done:

At 6 wk: Gonorrhea, chlamydial infection, human papillomavirus infection

(initially using a cervical sample from a Papanicolaou test), syphilis, and
hepatitis
At 90 days: HIV infection

At 6 mo: Syphilis, hepatitis, and HIV infection

However, testing for STDs is controversial because evidence of preexisting STDs may be used
to discredit the patient in court.

If the vagina was penetrated and the pregnancy test was negative at the first visit, the test is
repeated within the next 2 wk. Patients with lacerations of the upper vagina, especially children,
may require laparoscopy to determine depth of the injury.

Evidence that can provide proof of rape is collected; it typically includes clothing; smears of the
buccal, vaginal, and rectal mucosa; combed samples of scalp and pubic hair as well as control
samples (pulled from the patient); fingernail clippings and scrapings; blood and saliva samples;
and, if available, semen (see Table 1: Typical Examination for Alleged Rape ). Many types of
evidence collection kits are available commercially, and some states recommend specific kits.
Evidence is often absent or inconclusive after showering, changing clothes, or activities that
involve sites of penetration, such as douching. Evidence becomes weaker or disappears as time
passes, particularly after > 36 h; however, depending on the jurisdiction, evidence may be
collected up to 7 days after rape.

Typical Examination for Alleged Rape

Category
Specifics
General information Demographic data about the patient
Name, address, and phone number of the guardian if the patient
is under age
Name of police officer, badge number, and department
History

Date, time, and location of examination

Circumstances of attack, including

Date, time, and location (familiar to patient?)

Information about assailants (number, name if known,
description)

Use of threats, restraints, or weapon

Type of sexual contact (vaginal, oral, rectal; use of

condom?)

Types of extragenital injuries sustained

Occurrence of bleeding (patient or assailant)

Occurrence and location of ejaculation by the assailant

Activities of the patient after the attack, such as

Douching or bathing
Use of a tampon or sanitary napkin

Urination or defecation

Changing of clothing

Eating or drinking

Use of toothpaste, mouthwash, enemas, or drugs

Last menstrual period

Date of previous coitus and time, if recent
Contraceptive history (eg, oral contraceptives, intrauterine
device)
Physical examination General (extragenital) trauma to any area
Genital trauma to the perineum, hymen, vulva, vagina, cervix,
or anus
Foreign material on the body (eg, stains, hair, dirt, twigs)
Data collection

Examination with Wood's lamp or colposcopy when available

Condition of clothing (eg, damaged, stained, foreign material
adhering)
Small samples of clothing, including an unstained sample,
given to the police or laboratory

Hair samples, including loose hairs adhering to the patient or

clothing, semen-encrusted pubic hair, and clipped scalp and
pubic hairs of the patient (at least 10 of each for comparison)
Semen taken from the cervix, vagina, rectum, mouth, and
thighs
Blood taken from the patient
Dried samples of the assailant's blood taken from the patient's
body and clothing
Urine
Saliva
Smears of buccal mucosa
Fingernail clippings and scrapings

Laboratory testing

Other specimens, as indicated by the history or physical

examination
Acid phosphatase to detect presence of sperm*
Saline suspension from the vagina (for sperm motility)
Semen analysis for sperm morphology and presence of A, B, or
H blood group substances
Baseline serologic test for syphilis in the patient
Baseline testing for sexually transmitted diseases in the patient
Blood typing (using blood from the patient and dried samples
of the assailant's blood)
Urine testing, including drug screen|| and pregnancy tests

Treatment, referral,
physician's clinical
comments
Witness to
examination
Disposition of

Other tests, as indicated by the history or physical examination

Specify
Signature
Name of the person who delivered the evidence and the person

evidence

who received it

Date and time of delivery and receipt

*This test is particularly useful if the assailant had a vasectomy, is oligospermic, or
used a condom, which may cause sperm to be absent. If the test cannot be done
immediately, a specimen should be placed in a freezer.

This test should be done by the examining physician if it can be done in time to
detect motile sperm.

In 80% of cases, blood group substances are found in semen.

This test is not recommended by all authorities because evidence of preexisting

sexually transmitted diseases may be used to discredit the patient in court.
||
Many authorities recommend not including comments or tests regarding the
presence of alcohol or drugs in the patient because evidence of intoxication may be
used to discredit the patient in court.