Unrecognized coital laceration in a series of nonvirginal adolescent girls

BACKGROUND: Nonvirginal adolescent patients with vaginal injuries as a result of apparently normal sexual intercourse constitute a small but important group of Emergency Room presentations. METHODS: A series of three nonvirginal adolescents who sustained vaginal injuries during normal coitus is presented. RESULTS: The ages were fourteen, fifteen, and sixteen. All presented to the Pediatric Emergency Department with profuse or prolonged vaginal bleeding. Two had previous hypotensive episodes. None had a hemoglobin less than 10%. One had admitted to sexual activity 24 hours prior to presentation. The other two had initially denied it but upon confidential questioning by the Gynecology consult admitted to the act many hours prior to presentation. For all of the young women, it was their second act of sexual intercourse. All denied the use of excess force or inanimate objects. All felt that the act was no different than the previous act although it was a different partner. Only one patient presented with abdominal pain. The diagnosis was not suspected in any of the patients prior to the gynecologic consult. Two of the patients were taken directly to the operating room because of profuse bleeding and the diagnosis was quickly made. One was admitted for observation for presumed dysfunctional bleeding but continued to be hypotensive with a decreasing H&H and was diagnosed by reexam. All had significant lacerations to the right vaginal fornix, one involving entry into the peritoneal cavity yet had no laceration or injury to the perineum. All had immediate repair and have done well since. None have resumed sexual activity. CONCLUSIONS: The pelvic organs are well suited for intercourse thus coital injuries, especially from consensual sex, are highly unusual. Minor injuries of the female external genitalia and introitus often occur with initial intercourse but rarely present with anything more than minor pain and bleeding. Laceration and rupture of the vaginal vault are more serious but the etiology of most is unclear. It has been postulated that the right vaginal fornix is larger than the left and because of the pouching of the glans is probably stretched most during coitus. The almost universal presentation is vaginal bleeding. Deaths from exsanguination have been reported with infection as a late complication. Management consists of control of hemorrhage and management of shock if present, prophylaxis, treatment of infection and repair of injuries. Prompt recognition and treatment of coital injuries is vital as there is significant morbidity and mortality. This series reemphasizes the importance of a detailed confidential sexual history in all our adolescent patients who present to the ER as this information may not be voluntarily given to the physician. Any patient with postintercourse pain or vaginal bleeding deserves full evaluation by the physician.