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4 December 1986
N. SUBRAMANIAM
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343
TABLE I
SITE OF LACERATION WITH RElATION TO AGE, RACE, POSSIBLE
PREDISPOSING FACTORS AND PARITY
Age
Race Associated factors Site of laceration Parity
lvrsl
a-half years previously; one patient had a total In our series, only one patient had multiple
abd. hysterectomy 16 years previously. (two) lacerations. The remaining six showed
only Cl single laceration (Table I). Two patients
had lacerations involving the posterior fornix. In
Clinical presentation one patient this took the form of a simple
All seven patients presented with vaginal transverse laceration and in the other, there were
bleeding of varying degree and most of them had two small lacerations.
felt pain during intercourse and subsequent to it.
The duration of bleeding varied between three Three patients had vaginal wall lacerations
hours to a few days. One patient in the post which were actively bleeding and all of them
menopausal age group who was managed conser- had these lacerations situated in the right post-
vatively had been bleeding for two months! erolateral aspect of the vagina. In one of them,
it was situated in the lower third, whereas in the
Two patients presented with profuse bleeding other two the lacerations were in the upper
and clinical features of hypovolaemic shock, third. The two patients who were managed as
and had to be resuscitated with plasma expanders outpatients revealed single laceration in the right
and blood transfusion before definitive surgery vaginal wall which was healing and did not
could be performed. require surgical treatment.
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it was not difficult to elicit a history of preced- Many postulates have been suggested as to the
ing coitus in all our patients, and this helped us aetiologic basis of coital vaginal inju,'ies, and they
in arriving at an early diagnosis. Include:" ,6, 7 disproportion between the male
and female genitalia - this assumes special signi-
Management finance in prepubertal females, post-menopausal
Five of our patients required active manage- women, post-operative shortening of the vagina
ment. Two who exhibited a state of hypovolaemic and post-radiation vaginal atrophy; dorsal decu-
shock had to be resuscitated prior to surgery. bitus with hyperflexion of the thighs, standing and
Initial vaginal packing with flavine roller-gauze sitting positions during intercourse, roughness and
while awaiting surgery was imperative in control- violent thrusts of the penis during sexual inter-
ling vaginal bleeding temporarily. course; congenital abnormalities e.g., presence
of a vaginal septum which may be torn during
Five patients had an examination under anaes- intercourse; women at greatest risk are those who
thesia and subsequent repair of the vaginal lacera- resume intercourse after a prolonged period of
tions. All patients had prophylactic antibiotic abstinence, those who have undergone hysterec-
therapy. Two patients in the post-menopausal tomy and those who are post-menopausal; the
group who were treated as outpatients were vagina becomes, susceptible to injury when its
managed conservatively as their lacerations were musculature goes into spasm, causing shortening
healing. They were prescribed conjugated oes- and narrowing of the vagina.
trogen cream for local application and advised use
of lubricant jelly prior to intercourse. Both sub- It has been reported that lacerations are most
sequently had no further problem. frequently located in the posterior fornix,
posterior and lateral vaginal wall more often on
DISCUSSION the right than the left.
Post-coital lower genital tract injuries, though
not a frequent occurrence, are a significant cause This may be due to the fact that during coitus
of vaginal bleeding in any age group amongst the lower third of the vagina contracts whilst the
sexually active women. upper two thirds expand and lengthen, the uterus
rises ventrally thereby exposing the posterior
Reported post-coital complications other than fornix to direct trauma by the glans penis. Further-
vaginal lacerations include post-coital pneumo- more, as the right fornix is usually deeper than the
peritoneum.' post-coital vaginal vau It disruption left fornix it is more likely to accommodate the
in a patient who had undergone hysterectomy glans penis and be stretched by it. In addition,
previously / vaginal evisceration," and air the poor fascial support of the upper vagina
embolism following coitus during preqnancv." especially the posterior fornix makes it very
vulnerable to injury during coitus.
The problem assumes a greater significance
especially when history of coitus is not forth- Though in Wilson's8 series of 37 patients, only
coming from the patient and the condition six suffered injury during the first coitus and the
could be subsequently misdiagnosed thus delay- others had cohabited several times previously,
ing prompt surgical treatment. Srnith ' in his study in our series, three out of the four patients in the
on 19 patients reported misdiagnosis on admission younger age group claimed it was their first
in 12 of those patients - an extremely high per- sexual experience.
centage indeed. Hence, a careful speculum
examination in all cases of vaginal bleeding is CONCLUSION
absolutely essential as there have been reports This article attempts to illustrate our expe-
in the literature of fatalities associated with coital rience with post-coital vaginal lacerations. The
vaginal injury. incidence, precipitating factors and mode of
345
presentation of our patients tend to be largely 2 Hacker N F, Charles E H, Savage E W. Post-coital
similar to other reported studies. However, first post-hysterectomy vaginal vault disruption. Aust N Z
intercourse does seem to be a risk factor in the J Obstet Gynaeco/1980; 20: 182-184.
aetiology of coital vaginal lacerations in our series.
3 Hall D B, Phelan J P, Pruyn S C, Gallup DE. Vaginal
The importance of early diagnosis and simplicity evisceration during coitus. Am J Obstet Gynaecol
in treatment is stressed. In every case of vaginal 1978; 131 (1): 115-116.
bleeding, possible coital laceration should be kept
in m ind and considered in differential diagnosis. 4 Lifschultx B D, Donoghue E R. Air embolism during
intercourse in pregnancy. Journal of Forensic
ACKNOWLEDGEMENTS Sciences 1983; 28(4): 1021-1022.
We would like to thank the Director-General, 5 Smith N C, Van Coeverden De Groot H A, Gunston
Ministry of Health for granting us perm ission to K D. Coital injuries of the vagina in non virginal
publish this paper. We would also like to tender patients. S A Med Journal 81983; 64: 746-747.
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