What is the indicated study for a 21-year-old female with a broom (object) injury to the vagina with concern for vaginal rupture in the Emergency Department (ED)?

Vaginal Trauma with Suspected Rupture: Diagnostic Approach

For a 21-year-old female with penetrating vaginal trauma from a broom injury and concern for vaginal rupture, immediate examination under anesthesia in the operating suite is the indicated diagnostic and therapeutic approach, not imaging studies in the ED.

Primary Diagnostic Approach

The definitive evaluation requires examination under general anesthesia in the operating room to directly visualize the extent of injury, assess for peritoneal violation, and perform immediate repair if needed. 1, 2

Key Clinical Decision Points

• Penetrating vaginal injuries require operative evaluation because they carry high risk for:

  • Vaginal apical rupture with peritoneal violation 1
  • Intestinal prolapse through posterior fornix rupture 3
  • Associated urological injuries (30% incidence with complex vaginal trauma) 4

• Factors mandating operating suite evaluation include:

  • Penetrating mechanism of injury 2
  • Injuries involving hymen/vagina 2
  • Obvious vaginal lacerations with active bleeding 1
  • Concern for rupture into peritoneal cavity 3, 5

Hemodynamic Status Determines Urgency

If Hemodynamically Unstable:

• Proceed directly to operating room for examination under anesthesia and hemorrhage control 1
• Consider E-FAST at bedside only if it won't delay definitive surgical management 6
• Activate massive transfusion protocol as needed 7

If Hemodynamically Stable:

• CT scan of abdomen/pelvis with IV contrast can be obtained if there is concern for associated intra-abdominal injuries or if the patient's hemodynamic stability allows 7, 8
• However, this should not delay examination under anesthesia, which remains the definitive diagnostic modality 1, 2

Why Imaging Alone Is Insufficient

The available pelvic trauma guidelines 7 focus primarily on skeletal pelvic fractures and associated hemorrhage, not isolated soft tissue vaginal injuries. These guidelines are not directly applicable to penetrating vaginal trauma without pelvic fracture.

Critical distinction: Vaginal rupture requires direct visualization to:

• Determine depth and extent of laceration 1, 5
• Identify peritoneal violation 3
• Assess for bowel or bladder injury 4
• Enable immediate surgical repair 5

Associated Injury Assessment

While in the operating suite, systematic evaluation must include:

• Urological injuries (bladder, urethra, ureter) present in 30% of complex vaginal trauma 4
• Rectal involvement if posterior vaginal wall injured 5
• Peritoneal violation requiring laparotomy if intestinal prolapse or contamination present 3, 5

Common Pitfalls to Avoid

• Do not rely on external examination alone - vaginal apical ruptures are not visible without speculum examination under adequate anesthesia 1
• Do not delay for imaging in patients with obvious vaginal lacerations and active bleeding 1
• Do not underestimate injury severity - penetrating vaginal trauma can cause life-threatening hemorrhage and peritoneal contamination 3, 5

Adjunctive Measures

• Broad-spectrum antibiotics for penetrating injuries 5
• Tetanus prophylaxis 5
• Blood product availability given transfusion requirements in complex vaginal injuries 4