A case of vulvar hematoma with rupture of pseudoaneurysm of pudendal artery
A 13-year-old female with gravida 0 and para 0 visited our emergency center and presented with sudden pain and swelling in the left labium. Her medical history included Rett syndrome and epilepsy, and she had used medication for this condition; however, the patient was not taking an anticoagulant medication upon admission. Because the patient was bedridden, a regular catheterization was performed by her mother to empty her bladder. A week before she presented in the emergency center, her parents found a 2×2-cm cystic mass on the left labium. Her pediatrician prescribed antibiotics and the mass size seemed to decrease daily with treatment. However, because the mass abruptly increased to 15×15 cm, her parents took her to the hospital.\nThe patient was alert and anxious. Her vital signs were recorded and her blood pressure was 120/76 mmHg, heart rate was 132 beats per minute, respiratory rate was 32 breaths per minute, and temperature was 37.3℃. Palpation of her perineum revealed that the patient had severe tenderness in this area. A genital examination revealed that there was a tense, 15×7-cm hematoma of the left labia majora that significantly distorted the anatomy, along with redness but no laceration (). There was no history of sexual assault or trauma, especially related to catheterization. Laboratory analysis indicated that the patient had a hemoglobin level of 13.3 g/dL (reference range, 12-16 g/dL), a hematocrit of 41.9% (reference range, 36%-48%), a platelet count of 28.5×104/µL (reference range, 13-40×104/µL), and an international normalized ratio of 1.08 (reference range, 1.00-1.10).\nComputed tomography of the pelvis with angiography showed marked dilatation of the vagina (7.0×4.8 cm in size) and left vulvar area (7.5×4.4 cm, red arrow) () and an abnormal, round high density in the left vulvar area, which was suspected to be a pseudoaneurysm. The radiologist confirmed extravasation of blood and active bleeding in the lower vagina and left anterior vulvar area. After evaluation and during urinary catheterization, the hematoma was opened. About 400 mL of bloody discharge was drained. The hemoglobin level dropped to 8.5 g/dL and the patient was given a transfusion of 3 units of packed red blood cells. Angiography subsequently confirmed the existence of a small pseudoaneurysm, and a branch of the internal pudendal artery and embolization were successfully adhered with a 1:5 mixture of lipidol ().\nThere was no indication of further vulvar bleeding after embolization, but the hematoma was still present and we therefore opted for evacuation as treatment. Under local anesthesia, the hematoma was evacuated and no vessels were ligated. No further bleeding was noted after this procedure. During the first postoperative day, her vital signs were stable, and the hematoma resolved on the second day. She was discharged from the hospital on the fourth postoperative day.