Vaginal Hematoma: Symptoms, Types, Causes and Treatment

Vaginal hematomas are a rare but significant complication, most often associated with childbirth and gynecological procedures. While they may not be common, their impact can be serious, leading to discomfort, pain, and in some cases, more severe maternal morbidity. Understanding the symptoms, types, causes, and treatment options for vaginal hematoma is crucial for early detection, effective management, and optimal patient outcomes. This article provides a comprehensive, evidence-based overview of vaginal hematomas, drawing from current research and clinical case studies.

Symptoms of Vaginal Hematoma

Vaginal hematomas can present with a variety of symptoms, often mistaken for other postpartum or gynecological conditions. Early recognition is key to preventing complications and ensuring timely treatment.

Main Symptom	Associated Signs	Diagnostic Clues	Source(s)
Pain	Rectal or perineal pain	Sudden onset, severe	1, 4, 5
Swelling	Palpable vaginal mass	Localized, expanding	4, 5
Urinary retention	Difficulty urinating	Mass effect, urgency	5
Hemodynamic changes	Drop in hemoglobin, shock	Dizziness, pallor	5

Table 1: Key Symptoms

Recognizing the Symptoms

Vaginal hematomas often manifest soon after delivery or gynecological intervention. The most immediate and common symptom is pain, which can be severe and localized to the perineal, rectal, or vaginal area. In some cases, women report a sudden onset of intense discomfort or pressure, which may be mistaken for normal postpartum soreness but is often more severe and persistent 1, 4.

Physical Findings and Diagnostic Cues

• Swelling and Mass: A firm, tender mass may be palpated within the vaginal wall or perineum. This mass can expand over time as bleeding continues.
• Visible Changes: While some hematomas may be visible externally, many are located deeper within the vaginal wall or pelvis and are only detectable through examination or imaging 4, 5.
• Urinary Symptoms: When a hematoma is large or situated near the urethra or bladder, urinary retention or difficulty voiding can occur 5.
• Systemic Symptoms: In severe cases, ongoing blood loss may cause a drop in hemoglobin levels, leading to dizziness, pallor, or even signs of shock 5.

Imaging and Evaluation

Diagnostic imaging, such as transperineal or transabdominal ultrasound, is instrumental in confirming the presence, size, and location of a hematoma, especially when physical examination is inconclusive 4, 5. These tools help differentiate hematomas from other postpartum complications and guide management.

Types of Vaginal Hematoma

Not all vaginal hematomas are the same; their classification is based on location, size, and origin. Understanding the types helps tailor management strategies and anticipate potential complications.

Type	Location	Distinguishing Feature	Source(s)
Vulvar Hematoma	Labia majora/minora	Often visible externally	2
Vaginal Hematoma	Vaginal wall, fornices	Palpable, less visible	4, 5
Supralevator Hematoma	Above levator ani muscle	Deep pelvic location	1
Vault Hematoma	Vaginal vault (post-surgery)	Associated with hysterectomy	3
Retroperitoneal Hematoma	Retzius space, pelvis	Rare, can cause urinary symptoms	5

Table 2: Types of Vaginal Hematoma

Vulvar and Vaginal Hematomas

• Vulvar Hematomas are typically the most apparent, presenting as swelling and discoloration of the labia. They are often noticed immediately after trauma or delivery and are usually easier to diagnose due to their superficial location 2.
• Vaginal Hematomas form within the walls of the vagina or at the fornices (the uppermost portions of the vagina). These may not be visible externally but can be felt as a firm, tender mass during examination 4, 5.

Deeper and Complex Hematomas

• Supralevator Hematoma: Located above the pelvic floor muscles, these hematomas are deeper, harder to detect, and may cause significant internal bleeding. They often require imaging for diagnosis and may present with more pronounced systemic symptoms 1.
• Vault Hematoma: This type occurs after surgical procedures such as vaginal hysterectomy, forming at the site where the vaginal canal is surgically closed (the "vault"). Vault hematomas can lead to post-operative morbidity if not promptly identified and managed 3.
• Retroperitoneal (Retzius Space) Hematoma: Extremely rare, these develop in the space behind the pubic bone and in front of the bladder. They can cause urinary retention and abdominal pain, making diagnosis challenging unless imaging is performed 5.

Causes of Vaginal Hematoma

Vaginal hematomas arise from a variety of causes, most often related to trauma or surgical intervention. Recognizing these risk factors can help in both prevention and early intervention.

Cause	Mechanism	Common Scenario	Source(s)
Childbirth trauma	Tearing of blood vessels	Vaginal/assisted delivery	1, 2, 4, 5
Surgical procedures	Vessel injury	Hysterectomy, repair	3
Instrumental delivery	Forceps, vacuum use	Assisted vaginal birth	1, 2
Coagulopathy	Bleeding disorders	Underlying medical issue	1
Spontaneous rupture	Weak vessel walls	No trauma or surgery	5

Table 3: Causes of Vaginal Hematoma

Traumatic Causes

• Childbirth-Related Trauma: The stretching and pressure involved in vaginal delivery can cause tears in blood vessels, especially when delivery is rapid or complicated. Assisted deliveries with forceps or vacuum devices increase the risk of vascular injury 1, 2, 4.
• Instrumental Delivery: The use of obstetric tools, while sometimes necessary, can inadvertently damage soft tissue and vessels, creating a higher risk for hematoma formation 1, 2.

Surgical Causes

• Gynecological Surgery: Procedures such as vaginal hysterectomy can injure vessels in the vaginal vault, leading to post-surgical hematomas. Inadequate closure or failure to include the peritoneal edges during vault repair increases this risk 3.

Non-Traumatic and Medical Causes

• Coagulopathies: Women with bleeding disorders or on anticoagulant therapy are predisposed to hematoma formation even with minimal trauma 1.
• Spontaneous Hematoma: Rarely, hematomas may develop without clear trauma or intervention, possibly due to spontaneous vessel rupture or underlying vascular weakness 5.

Treatment of Vaginal Hematoma

Management of vaginal hematomas depends on their size, location, severity, and the patient’s hemodynamic status. New advances have improved outcomes and reduced the need for invasive surgery in many cases.

Approach	Indication	Outcome/Benefit	Source(s)
Conservative	Small, stable hematomas	Observation, recovery	5
Surgical drainage	Large, expanding, unstable	Immediate decompression	3, 5
Arterial embolization	Large, ongoing bleeding	Minimally invasive, effective	1, 2
Imaging-guided management	Diagnostic uncertainty	Accurate localization	4, 5

Table 4: Treatment Options

Conservative (Non-Surgical) Management

• Observation and Supportive Care: Small, stable hematomas without ongoing bleeding can often be managed conservatively. This includes pain control, antibiotics to prevent infection, close monitoring of vital signs, and transfusion if indicated. Imaging helps ensure the hematoma is not expanding 5.
• Indications: Patient is hemodynamically stable, hematoma is not enlarging, no signs of infection or tissue compromise.

Surgical Intervention

• Drainage and Evacuation: When hematomas are large, rapidly expanding, or causing significant compromise (pain, urinary retention, hemodynamic instability), surgical evacuation is often necessary. This involves incision and drainage, with ligation of bleeding vessels when possible 3, 5.
• Post-Surgical Hematomas: Vault hematomas after hysterectomy that are clinically significant may also require drainage, though preventive surgical techniques can reduce their occurrence 3.

Minimally Invasive Approaches

• Arterial Embolization: Increasingly, selective arterial embolization is being used as a first-line treatment for large or unresponsive postpartum and vulvovaginal hematomas. This procedure uses interventional radiology to block bleeding vessels, halting the hematoma’s growth and promoting resolution without the need for open surgery 1, 2.
• Benefits: Minimally invasive, effective for controlling bleeding, often results in shorter hospital stays and faster recovery 1, 2.

The Role of Imaging

• Ultrasound and CT Scanning: Imaging is invaluable for diagnosing the location, size, and extent of hematomas. Transperineal and transabdominal ultrasounds are commonly used, while CT scans are reserved for complex or deeply situated hematomas 4, 5.
• Guiding Management: Imaging findings help determine the best course of action, from conservative management to embolization or surgery 4, 5.

Conclusion

Vaginal hematomas, though rare, are significant complications most commonly associated with childbirth and gynecological surgery. Their timely recognition and management are essential for preventing morbidity and ensuring optimal recovery.

Key Points:

• Symptoms: Severe pain, swelling, palpable mass, urinary retention, and potential hemodynamic changes are important signs to watch for 1, 4, 5.
• Types: Hematomas can be vulvar, vaginal, supralevator, vault, or retroperitoneal, each with unique features and risks 1, 2, 3, 4, 5.
• Causes: Most often due to trauma from childbirth or surgery, but can also result from coagulopathy or spontaneous vessel rupture 1, 2, 3, 4, 5.
• Treatment: Options range from conservative management and surgical drainage to arterial embolization, with imaging playing a critical diagnostic and guiding role 1, 2, 3, 4, 5.

Prompt diagnosis, individualized treatment, and multidisciplinary care are paramount to achieving the best outcomes for women affected by vaginal hematomas.