Most injuries to the vagina are caused by forceful blunt trauma either by the penis, fingers/hands, or foreign bodies. However, these injuries are more common in women who do not have adequate lubrication of their vagina before intercourse. Inadequate lubrication can be the result of menopause, lack of sufficient foreplay, and previous history of sexual abuse. Experts have also hypothesized that certain positions during intercourse make a woman more vulnerable for genital trauma, primarily when their male counterpart is on top. The same can be postulated about those females who are having sexual toys being forcefully inserted into their vaginas since certain positions can also make them more vulnerable for injury [17].

The typical presentation of a woman with a vaginal tear is that of a burning and painful sensation in their vagina. There is usually minimal bleeding. If the vaginal laceration is more complex, the patient will most likely complain of more pain and more bleeding. There have even been a few case reports of women who have bled to the point of shock because of deep vaginal tears, but these presentations are rare. Subsequently, a deeper laceration of the vagina could mean that the vagina has been perforated. There have also been reports of vaginal–rectal fistulas that have occurred as a result of forceful sex . Vaginal tears have also been the result of oral sex as the piercings on their partner’s tongue/lips may lacerate the external genitalia. If a patient presents with the above presentation, the clinician must use their clinical judgment and investigate/report the case if warranted [18].

In addition to obtaining a proper history, the primary manner in diagnosing a vaginal tear is by careful examination of the external (labia majora and minora) and the internal genitalia (the vaginal vault). Most importantly, the extent and depth of the injury should be determined so as not to miss a vaginal perforation and/or simultaneous rectal perforation [19, 20].

Treatment usually consists of repairing and suturing the laceration. Care must be taken in suturing more complex lacerations, as each layer that is breached must be sutured separately. In the case of a rectovaginal tear, three different layers must be repaired; the vaginal mucosa, the rectovaginal septum and the rectal mucosa. Some tears involving the rectum can be so severe that they have to be repaired in the operating room for primary repair of the tear and diverting colostomy. It is also prudent to send the patient home with oral antibiotics for prophylaxis [19, 20].

Prognosis is improved with early treatment. The longer one waits, the more susceptible they are to complications, i.e., delayed healing/closure, infections, and in some cases, death.

The most logical way to approach prevention is by reviewing the cause for such tears. Naturally, the better the lubrication, the less risk there is of sustaining such tears. There are numerous synthetic lubricants available for women in menopause to use just before sex. There are also different types of hormonal therapy that can be used but these become more risky for older women. As for younger women, they may want to have their partners engage in longer foreplay to achieve appropriate lubrication. Experts have also recommended that a women may consider changing her positioning. For instance, by putting herself on top of her partner, she, in theory, is in more control in regards to the force of intercourse.

Most importantly, two consenting adults engaging in any kind of sexual activity should communicate with each other and be able to express freely what gives them pleasure and vice versa [17].

The two most common locations for Foreign Body (FB) entrapment to occur are the vagina and the rectum (foreign bodies in the rectum are discussed later in the chapter).

The most common retained vaginal foreign body after intercourse is a condom. However, there have been case reports of objects such as sex toys and other plastic objects (used to enhance sexual pleasure) that have been retained [21].

For women presenting with a retained vaginal FB, their usual complaints are persistent malodorous vaginal discharge, vaginal spotting, and vaginal irritation/itching. It is also not uncommon for women to complain of dysuria and a genital rash. Many times, the patient will not suspect the possibility of having a retained vaginal FB [21].

Diagnosis of retained foreign bodies is primarily made by history and physical. Visual inspection via pelvic speculum exam will usually be sufficient for the clinician to locate the foreign body. Ultrasound of the pelvis has also been shown to be useful in locating a vaginal foreign body. In the case of a foreign body that has perforated the vaginal vault, a plain film of the torso may be obtained to look for free air, but an abdominal/pelvic CT may reveal a more definitive diagnosis [21].

For those patients for whom radiation is a concern, an MRI has also been used as a diagnostic tool but an MRI is absolutely contraindicated if the FB entrapped is known to have metal properties [22].

Once the clinician has located the foreign body, forceps may be used to pull the foreign body out. There are those rare instances in which a vaginal foreign body may be too large or it may have even perforated into the peritoneal cavity. In those cases, a gynecologist must be consulted immediately as these injuries require immediate surgery. There have also been case reports of foreign bodies leading to vesico-vaginal fistulas (communication between the bladder and the vagina) and to colo-uterine fistulas (communication between the colon and the uterus). These injuries are rare and may have occurred at the time of penetration into the vaginal vault or as a result of a foreign body left in the vaginal vault for an extended period of time. Such complications ultimately require surgical repair [23, 24].

These patients will do well if they are treated appropriately. However, for those women who present much later, they may sustain long-term complications [25].

While ruptured ovarian cysts are relatively common among women, it is unclear exactly what percent of these ruptured cysts are due to intercourse. None the less, intercourse has been known to be a cause of ruptured ovarian cysts. Very rarely, these ruptured cysts lead to a hemoperitoneum, which can lead to hemorrhagic shock. The data is scant on the rate at which these ruptured ovarian cysts occur as a result of sexual intercourse and there are only a handful of case reports describing patients who suffered hemorrhagic shock as a result of hemoperitoneum caused by a ruptured ovarian cyst after sexual intercourse [26].

Women presenting with ruptured ovarian cysts will usually complain of sudden onset of severe lower abdominal pain localized to one side. This acute onset of pain may be associated with nausea, vomiting, and diaphoresis. The pain is usually the worst in the first hours after the cyst ruptures, but gradually, the pain lessons but is still felt with movement and ambulation. Patients with hemoperitoneum, however, will have persistent severe pain and they may even be hypotensive on arrival [27, 28].

A good history from the patient is often helpful, but diagnosis is usually made by visualization of free fluid in the pelvis via ultrasonography. A pelvic ultrasound yields the best results if performed trans-vaginally. After a cyst has ruptured, the ultrasound (US) technician may or may not see an ovarian cyst, but seeing some free fluid in the pelvis may indicate that a cyst has ruptured. The technician is usually able to tell if the free fluid is consistent with blood or not. If a pelvic US is inconclusive or if a patient is found to have a hemoperitoneum, then a CT scan of the abdomen and pelvis with IV contrast should be considered to rule out other emergent causes of free fluid and hemoperitoneum in the pelvis. The contrast will allow visualization of extravasation and source of bleeding. For instance, a case was reported of a hemoperitoneum being found in a female after sexual activity which happened to be a result of a laceration of their round ligament rather than a ruptured ovarian cyst [29]. If the patient’s pain is in the right lower quadrant of the abdomen, there is always concern that the cause of pain could be due to appendicitis. Therefore, in some cases, a CT is necessary to differentiate whether or not a patient’s pain is due to appendicitis especially since management is completely different for both. Keep in mind that a CT scan of the abdomen does expose a patient to a considerable amount of radiation and this should always be taken into account when ordering a CT scan, especially since ruptured ovarian cysts can be a recurrent problem and may put a patient at risk for having more CT scans (i.e., more radiation exposure) in the future [27, 28].

A urine pregnancy test should always be performed because if positive, an ectopic pregnancy must be ruled out. Blood work may be diagnostic in the sense that an elevated white blood cell count (WBC) with a left shift may suggest something other than a ruptured cyst. However, it is not uncommon to see an elevated WBC with a simple ruptured ovarian cyst. A low hemoglobin (HgB) may suggest that a patient has had significant amount of blood loss indicating that a patient may require a blood transfusion and emergent surgical intervention [27, 28].

Treatment of a ruptured ovarian cyst where there is minimal free fluid in the pelvis requires usually only pain control. Ketorolac (Toradol) 30 mg IVP or 60 mg IM (intramuscular) is usually very effective for pain control. Oral lbuprofen (Motrin) 600 mg per oral (PO) is also helpful but must be taken with food. Many times these patients come in nauseated and have to be given antiemetics first. Some common antiemetics include Zofran (odansetron) 4 mg PO or IVP, Metoclopramide (Reglan) 5–10 mg PO, IVP, or IM, and Promethazine (Phenergan) 12.5–25 mg IM or IVP. Note that romethazine has a tendency to cause sedation and sometimes may affect respiratory drive (especially in older patients and children). If Toradol is not enough to control the pain, then IV or IM opiates should be considered. If a patient has vomited several times, then a liter of IVFs (normal saline) may be administered [28].

Treatment of a ruptured ovarian cyst resulting in a large hemoperitoneum and shock is a true emergency and a gynecologist on duty should be called emergently. The patient should be hemodynamically stabilized with IVFs (usually normal saline), but type and cross-matched blood may need to be administered if patient’s low blood pressure is not responding to IVFs or if the patient’s HgB is less than 7 (or less than 8 and patient is symptomatic). If a hemoperitoneum due to a ruptured cyst is diagnosed, then a gynecologist is needed emergently to take the patient to the Operating Room (OR) to perform an emergent laparotomy [29].

It is very difficult to predict who will develop ovarian cysts. However, a patient who has a history of a known ovarian cyst is at higher risk of having recurring cysts and subsequently a higher likelihood of suffering from a recurring ruptured ovarian cyst. Very often, females who develop recurrent cysts are started on birth control pills in order to prevent the formation of ovarian cysts and ultimately, the complications of having these ovarian cysts (e.g. chronic pain and ruptured ovarian cysts) [27].

Most of these patients do well especially if it was a simple ovarian cyst that ruptured. However, Patients who develop a hemoperitoneum are at risk for exsanguinating and dying. For this reason, if diagnosis is made in a timely manner and source of bleeding is detected and stopped, then the patient will also recover without any negative sequelae.

While anal injuries are rare, they do occur more frequently than one might think. Injuries of the anus and rectum can range from a small tear also know as a fistula to a complete perforation. Anal and rectal injuries are caused by forceful anal intercourse, anal foreign bodies, and handballing (also known as fisting in which primarily gay men place their fists into their partners’ anus) [30–32].

Clinical presentation of a patient with an anal injury will vary based on the complexity of the injury. For instance, a patient who sustains an anal fistula will more likely present with pain in the rectum, anal bleeding, and pain upon sitting/defacating. The patient may also have mild lower abdominal pain. A patient with an anal perforation, however, will present with severe abdominal pain, or with rectal bleeding and pain being secondary [33].

A good history from the patient can usually be sufficient to hone in on the diagnosis. However, patients who have engaged in anal intercourse or other forms of anal eroticism may not be so forth coming with how they sustained their injuries. Even worse is that patients may hold off on seeking treatment due to their being embarrassed of having engaged in such activities. Unfortunately, the longer these patients wait before seeking treatment, the higher the risk that they are likely to suffer severe morbidity and even mortality.

Once the patient presents to the ED, visual inspection, and even anal endoscopy may be needed to diagnose an anal tear/fistula . However, if anal perforation is suspected, then abdominal and chest X-rays may be obtained to look for free air in the peritoneum (see Figure 33-5). Some tears and lacerations are difficult to locate, but studies have shown that the use of certain dyes like toluidine blue can be helpful. Toluidine blue binds to cells in the deeper layers of tissue and therefore any region that retains the dye is usually consistent with a tear [34].

A surgeon, primarily a colorectal surgeon, should be consulted emergently. Patient should be started on appropriate antibiotics. If perforation has occurred, then a laparotomy is usually mandatory. Decision not to do a laparotomy is specifically up to the surgeon.