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ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 4  |  Page : 229-234

Nonobstetric lower genital tract injury patients of a tertiary care center in Eastern Uttar Pradesh, India: A cross-sectional study


1 Department of Obstetrics and Gynecology, B. R. D. Medical College, Gorakhpur, Uttar Pradesh, India
2 Community Medicine, B. R. D. Medical College, Gorakhpur, Uttar Pradesh, India

Date of Submission24-Feb-2022
Date of Acceptance21-Apr-2022
Date of Web Publication26-Dec-2022

Correspondence Address:
Dr. Harish Chandra Tiwari
Department of Obstetrics and Gynaecology, B. R. D. Medical College, Gorakhpur - 273 013, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijciis.ijciis_16_22

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   Abstract 


Background: Injuries of lower genital tract are commonly seen in obstetrics patients during labor and delivery. Nonobstetric genital injuries are seen less commonly. Research on injuries to the lower genital tract from nonobstetric trauma is therefore scant. The purpose of this study was to document causes, treatment, and outcomes among patients of lower genital tract injuries visiting to B. R. D. Medical College and Nehru hospital, Gorakhpur, U.P.
Methods: Admission and operation theater registers of the department of obstetrics and gynecology during 1 year were scrutinized for cases admitted with the diagnosis of genital trauma. Bed-head tickets of patients were scrutinized with the help of a data abstraction form, and information regarding age, cause of injury, site, size and pattern of injuries, treatment, and short-term outcome were recorded.
Results: Of a total of 43 cases of traumatic genital tract injuries, 39 women received treatment. Maximum cases were seen in girls aged 6–10 years. Three women were pregnant at the time of injury. Noncoital injuries predominated over coital injuries, i.e., 59% versus 38.4%. Among the noncoital injuries, fall was the most common cause accounting for 75% of the cases. Coital injuries following consensual sex occurred more commonly in women who were sexually active, lactating, or postmenopause. The chief presenting complaint was vaginal bleeding. Vaginal wall laceration/tear was the most common injury reported. Multiple injuries were seen in 40% (17/39) of the cases. Twenty-one cases of laceration/tear (53.8%) were repaired surgically of which seven required examination and repair under anesthesia. Vulvar hematomas were managed by incision and drainage. There was no major morbidity or mortality.
Conclusions: The results of this study from eastern Uttar Pradesh, India, support those from other developing nations. Noncoital injuries were found to be the most predominant cause of non-obstetric genital trauma, though, contrary to others, children were seen to be at the greatest risk. It is important to teach children about playing safely and following safety measures while on the road. We must also make them aware so that they do not become victims of rape.

Keywords: Injuries, lower genital tract, nonobstetric, trauma, vulvovaginal


How to cite this article:
Aditya V, Mishra R, Tiwari HC. Nonobstetric lower genital tract injury patients of a tertiary care center in Eastern Uttar Pradesh, India: A cross-sectional study. Int J Crit Illn Inj Sci 2022;12:229-34

How to cite this URL:
Aditya V, Mishra R, Tiwari HC. Nonobstetric lower genital tract injury patients of a tertiary care center in Eastern Uttar Pradesh, India: A cross-sectional study. Int J Crit Illn Inj Sci [serial online] 2022 [cited 2023 Feb 9];12:229-34. Available from: https://www.ijciis.org/text.asp?2022/12/4/229/364735




   Introduction Top


Injuries of the lower genital tract are commonly seen in obstetrics patients during labor and delivery. A rising trend has been seen in nonobstetric genital injuries patients due to modern lifestyle such as high-speed road transportation, recreational activity, and increased sexual assault which often leads to vulvovaginal injuries.[1] Patients due to nonobstetric lower genital tract injuries are also visiting to our center for seeking medical care. However, literature available on nonobstetric lower genital tract injuries is scant both in the developed and the developing world.[2] The incidence, etiology, and pattern of injuries may vary depending on geographical location, socioeconomic development, education, occupation and leisure, and sports activities available. The study of incidence of nonobstetrics genital injuries in our setting will help to figure out the burden of nonobstetric genital injuries in eastern Uttar Pradesh. Information on etiology and pattern of nonobstetric genital injuries will help regarding prevention as well as management planning of such patients.[3] Keeping the above facts in mind, the present study was designed aiming to document lower genital tract injuries in eastern Uttar Pradesh, India. More studies from different areas would help to identify the population at risk and know the regional causes of genital trauma. Appropriate preventive measures can then be executed and uniform treatment protocols formulated.


   Methods Top


A cross-sectional study was done in patients presenting with nonobstetric genital injuries to the Obstetrics and Gynaecology Department of B. R. D. Medical College in India. Patients were enrolled from April 1, 2020, to March 31, 2021. The study was approved by the institutional review board/ethics committee (Approval # 49/2020).

Patients of any age group with perineal trauma\injury, vulvar hematoma, postcoital tear, alleged rape, and sexual assault admitted for treatment in any of the gynecology wards were included in the present study, while patients with vulvovaginal injuries or vulval injuries occurring during labor and childbirth or within 6 weeks after childbirth were excluded from this study.

Admission and operation theater registers of Department of Obstetrics and Gynecology for 1 year (from April 2020 to March 2021) were scrutinized on every Monday, Wednesday, and Saturday. Cases admitted with the diagnosis of genital tract injuries were noted. The bed-head tickets of these patients were scrutinized with the help of a data abstraction form prepared by us. Information regarding the age of patients, cause of injury, presenting complaints, site, size and pattern of injuries, treatment, and short-term outcome were recorded. Written informed consent for the study as well as the publication was taken from these patients during their treatment or follow-up visits.

Statistical methods

Data collected were entered into the Microsoft Excel sheet. Data were analyzed and tabulated using Microsoft Excel 2017. Categorical variables were presented in terms of frequency and percentages. Mean ± standard deviation was calculated for continuous variables. The independent samples t-test was used for comparison of the continuous variables. P < 0.05 was considered statistically significant.


   Results Top


A total of 43 patients visited for treatment of genital injuries during 1 year of study duration. Among these, 39 patients presented directly to the emergency of obstetrics and gynecology, two patients were referred from orthopedics emergency and one patient from pediatrics emergency and one patient from surgery emergency. Three patients refused to get admitted, and one patient was referred in need of super specialty services. Hence, a total of four patients were excluded from the study. A total of 39 women comprised the sample size [Figure 1].
Figure 1: Details of patients of genital injuries visited from April 2020 to March 2021

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The mean age of women presenting with genital injuries was 19.5 years ± 14.95 and ranged from five to 65 years. However, most victims belonged to 6–10 years of age group. The victims were most frequently aged 6, 10, or 25 years at the time of presentation. In almost 50% of the cases, the victims had been referred from peripheral health centers. In two cases, injuries were repaired before referral to our center [Table 1].
Table 1: Causes, pattern and treatment of genital injuries

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Multiple injuries were seen in 17 of 39, i.e., 40% of the cases. Active bleeding was used as criteria for surgical repair in lacerations. Twenty-one cases (53.8%) were repaired surgically, of which seven were repaired under general anesthesia and two under spinal anesthesia. Vulvar hematomas were seen in six, and all being either large (>5 cm) or expanding, were evacuated by surgery, i.e., incision and drainage. Seven women were transfused blood. Extragenital injuries were seen in four. There was no major morbidity or mortality. Genital injuries were broadly classified as coital injuries, injuries from sexual assault, and noncoital injuries. The cause of injury could not be ascertained in a mentally challenged child, and this case remained unclassified [Table 1].

Overall, noncoital injuries predominated in this study, seen in 58.9%. Furthermore, they were reported earlier than coital injuries. The mean time from injury to presentation was 12.3 h in those with coital injuries compared to 8.3 h in the noncoital injuries group though not statistically significant. Fall accounted for 75% (18/23) of the cases of noncoital injury in our study. Ten occurred falling astride objects that were either blunt or, in a few cases, sharp [Table 1]. One among them was pregnant at the time of injury. More than 50% of the falls were in prepubertal and adolescent girls. One child suffered a fracture calcaneum. Straddle injuries from bicycle falls were seen in two [Table 1].

Genital injuries from automobile accidents were seen in three cases, all <13 years. Two suffered a closed fracture of the pelvis, i.e., superior and inferior ramus of the pubic bone. Below-knee skin traction was applied to manage pelvic fracture. One of the girls also had a fractured shaft of the femur and a minor scalp injury. The genital injuries, in this case, required surgical repair under anesthesia, and for femoral fracture, a Thomas splint was applied.

Cattle horn injury in a postmenopausal woman occurred when she was working on the field. She suffered paraurethral and suburethral tears that bled actively and were repaired under general anesthesia. She received one unit of blood, and a Foley catheter was kept for 21 days. Urinary functions were completely restored to normal thereafter. A chemical injury was seen in a woman who sought an abortion from a traditional birth attendant. Some chemical preparation was inserted in the vagina to affect abortion. This caused sloughing and necrosis of the vagina and cervix. The posterior lip was not present 4 days later, at the time of presentation. With systemic antibiotics and local dressing slough disappeared, and the wound gott healed in 10 days [Table 1].

Laceration/tear was the most common injury, and the most common site for laceration was the vagina [Table 2]. Coital injury accounted for 38.4% (15/39) of the vulvovaginal injuries in this study [Table 2]. Consensual coital act was causative in nine women [Figure 2].
Figure 2: Parity and physiological/marital state of women with consensual coital injuries

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Table 2: Type and site of injury in victims of genital trauma

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In four women, the injury occurred at the first intercourse, and in all four, vaginal wall lacerations were seen in the upper vagina. In another three women, who used to breastfeed at the time of injury, injuries occurred at the first intercourse after childbirth, i.e., 2, 4, and 18 months. Moreover, a case each was reported in a multiparous postmenopausal lady and in a sexually active unmarried girl who was a chronic carrier of hepatitis B [Figure 2]. Injuries were managed by packing alone in four cases, while three required repair under general anesthesia. One woman was in shock and transfused one unit of packed blood [Table 1].

Genital injuries that allegedly resulted from rape were seen in five. Four were girls <12 years of age. Most victims knew the accused, usually a neighbor. In all cases, injuries were seen as perineal tears that were repaired under general anesthesia. The tears were more severe in the younger girls, one of whom also suffered perforation of the vaginal vault into the peritoneal cavity. Fortunately, the perforation could be managed vaginally. In another girl, the vagina was absent, and there was an injury to the anal sphincter and anal mucosa, probably from forceful anal penetration. The repair required assistance from a surgeon. A case of rape was also alleged by a postmenopausal woman. She reported being fisted in the vagina by her nephew. Active bleeding from vaginal wall laceration required surgical repair.

A pregnant woman alleged sexual assault with a knife. She had a profusely bleeding vulvar laceration that was repaired at the PHC before being referred. The cause of injury could not be ascertained in the mentally challenged child. A medicolegal examination was done, and samples were taken to rule out sexual assault, and the 2nd degree perineal tear was repaired under GA [Table 1].


   Discussion Top


Trivial injuries heal without much treatment. Associated embarrassment may also be responsible for underreporting and delay.[4] Sometimes, injuries are brought to notice when they become life-threatening.[5] An injury would be missed in such a case if the examination is done digitally, without a speculum. Therefore, speculum examination must be done in all women with abnormal vaginal bleeding to rule out trauma as the cause of bleeding.[6],[7] Smith et al. reported misdiagnosis in 12 of 19 cases in their study.[8] When the assessment is not possible because of pain or the presence of a large clot obscuring the injury, an examination must be done under anesthesia.[9] Vulvovaginal injuries in children have forensic implications as young girls are potential victims of rape. In suspected cases, injuries must be carefully examined and swabs collected as a precaution in case rape was the true cause of injury.[6]

Victims of lower genital tract injuries in this study were most frequently aged 6, 10, or 25 years, and the most vulnerable age group was 6–10 years. Similar to the present study Danso also reported children <10 years (22.9%) to be at the greatest risk of genital injury.[3] In other studies, however, genital injuries were the most common in the 20–30 years of age group.[6],[9],[10] All cases presented with a history of bleeding per vaginum. The most common type of injury was laceration, and the most common site was the vagina. Similar findings are documented in other researches.[3],[4],[6] Repair of lacerations was required in 21 of 39 (54%) cases though in other studies, primary repair was attempted in a greater number of women, i.e., 87%–96%.[4],[6] Seven women (20%) were transfused blood. Anemia in hemodynamically stable women was managed with intravenous iron sucrose, available free of cost. In other studies, a greater proportion of women was reported to be transfused blood, i.e., 28.5% by Jana et al., 50% by Sau et al.[4],[7]

Noncoital injuries (59%) predominated over coital injuries in this study like in other studies from India and other developing nations, ranging from 58% to 75%. Fall was the most common cause of noncoital injuries in all.[3],[4],[6] Researches from higher-income countries have reported a greater proportion of coital injuries which may relate to the sexual practices and behavior while in low-income countries, socio-cultural factors may deter reporting of coital injuries.[3],[4] In a small study of 12 cases from Australia, all lower genital tract injuries were coitus related.[9] In another study from the United States, coital injuries contributed to 61% (18/31) cases of genital trauma.[11]

Roadside trauma more commonly results in injuries to the upper genital tract, i.e., gravid uterus, ovary, tube, etc., and are also more serious than lower genital tract injuries.[11] Vulva being protected direct injury is rare. The vagina may be injured indirectly in open variety pelvic fracture. Vaginal lacerations from a pelvic fracture, if undetected, may lead to pelvic abscess and osteomyelitis. Fallat ME et al. reported five cases of pelvic fracture, of which three were an open type. In this study, there were two cases of pelvic fracture resulting from roadside trauma, both of the closed type. They sustained lower genital trauma from direct impact on the vulva.

Coital injuries are usually minor and self-limiting though sometimes, women may avoid consultation in spite of significant blood loss. Young virgins and postmenopausal women have been considered to be at risk.[12],[13] Early age at marriage and a vast difference in age of husband and wife leading to peno-vaginal disproportion, vigorous and violent thrusting of the penis under the influence of alcohol, lack of foreplay are some of the factors responsible in causing coital injury, especially at first intercourse.[14],[15] Menopause, a hypoestrogenic condition leads to vulvovaginal thinning, atrophy, and reduced elasticity from loss of collagen, which makes the vagina susceptible to injuries.[16],[17] However, most studies now support that parous women in reproductive age, particularly during breastfeeding, are at equal or greater risk.[4],[7] Like menopause, lactation is also a hypoestrogenic condition and can predispose to injury during normal sexual act.[6] This study also supports that injuries in parous women are not so uncommon. All three parous women with coital injuries in the present study and five of nine in Sill's study used to breastfeed at the time when they suffered coital injury.[6]

In virgin women, genital injuries during 1st intercourse are usually seen to be limited to lower vagina and introitus while in parous women injuries are more common in the upper vagina.[6],[7] Dickinson postulated that upper vagina being unsupported, except anterolaterally, is more prone to lacerations. He also observed that the right fornix being larger is more likely to accommodate the glans penis and hence more likely to be stretched. A tear may then occur across the posterior fornix.[18] Levator muscle spasm rather than direct injury has also been suggested as an alternative mechanism for tears in the upper vagina.[15] In this study, in all the four virgin women, injuries were seen in the upper vagina. Spasm of levator muscle may occur due to vaginismus, a condition common in virgin women and may explain these injuries. Five of 9 cases (55%) of postcoital injuries required surgical repair in the present study. In a review by Geist, 75% of coital injuries were managed surgically.[19]

Rape and sexual violence accounted for 15% of the total genital injuries. A similar figure was reported in a study from Ghana[3] though the study from Papua New Guinea, way back in 1989, reported an alarmingly high proportion of cases, i.e., 36% from rape and sexual assault.[6] Of five cases alleging genital injuries from rape in this study, four were girls <12 years. The other was a case of a postmenopausal lady who was fisted in the vagina. Sexual assault was alleged by a woman who was also pregnant at the time of injury. Overall, the victims comprised of either pregnant or postmenopausal women or children, and in most cases, the accused was a person known to the victim. This reflects the antisocial and criminal background of the accused/assailants. Health professionals certainly have an important role in eradicating such heinous crime from society. Ample evidence should be collected and injuries documented so that the law enforcing agencies can make a conviction.

Vaginal vault lacerations extending into peritoneal cavity occur in <1% women.[19] Omental prolapse following sexual assault and intestinal prolapse following consensual coitus have been reported before, both requiring laparotomy subsequently.[6],[10] In this study, vaginal vault perforation was seen in a prepubertal girl, an alleged victim of rape. Fortunately, in the absence of visceral herniation, laparotomy was averted by repairing the injury vaginally.

Most cases of fall (10/18), automobile accidents (3/3), and rape (4/5) in this study seen in prepubertal or adolescent girls were a disturbing fact. Poor lighting, long power cuts and unsafe dwellings were some of the underlying causes of fall. The children belonged to low socioeconomic status, and their parents spending major time earning livelihood were unable to take proper care. Danso also reported more than 50% of cases of fall occurring in children <10 years. He suggested that children fall easily as they do not have a well-developed sense of danger and are not mindful of their environment when playing.[3] Sill also observed falls and rape to be more common in young girls.[6] Importantly, children should be taught safety measures while they are playing or on the road. We should also make them aware and careful so that they do not become victims of rape. Providing free boarding facilities in schools could be a preventive step by the government in this direction.

Cattle horn injuries, more common in rural areas, can sometimes be difficult to assess because of concomitant urethral, perineal, vulvar, and anorectal injuries. If missed, they may be potentially fatal.[4] Jana N et al. reported anorectal injuries in a young girl missed in the first instance that resulted in florid sepsis later. Insertion of chemical preparations in the vagina to ward off vaginal discharge, dysmenorrhea, unwanted pregnancy, etc., is a common cultural practice in some places like Ghana.[3] Chemical injuries can have a devastating effect on fertility, reproductive outcome and coital function. In the present study, the insertion of chemical preparation in a woman to affect abortion resulted in sloughing off of the posterior lip of cervix. Cattle horn and leech bite injuries are related to the socioeconomic status and cultural practices. This is evident in two studies from the same country. A study from the rural background of West Bengal, India, reported cattle horn and leech bite injury to be quite common (20% and 9%) while that from the city of Chandigarh, India, reported only a single case of cattle horn injury during 4 years.[4],[7]

The strength of the present study is a large number of genital injury cases of varied etiology. Most of the previously reported studies were limited to case reports[20] or case series.[2],[6],[9],[10] Some studies have focused on coital injuries alone[2],[15] or coital injuries in cases of rape/sexual assault.[21] In some that included cases of varied etiologies, injuries resulting from sexual assault were intentionally excluded or not encountered.[4],[7] Danso's study included injuries of varied etiology but did not discuss their treatment.[3] In the present study, all types of coital injuries, as well as noncoital injuries along with their treatment, have been discussed. In comparison to other studies, a difference was seen in the lead causes and the population susceptible to genital tract trauma. However, being a retrospective study, details like the extent of the wound, as measured in centimeter and quantitative estimate of blood loss were not available in some cases. It was also not possible to assess long-term sequelae.


   Conclusions Top


Victims of lower genital tract injuries in this study were mostly children (6–10 years) or young patients of about 25 years. Noncoital injuries (59%) predominated over coital injuries. Cause of noncoital injuries in most cases was fall (25.4%), automobile accidents (7.6%), and rape (10.25%) and was commonly seen in prepubertal or adolescent girls. Consensual coital injury acquired either during 1st intercourse (10.25%) or during 1st intercourse after child birth (7.6%). Rape and sexual violence accounted for 15% of the total genital injuries. All cases presented with a history of bleeding per vaginum. Vaginal laceration was the most common injury. Repair of lacerations was required in 54% cases and blood transfusion in 20% of cases. Patients recovered well after management without any major morbidity or mortality.

Research quality and ethics statement

This study was approved by the Institutional Review Board/Ethics committee at Baba Raghav Das Medical College Gorakhpur (Approval # 49/2020; Approval date Feb 15, 2020). The authors followed the applicable EQUATOR Network (http://www.equator-network.org/) guideline, specifically the STROBE guideline, during the conduct of this research project.

Acknowledgments

We would like to thank all women who took part in the survey.

Financial support and sponsorship

All work was done by the author's personal expenditure.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sarkar M, Mandal J, Roy D. Non obstetric genital tract injury in a rural Indian medical college. J Evol Med Dent Sci 2018;7:5003-5.  Back to cited text no. 1
    
2.
Sloin MM, Karimian M, Ilbeigi P. Nonobstetric lacerations of the vagina. J Am Osteopath Assoc 2006;106:271-3.  Back to cited text no. 2
    
3.
Danso KA, Turpin CA. Vulvo-vaginal injuries: Analysis of 170 cases at Komfo Anokye Teaching Hopital, Kumasi, Ghana. Ghana Med J 2004;38:116-9.  Back to cited text no. 3
    
4.
Jana N, Santra D, Das D, Das AK, Dasgupta S. Nonobstetric lower genital tract injuries in rural India. Int J Gynaecol Obstet 2008;103:26-9.  Back to cited text no. 4
    
5.
Ikedife D. Fatal coital rupture of pouch of Douglas. Niger Med J 1976;6:210-1.  Back to cited text no. 5
    
6.
Sill PR. Non-obstetric female genital tract trauma in Port Moresby, Papua New Guinea. Aust N Z J Obstet Gynaecol 1987;27:164-5.  Back to cited text no. 6
    
7.
Sau AK, Dhar KK, Dhall GI. Nonobstetric lower genital tract trauma. Aust N Z J Obstet Gynaecol 1993;33:433-5.  Back to cited text no. 7
    
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Smith NC, van Coeverden de Groot HA, Gunston KD. Coital injuries of the vagina in non-virginal patients. S Afr Med J 1983;64:746-7.  Back to cited text no. 8
    
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Jones IS, O'Connor A. Non-obstetric vaginal trauma. Open J Obstet Gynecol 2013;3:21-3.  Back to cited text no. 9
    
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Habek D, Kulas T. Nonobstetrics vulvovaginal injuries: Mechanism and outcome. Arch Gynecol Obstet 2007;275:93-7.  Back to cited text no. 10
    
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Fallat ME, Weaver JM, Hertweck SP, Miller FB. Late follow-up and functional outcome after traumatic reproductive tract injuries in women. Am Surg 1998;64:858-61.  Back to cited text no. 11
    
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Jeffcoate TN. Principles of Gynaecology. 4th ed. London: Butterworths; 1975. p. 233.  Back to cited text no. 12
    
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Biggs M, Stermac LE, Divinsky M. Genital injuries following sexual assault of women with and without prior sexual intercourse experience. CMAJ 1998;159:33-7.  Back to cited text no. 13
    
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Van de Velde TH. Ideal Marriage: Its Physiology and Technique. New York: Random House Publishers; 1963. p. 205.  Back to cited text no. 14
    
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Ahnaimugan S, Asuen MI. Coital laceration of the vagina. Aust N Z J Obstet Gynaecol 1980;20:180-1.  Back to cited text no. 15
    
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Ramin SM, Satin AJ, Stone IC Jr., Wendel GD Jr. Sexual assault in postmenopausal women. Obstet Gynecol 1992;80:860-4.  Back to cited text no. 16
    
17.
Templeton DJ. Sexual assault of a postmenopausal woman. J Clin Forensic Med 2005;12:98-100.  Back to cited text no. 17
    
18.
Dickinson RL. Atlas of Human Sex Anatomy. 2nd ed. Baltimore: Williams & Wilkins Co.; 1949. p. 100-1.  Back to cited text no. 18
    
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Geist RF. Sexually related trauma. Emerg Med Clin North Am 1988;6:439-66.  Back to cited text no. 19
    
20.
Virgili A, Bianchi A, Mollica G, Corazza M. Serious hematoma of the vulva from a bicycle accident. A case report. J Reprod Med 2000;45:662-4.  Back to cited text no. 20
    
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Bowyer L, Dalton ME. Female victims of rape and their genital injuries. Br J Obstet Gynaecol 1997;104:617-20.  Back to cited text no. 21
    


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