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Doi:10.1016/j.jpag.2009.01.023

metabolic and sexual/reproductive adverse events asso- Comments: The finding of an isolated hymenal in- ciated with antimanic agents and co-prescribed psycho- jury without bruising or injury to the external genita- tropic medications. Carbamazepine, and co-prescribed lia is diagnostic of a penetrating injury, and raises selective serotonin reuptake inhibitors and antipsy- suspicions of sexual abuse. Although straddle injuries chotics impart the highest risk of developing metabolic usually cause signs of trauma to the external genitalia, and sexual/reproductive adverse events and require vigi- very rarely isolated penetrative hymenal injuries have lant monitoring in preadolescent and adolescent patients.
been reportedwith accidental injury. This may occurin the context of falling onto a projecting object. A careful social history should always be elucidated torule out sexual abuse, and child abuse physiciansshould be consulted.
Labial Bruising Due toa Straddle Injury: A Case Severely Obese AdolescentFemales Seeking Bariatric Joe¨lle Dennie, MSc, MD, FRCSC,Anne Smith, MBBS, FRACP, and Yasmin Jayasinghe, MBBS, FRANZCOGRoyal Children’s Hospital, Parkville, Victoria, Australia Jennifer B. Hillman, MD, MS, RachelJ. Miller, MD, and Thomas Inge, MD, PhD Background: Straddle injuries are known for caus- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH ing lacerations, ecchymoses and abrasions to the ex-ternal genitalia, including the mons, clitoris and Background: Obesity affects nearly every organ labia. Impalement injuries can also cause trauma to system in the body, including the reproductive organs.
the vagina, anus, rectum and peritoneal cavity as well For example, polycystic ovary syndrome (PCOS) is as the external genitalia. Injuries to the hymen often more common among obese than non-obese females.
raise the suspicion of sexual abuse. We present a case Additionally, contraceptive options are often limited of an alleged straddle injury resulting in an isolated by obesity-related comorbidities that are contraindica- tions to estrogen-containing contraceptives. Some Case: A 7 year old girl presented to the Emergency contraceptives result in weight gain, and others have Department with vaginal bleeding soon after falling decreased efficacy with severe obesity. As bariatric onto a bed rail. The fall was reported to have been wit- surgery has recently become a treatment option for se- nessed by her female cousin, and family members in the verely obese adolescents, gynecologic consultation house at the time became aware of events immediately.
among this group has become even more essential.
She was otherwise healthy. An examination in the ED The American College of Obstetricians and Gyneco- revealed no laceration or bruising visible on the labia logists recommends postponing pregnancy 12-18 majora or minora. There was a small purple bruise on months after bariatric surgery due to the surgically the inner right thigh. Clot and fresh blood was seen induced catabolic state and nutritional concerns.
coming from the introitus, but the exact site of injury Intrauterine contraception is a viable contraceptive was hard to visualize. She denied any abdominal pain alternative and provides non-contraceptive benefits.
and was able to pass urine. Behavioural assessment Little is known about reproductive issues and accept- was consistent with her history. When she was exam- ability of the levonorgestrel releasing intrauterine sys- ined under general anesthesia, a small 3mm laceration tem (IUS) among severely obese adolescents seeking was observed at the base of the hymen at the 7 o’clock position. It did not extend to the edge of the hymen Methods: This is a retrospective chart review of fe- which did not appear to be injured. There was minimal males who underwent bariatric surgery at an aca- bruising to the fossa navicularis. The bleeding ceased demic children’s hospital in the Midwestern United States from September 2006 through mid-November After discussion with the child forensics service 2008. We included girls age 13 and older who were a further careful social history was taken following seen preoperatively for gynecologic consultation the examination under anesthesia. No concerns regard- (n528) and excluded girls with hypothalamic amen- ing sexual abuse were raised by the parents or child.
orrhea or other conditions associated with primary

Source: http://www.vfpms.org.au/pages/documents/hymenalinjury.pdf

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