Perineal Hematoma: Causes, Symptoms & Treatment

A perineal hematoma is a localized collection of blood in the perineum (the region between the anus and genitals). It results from vascular injury and can range from small/self-limiting to large/life-threatening.

Causes

• Obstetric trauma: Vaginal delivery (especially operative: forceps, vacuum), episiotomy, perineal lacerations (3rd/4th degree).
• Trauma: Straddle injuries, falls, assault, pelvic fractures.
• Surgical: Perineal/rectal/vaginal procedures, hemorrhoidectomy.
• Spontaneous: Anticoagulation, bleeding disorders (hemophilia, von Willebrand), vascular malformations.

Symptoms

• Perineal pain (often severe, throbbing)
• Swelling, bruising (ecchymosis), palpable mass
• Difficulty sitting, walking, voiding, defecating
• Urinary retention (compression of urethra)
• Signs of anemia (if large/rapid): tachycardia, hypotension, pallor

Diagnosis

• Clinical exam: inspection, palpation, speculum/rectal exam.
• Ultrasound/CT/MRI: delineate extent, rule out extension (ischiorectal fossa, retroperitoneum).
• Labs: CBC, coagulation studies, type & screen.

Treatment

Conservative (Small/Stable Hematomas)

• Ice packs (20 min on/off)
• Analgesia (NSAIDs, opioids if needed)
• Sitz baths (after 24–48 hrs)
• Elevation, donut cushion
• Monitor for expansion

Surgical (Large/Expanding/Infected)

• Incision and drainage under anesthesia
• Hemostasis: suture ligation, electrocautery, topical agents
• Packing or drain placement
• Debridement if necrotic/infected
• Transfusion if hemodynamically unstable

Complications

• Infection/abscess
• Necrotizing fasciitis (rare, fatal)
• Urethral stricture, fistula
• Chronic pain, dyspareunia

Prompt recognition and appropriate management—conservative or surgical—prevent morbidity. High index of suspicion in postpartum and anticoagulated patients.