The Vulva: An Uncommon Presentation of a Pressure Ulcer

Pressure ulcers may develop in different locations. Vulvar pressure ulcers can be easily misdiagnosed and, moreover, have been rarely reported in the literature. Surgical procedures that involve prolonged pressure on this area may trigger these lesions. Case Report. The authors present a case of a vulvar pressure ulcer secondary to the use of a perineal post to provide countertraction during surgical repair of a hip fracture. Diagnosis was made after excluding other possible causes with anatomopathological and microbiological analysis. Wound care was based on relieving local pressure. Conclusion. Faced with the acute development of ulcers in the external genitals of women after this kind of surgical procedure, even with the use of padded posts, diagnosis of a pressure ulcer should be considered after excluding other possible causes.

The vulvar region is an unusual location for a pressure ulcer, and few cases have been reported. The essential mechanisms for the development of pressure ulcers are pressure and tissue ischemia. Even though the more frequent trigger is the pressure of the body against a bed, any other prolonged pressure on the body can produce these lesions.¹ The authors present the case of a patient who developed a vulvar pressure ulcer secondary to a surgical repair of a hip fracture with an intramedullary nail.

An 82-year-old woman with history of hypertension, dyslipidemia, and obesity was hospitalized in the geriatric department. She presented with a large, painful ulcer involving the internal faces of her labia majora and its posterior commissure. The mucous membrane was preserved. The lesion had well-defined erythematous edges and a wound bed covered with fibrous tissue (Figure 1). No bullae were observed. 

Four days prior to the authors’ examination, she had undergone a surgical repair of a hip fracture with an intramedullary nail. Postoperative evolution was normal. The patient had been feeling pain for 3 days, but she had not notified the surgeon about pain in the area; consequently, her external genitals had not been previously explored. Other mucosal areas were examined to exclude systemic involvement. Her oral mucosa was preserved. Skin biopsies were taken for anatomopathological and microbiological analysis. Histological findings showed an acute inflammatory infiltrate with no specific features. Bacterial culture and polymerase chain reaction (PCR) test for herpes simplex virus were negative. After excluding possible inflammatory or infectious causes, the diagnosis of a vulvar pressure ulcer was considered.

The hip surgery involved the use of a perineal post to provide countertraction (Figure 2). Even though a padded perineal post was used and the procedure lasted less than 1 hour, this pressure ulcer was suspected to have developed secondary to tissue ischemia during surgery. Femoral pulses were palpable, and the hip incisions healed without complication. Following the indications of care after hip surgery, the patient was asked to maintain the proper position in order not to bend the hip beyond a right angle and to keep her legs apart. These conditioning factors hindered frequent position changes and the use of offloading devices, which are important methods in treating pressure ulcers. 

Conventional wound care treatment of a moist environment was started. Hydrogel and soft silicone dressings were used to promote autolytic debridement. Gauze was used to separate the labia majora, keep urine and stool out the wound, and provide offloading to the lesions. Dressing changes were made on alternate days. The patient remained in the hospital for 15 days. Slough decreased and incipient signs of epithelialization in wound edges were observed. She was discharged before achieving complete wound healing and was instructed to continue with proper positioning and conventional treatment. 

Pressure ulcers are mainly associated with bedridden patients. Typical locations are bony prominences that produce continuous pressure against the bed and subsequently develop tissue ischemia. However, a wide variety of situations may produce an increased pressure in different areas of the body and lead to an ulcer. Nasogastric probes, oxygen masks, or urinary catheters may be causative agents.² Other possible sources of external pressure against the body are the medical devices used to facilitate surgical procedures, which may be overlooked as potential triggers, as initially happened in the present case. 

Surgical repair of a hip fracture with an intramedullary nail involves the use of a perineal post, which is commonly padded, to provide countertraction. The surgical procedure normally lasts less than 1 hour. However, as patients who commonly undergo this kind of surgery are elderly with several comorbidities and skin and capillary fragility, ischemia secondary to the pressure of the post against the genitals may develop. Postoperatively, patients are asked to maintain a proper position to avoid bending the hip beyond a right angle and to keep their legs apart. 

Consequently, complications associated with this procedure include injuries secondary to the compressive force exerted by the device. Besides pudendal nerve injuries, soft tissues such as the scrotum and the labia majora may be directly affected. Severity of the lesions may vary from edema or hematoma formation to pressure necrosis.³ 

Diagnosis of a vulvar pressure ulcer is made based on clinical presentation and the presence of a probable trigger. It is confirmed by exclusion of other disorders with microbiological, histological, and immunofluorescence test results. Considering that some diseases present with both cutaneous and mucosal involvement (oral, genital, or both), the physical exam should always include oral mucosa and the skin.⁴ Differential diagnosis includes bullous diseases such as bullous and cicatricial pemphigoid, pemphigus vulgaris, and paraneoplastic syndromes; inflammatory diseases such as erosive lichen planus, erythema multiforme, fixed drug eruption, complex aphthosis, Behçet’s disease, vulvar metastatic Crohn’s disease, hidradenitis suppurativa and pyoderma gangrenosum.⁵ Infectious diseases (ie, herpes simplex and syphilis) may also present with vulvar ulcers. Acute idiopathic vulvar ulcer should also be considered in the premenarchal age. In the elderly, malignancies, such as squamous cell carcinoma or extramammary Paget’s disease, may be considered in differential diagnosis.⁶

In summary, the authors have presented a case of a vulvar pressure ulcer secondary to the use of a perineal post to provide countertraction during surgical repair of a hip fracture. Wound care was based on relieving local pressure. As the vulva is an uncommon localization for pressures ulcers, to improve prevention measures and avoid misdiagnosis, it is important to be familiar with this possible complication after such a common surgical procedure. After this type of surgery, even with the use of padded posts, diagnosis of a pressure ulcer should be considered after excluding other possible causes.

From the Department of Dermatology, Hospital Universitario Infanta Leonor, Madrid, Spain; and the Department of Orthopaedic Surgery, Hospital Universitario Infanta Leonor

Address correspondence to:
Elena Conde Montero, PhD
Consultant
Hospital Infanta Leonor
Department of Dermatology
Alcalá 124, 4b
28009 Madrid, Spain
elenacondemontero@gmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.