Question

A woman develops a painful, tense, fluctuant swelling in the vulvovaginal region following a forceps delivery, along with difficulty in passing urine. The most likely diagnosis is:

• A. Vulvovaginal hematoma
• B. Urethral diverticulum
• C. Cervical tear
• D. Local infection / abscess

Hint:

Acute, tense, painful swelling right after forceps = blood collecting in the tissue planes.

Answer 1

The Correct Option is A

Step 1: Read the clinical clues. The key features are (a) recent forceps (instrumental) delivery, (b) pain, (c) a fluctuant, tense swelling in the vulvovaginal area, and (d) difficulty in micturition from local pressure.

Step 2: Link mechanism to diagnosis. Forceps application traumatises the vaginal and paravaginal tissues and can shear blood vessels beneath an intact mucosa. Bleeding then collects in the loose paravaginal/vulval tissue planes, producing a puerperal hematoma. A hematoma classically presents as an acute, painful, tense, fluctuant swelling appearing soon after delivery, and a large one presses on the urethra to cause urinary retention or difficulty voiding.

Step 3: Confirm the answer. The combination of immediate post-instrumental onset, severe pain, fluctuant tense swelling and voiding difficulty is the textbook picture of a vulvovaginal hematoma.

Step 4: Why the others are wrong. A urethral diverticulum is a chronic condition presenting with post-void dribbling, dyspareunia and a small anterior-wall swelling, not an acute post-forceps tense mass. A cervical tear presents with continuous fresh bleeding from a contracted uterus, not a fluctuant vulval swelling. Local infection/abscess evolves over days with fever and erythema, not immediately after delivery.

Key fact: An acute, painful, fluctuant vulvovaginal swelling with urinary difficulty after instrumental delivery is a puerperal (vulvovaginal) hematoma.