children unable to provide a clean-catch specimen A pregnancy test should be obtained in all menstruating females presenting with a urinary complaint, and sexually transmitted infection (STI) testing (including urine gonococcal and chlamydial testing) is warranted for sexually active adolescents Additional urinary studies, such as urine chemistries, may be indicated if renal parenchymal or tubular diseases, such as Fanconi syndrome, are suspected Serum testing should be undertaken if the diagnosis is not readily apparent or if indicated by the potential diagnosis implied by the urinalysis If there is concern for renal parenchymal disease, then electrolytes, blood urea nitrogen, creatinine, and calcium should be obtained Serum electrolytes should be evaluated when concern exists for either central or nephrogenic DI, and a venous blood gas, in addition to a hemoglobin A1C, should be collected when concern for DM exists Inflammatory markers can be helpful if appendicitis is suspected FIGURE 78.1 Interpretation of urinalysis Imaging studies obtained emergently should be guided by the differential diagnosis A renal and bladder ultrasound is useful in assessing for nephrolithiasis, and is indicated nonemergently for UTIs that occur in infants Ultrasounds of the appendix and pelvis are warranted if appendicitis or ovarian torsion, respectively, are being considered An abdominal radiograph to assess stool burden can be obtained if constipation is suspected as the etiology of urinary frequency If a neurogenic bladder (related to a spinal cord lesion such as a tethered cord) or a space-occupying lesion (leading to central DI) is suspected, emergent neuroimaging, either via CT scan or MRI, is warranted A specialty consultation by a nephrologist is indicated if underlying renal parenchymal disease is suggested by history, physical examination, or laboratory studies; or by a urologist if obstructive urolithiasis or urethral disease is suspected Suggested Readings and Key References Balighian E, Burke M Urinary tract infections in children Pediar Rev 2018;39:3–12 Bergmann M, Corigliano T, Ataia I, et al Childhood extraordinary daytime urinary frequency—a case series and a systematic literature review Pediatr Nephrol 2009;24:789–795 Fernandez-Ibieta M, Ayuso-Gonzalez L Dysfunctional voiding in pediatrics: a review of pathophysiology and current treatment modalities Curr Pediatr Rev 2016;12:292–300 Muhammad S, Nawaz G, Jamil I, et al Constipation in pediatric patients with lower urinary tract symptoms J Coll Physicians Surg Pak 2015;25:815–818 Parekh DJ, Pope JC IV, Adams MC, et al The role of hypercalciuria in a subgroup of dysfunctional voiding syndromes of childhood J Urol 2000;164:1008–1010 Shaikh N, Morone NE, Bost JE, et al Prevalence of urinary tract infection in childhood: a meta-analysis Pediatr Infect Dis J 2008;27:302–308 CHAPTER 79 ■ VAGINAL BLEEDING MAMATA V SENTHIL, ALISON ROCKEY, LAUREN E ZINNS, JENNIFER H CHUANG, JILL C POSNER INTRODUCTION Vaginal bleeding can be either a normal event or a sign of disease Pathologic vaginal bleeding may indicate a local genital tract disorder, systemic endocrinologic or hematologic disease, or a complication of pregnancy During childhood, vaginal bleeding is abnormal after the first few weeks of life until menarche After menarche, abnormal vaginal bleeding must be differentiated from menstruation When evaluating patients with vaginal bleeding, it is important to distinguish between three types of bleeding: (1) prepubertal bleeding, (2) bleeding in nonpregnant adolescent females, and (3) bleeding associated with pregnancy VAGINAL BLEEDING IN THE PREPUBERTAL PATIENT Evaluation and Decision Important elements of the history include symptom onset, prior history of bleeding, associated abdominal pain, concern for foreign body, recent infections such as sore throat or diarrhea, rashes, masses, perineal skin changes, urinary and/or bowel symptoms, and estrogen-containing medications When trauma is suspected, questions pertaining to the mechanism of injury and concerns for sexual abuse guide management ( Fig 79.1 ) During the physical examination, the emergency clinician should note signs of hormonal stimulation (i.e., breast development, pubic hair growth, a dull pink vaginal mucosa, or physiologic leukorrhea), thyroid enlargement, and skin findings such as petechiae, excessive bruising, or café-au-lait spots Next, it is important to determine the source of bleeding For the initial examination of the genitalia, an infant or child should be placed in frog-leg position with heels near the buttocks while holding the legs flexed on the parent’s lap or examining table ( Fig 79.2A ) After inspecting the external genitalia, the left and right labia majora should be gently grasped by the examiner in an outward and downward direction to visualize the introitus and identify the source of bleeding If the vaginal tissues cannot be observed adequately, the knee-chest position is an alternative examination technique, allowing for relaxation of the abdominal musculature ( Fig 79.2B ) This position, however, may be uncomfortable, especially for patients with suspected sexual abuse or trauma Utilizing a child life specialist to assist in preparing the patient before the examination and aid with positioning may be beneficial A vaginal speculum should never be used in a young, awake child As genital injuries can be associated with peritonitis and/or rectal perforation, a careful abdominal examination and consideration for rectal examination is warranted Occasionally, a need for a more thorough examination under anesthesia by a pediatric surgeon, urologist, or gynecologist is necessary Laboratory evaluation for prepubertal patients is based upon the most likely diagnoses Vulvar Bleeding The vulva consists of several structures: the labia majora, labia minora, clitoris, and vaginal introitus A premenarcheal girl with the complaint of vaginal bleeding whose vulva looks abnormal may have a vaginal disorder, vulvar disorder, or both Trauma Most vaginal trauma results from a blunt straddle injury from a fall onto a hard surface causing an abrasion, a laceration, or a hematoma of the anterior genital tissues (labia, urethra, or clitoris) Penetrating trauma and sexual assault may damage the posterior tissues as well (hymen, vagina, rectum) Even a minor vulvar injury should alert the emergency physician to the possibility of concurrent, potentially serious vaginal, rectal, or abdominal injuries An upright abdominal X-ray should be obtained to evaluate for free air if there is concern for a penetrating abdominal injury Vulvar lacerations not often bleed excessively and usually not require repair However, resulting hematomas can extend widely through the tissue planes, forming large, painful masses that occasionally produce enough pressure to cause necrosis of the overlying vulvar skin Pressure dressings and ice packs can aid with healing Since minor periurethral injuries can produce urethral spasm and acute urinary retention, the injured child’s ability to void should be assessed Consider the possibility of sexual assault in every child with a genital injury Genital Warts Similar to vulvar trauma, genital warts are recognized by inspection and can produce bleeding from minor trauma when they are located on the mucosal surface of the introitus They appear as flesh-colored papules and are usually due ... Dysfunctional voiding in pediatrics: a review of pathophysiology and current treatment modalities Curr Pediatr Rev 2016;12:292–300 Muhammad S, Nawaz G, Jamil I, et al Constipation in pediatric patients... and concerns for sexual abuse guide management ( Fig 79.1 ) During the physical examination, the emergency clinician should note signs of hormonal stimulation (i.e., breast development, pubic hair... examination is warranted Occasionally, a need for a more thorough examination under anesthesia by a pediatric surgeon, urologist, or gynecologist is necessary Laboratory evaluation for prepubertal