urinary tract infection, weak pelvic floor muscles, and increased intra-abdominal pressure associated with chronic cough or constipation Some patients with urethral prolapse complain of dysuria or urinary frequency but most have painless bleeding as their only symptom Prolapse is diagnosed by its characteristic nontender, soft, doughnut-shaped mass anterior to the vaginal introitus The ring of protruding urethral mucosa is swollen and dark red with a central dimple that indicates the meatus When the child is supine, the prolapse is often large enough to cover the vaginal introitus and appears to protrude from the vagina Bleeding comes from the ischemic mucosa Urethral prolapse is sometimes mistaken for a urethral cyst or polyp, which may lead to vaginal bleeding; these lesions not surround the entire urethral orifice symmetrically If the diagnosis of urethral prolapse is in doubt, one may safely catheterize the bladder through the prolapse to obtain urine Most patients will improve with the use of sitz baths and topical estrogen creams applied twice daily In rare circumstances where the patient has difficulty voiding or if estrogen therapy fails, referral for surgical evaluation and possible excision of the prolapsed tissue is necessary BLEEDING IN THE NONPREGNANT ADOLESCENT PATIENT Normal Menstrual Cycle When an adolescent girl presents with a chief complaint of irregular menses, the emergency department (ED) physicians must first differentiate between normal and abnormal bleeding In most cases, a comprehensive history and physical examination, along with minimal ancillary testing, will uncover the etiology and guide management An understanding of the menstrual cycle and its hormones is key to treating the most common cause of adolescent uterine bleeding, anovulatory cycles Menstrual patterns during the first years after menarche vary The normal menstrual cycle averages 28 days but varies from 21 to 35 days Ninety-five percent of young adolescents’ menstrual periods last between and days; duration of days or more is considered abnormal An occasional interval of less than 21 days from the first day of one menstrual period to the first day of the next is normal for teenagers, but several short cycles in a row are abnormal Typical bleeding requires adolescents to change a pad or tampon four to five times daily without resultant anemia but this number may vary depending on individual hygiene practices During puberty, the hypothalamic–pituitary–ovarian axis regulates the development of secondary sexual characteristics and menstruation During the early teenage years, the menstrual cycles may be irregular due to immaturity of the hypothalamic–pituitary–ovarian axis Occasionally, an adolescent girl is brought to the ED by her parents to confirm their belief that she is having her first menstrual period About 65% of girls are in sexual maturity stage (Tanner stage 4) for breast development when menarche occurs ( Table 79.1 ) Of the remaining girls, about 25% are in breast development stage and 10% are in stage If the adolescent’s chronologic age and degree of pubertal development are consistent with this expected pattern of maturation, no further evaluation is necessary The normal menstrual cycle is divided into three phases based on the physiologic processes occurring in the ovary and uterus The ovarian cycle consists of the follicular phase, ovulation, and luteal phase, whereas the uterine cycle is divided into menstruation, proliferative phase, and secretory phase By convention, the cycle is counted in days beginning with the first day of bleeding During the follicular phase, ovarian follicles are stimulated by the release of pituitary follicle-stimulating hormone (FSH), one or two of the follicles become dominant, and the nondominant follicles atrophy The predominant hormone secreted from the ovary during the follicular phase is estrogen and induces proliferation within the uterine lining Approximately midcycle, there is a surge in secretion of luteinizing hormone (LH) from the pituitary stimulating ovulation, the release of an egg from the dominant follicle In the absence of fertilization, the ovum becomes the corpus luteum and secretes large amounts of progesterone Progesterone counteracts the estrogen effects on the endometrium, inhibiting its proliferation and producing glandular changes to prepare the lining for implantation of a fertilized ovum Estrogen and progesterone exert a negative feedback on FSH and LH secretion and these levels subsequently decrease In the absence of implantation, the corpus luteum involutes, progesterone and estrogen levels fall, the endometrium sloughs away and menstruation ensues, starting the cycle over again TABLE 79.1 DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING I At any time A Trauma B Tumor II Before normal menarche A Hormonal Neonatal bleeding Exogenous estrogen Precocious puberty B Nonhormonal Urethral prolapse Genital warts Lichen sclerosus Infectious vaginitis Foreign body III After menarche A Bleeding diathesis B Pelvic infection C Endocrinologic problem Midcycle spotting Abnormal uterine bleeding a Hormonal contraception b Axis immaturity c Polycystic ovarian syndrome d Hypothyroidism e Ovarian cyst D Ectopic pregnancy E Spontaneous abortion F Placenta previa G Abruptio placentae Terminology The American College of Obstetrics and Gynecology has recommended replacing the phrase dysfunctional uterine bleeding (DUB) with the phrase abnormal uterine bleeding (AUB) when describing an adolescent with prolonged vaginal bleeding Abnormal bleeding may be characterized as menorrhagia, defined as bleeding that occurs at regular intervals but lasts more than consecutive days or in excess of 80 mL Metrorrhagia is defined as bleeding that occurs at irregular intervals Menometrorrhagia denotes heavy and irregular bleeding Evaluation and Decision in the Nonpregnant Adolescent A comprehensive history and physical examination, along with minimal ancillary testing, usually points to an etiology to guide management (see Fig 79.3 ) The detailed history includes a review of the patient’s menstrual history including age at menarche, usual cycle duration, a relative estimate of usual blood loss, and how the current symptoms may differ from baseline Heavy bleeding from the first period may indicate an underlying bleeding disorder, most commonly von Willebrand disease Abdominal cramping may occur at the time of ovulation due to progesterone secreted in the luteal phase Prostaglandins released from the endometrium at the time of menstruation may contribute to uterine cramping, nausea, vomiting, or diarrhea, which are all common features of dysmenorrhea NSAIDs may alleviate the discomfort of dysmenorrhea by inhibiting prostaglandin release The presence of dysmenorrhea is not usually a feature of anovulatory bleeding Other pertinent historical details include the presence or absence of trauma, fainting, dizziness, fever, easy bruising, and excessive bleeding at other sites Postural dizziness and other signs of anemia can be elicited Questions regarding sexual activity, the possibility of pregnancy, sexual abuse, and/or sexually transmitted infection should be asked with the teen alone An opportunity for private conversation between a teen and her physician without parent(s) is a routine and necessary part of the adolescent medical evaluation regardless of chief complaint The physical examination helps the clinician determine the severity of blood loss in order to narrow the differential diagnosis The ED physician begins with an assessment of vital signs and the patient’s hemodynamic status Tachycardia, hypotension, orthostatic changes, and/or signs of anemia may indicate more significant blood loss The mucous membranes, conjunctiva, and palms of the hands/feet should be assessed for pallor The skin should be examined for signs of androgen excess such as acne, hirsutism, or acanthosis nigricans as well as purpura or petechiae to suggest an underlying bleeding disorder The thyroid should be palpated for nodules or enlargement Presence of a soft systolic flow murmur may be noted during the cardiac examination in the setting of anemia