Goals of Treatment Girls have some specific anatomic findings that may bring them in for evaluation The key to treatment is differentiating the few true emergencies from the more benign presentations Clinical Recognition The one anatomic urologic finding in a female that should cause alarm is the presence of a vaginal mass This may represent vaginal rhabdomyosarcoma The patient with a vaginal mass needs immediate referral to and evaluation by urology and oncology Some more benign vaginal “masses” may include vaginal cysts, Gartner duct cysts, Bartholin cysts, and paraurethral cysts These cysts may represent isolated findings, or could represent an ectopic ureter draining into the introitus Additionally, a pelvic or vaginal mass may represent hydrometrocolpos in a patient with vaginal agenesis, atresia, stenosis, or imperforate hymen Other female urologic issues that may present to the ER are urethral prolapse and labial adhesions Clinical Assessment If there is concern for a lower abdominal or pelvic mass on history or physical examination, a renal bladder ultrasound and a pelvic ultrasound should be performed The pelvic ultrasound will help to further define the vaginal mass, and a renal bladder ultrasound will help determine the etiology (duplicated kidney, absent kidney, hydroureteronephrosis) Urethral prolapse typically presents in African-American girls aged ∼6 to 11 years (but can occur at any time from birth to ∼11 years old) This entity often presents with spotting of blood in the underwear, but is otherwise asymptomatic On examination, a red ring of prolapsed mucosa surrounding the urethra is noticeable The introitus must be seen to be separate and uninvolved Labial adhesions appear as a “median raphe” formed by the two edges of labia minora Most commonly they begin at the posterior fourchette and extend toward the clitoris, with a pinpoint opening for urine to come out Symptoms may include UTI symptoms, dysuria, or spraying with urination Management For urethral prolapse, observation alone is often sufficient, but can be combined with estrogen cream and/or sitz baths For recurrent cases, surgical excision of the prolapsed mucosa may prevent further episodes