Nicole W. Karjane
History of present illness
A seven-year-old girl is brought to the emergency department by her mother because of persistent vaginal bleeding. Her mother reports that she has had blood-stained underwear for the past three weeks. The bleeding is minimal but has been persistent despite efforts to improve hygiene by front to back wiping, sitz baths, and using a bland topical emollient, as recommended by her pediatrician. Her mother notes only slight improvement despite these efforts. There are no other associated symptoms that her mother has noticed. Specific- ally, the child and mother report no fevers, vomiting, bowel changes, abdominal or genital pain, and no vaginal itching or foul-smelling discharge. Both the patient and her mother deny a history or concern for trauma or abuse. She has no significant past medical or surgical history, takes no medica- tions, and reports no recent illnesses. The patient gets routine well-child checks by her pediatrician that have been uneventful.
Physical examination
General appearance:Well-appearing girl who is apprehensive but in no distress
Vital signs:
Temperature: 37.0°C Pulse: 92 beats/min
Blood pressure: 95/50 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air HEENT:Normal
Neck:supple, without thyromegaly or lymphadenopathy Cardiovascular:Regular rate and rhythm
Lungs:Clear to auscultation bilaterally Breasts:Tanner stage I breast development
Abdomen:Soft, nontender, nondistended, no palpable masses
Genitalia:Tanner stage I pubic hair development with fair hygiene and normal prepubertal external genitalia. There were no vulvar or perineal lesions, lacerations, excoriations, or erythema. In frog-leg positioning with labial traction, a normal annular hymen without notches or lacerations is noted. Visualization above the hymen was limited due to patient’s inability to cooperate with further examination, but there was a small greyish mass noted and no active bleeding visualized
How would you manage this patient?
The patient was taken to the operating room for examination under anesthesia. Vaginoscopy was performed (Fig. 72.1).
How would you manage this patient?
The diagnosis is prepubertal vaginal bleeding due to a retained foreign body, in this case, toilet paper. The examination under anesthesia was significant for normal prepubertal external genitalia, a normal hymen, and a foreign body within the vagina. Saline vaginoscopy revealed several pea-size wads of toilet paper, which were irrigated out of the vagina during the procedure. The remainder of the vagina was normal appearing.
The patient did well postoperatively and was instructed on proper wiping and continued good hygiene measures. She had no further bleeding.
Prepubescent vaginal bleeding
Vaginal bleeding prior to puberty is a medical problem that requires thorough investigation. Neonates may experience physiologic vaginal bleeding in the first weeks of life due to withdrawal of maternal estrogen; however, beyond that,
Fig. 72.1 Findings on vaginoscopy.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
vaginal bleeding before puberty must be considered pathologic until proven otherwise. The differential diagnosis of prepuber- tal vaginal bleeding includes: trauma, abuse, vulvovaginitis, condyloma, urethral prolapse, cervical, vaginal, or urethral masses, estrogen-producing ovarian tumors, vaginal foreign bodies, excoriations, or bleeding from the gastrointestinal or genitourinary tract.
To evaluate girls with vaginal bleeding, it is essential to take a thorough history to exclude trauma or abuse as an etiology.
Girls who report abuse or who have perineal trauma should be evaluated by a specialized child sexual assault team that includes trained forensic nurses. Once abuse or trauma has been ruled out, the possibility of exogenous estrogen exposure should be explored, as well as history of recent illnesses that could predispose the patient to vulvovaginitis caused by a specific bacterial pathogen. A recent history of group A streptococcal pharyngitis may lead to streptococcal vaginitis, while a history of recent diarrheal illness may suggest aShigella vaginitis as the etiology of vaginal bleeding. Other associated symptoms may also guide the differential diagnosis. Nighttime peri-anal itching, for example, may signify pinworms, whereas, persistent vulvar itching may be caused by a vulvar dermatitis or lichen sclerosis.
On examination, careful attention should be paid to Tanner staging, as evidence of estrogen exposure would be concerning for precocious puberty (central or peripheral), estrogen-secreting ovarian tumors, or exogenous estrogen exposure due to use of hormone creams or tablets (either intentional or accidental). On abdominal examination, a pelvic mass would be concerning for an ovarian tumor and should be followed-up with imaging of the pelvis and evaluation of tumor markers. Thorough examination of the external geni- talia, including the urethral orifice and peri-anal region, should be performed, with careful attention to hygiene and estrogen status of the genitalia. Survey of the genitalia should note any discharge, lesions or lacerations that may be present. Gener- ally, the hymen and distal vagina can be easily visualized without discomfort to the patient by using labial traction, which involves gently grabbing the labia majora and pulling away from the patient, or by examining the patient in knee–
chest position. Labial separation, which is performed by gently pulling the labia majora laterally, is generally less effective at providing adequate visualization. If discharge is present, speci- mens should be obtained for culture.
In cases where a foreign body is visualized, as in this patient, removal of the foreign body may be accomplished in the outpatient setting. Options for removing soft foreign bodies from the vagina include using a cotton-tipped applica- tor and twirling it within the vagina or, more commonly, vaginal lavage [1]. Vaginal lavage can be performed by passing a small urethral catheter beyond the hymen and flushing the vagina with warm saline. With either procedure, care should be taken to avoid the hymen, as it is particularly sensitive to the touch in most prepubertal girls. This may be facilitated by having an assistant use gentle labial traction to open the
introitus while the catheter or swab is passed into the vagina.
Most patients tolerate the procedure very well and without significant discomfort; however, if the patient is reluctant or unwilling to cooperate, examination under anesthesia may be necessary, as was the case in this patient.
Examination under anesthesia can usually be accomplished in the frog-leg position using labial traction. Using this tech- nique, the hymen can be visualized in its entirety, and air enters the vagina to allow for visualization of the distal vagina as well.
Vaginoscopy is then performed using normal saline as the distention medium with either a 3 mm pediatric cystoscope or a 4–5 mm diagnostic hysteroscope [2,3]. The surgeon advances the scope above the hymen to examine the vagina and cervix while gently pressing the labia majora together to maintain distention of the vagina and improve visualization. Any foreign bodies are generallyflushed out with the saline. If the foreign body is solid, it may require removal with endoscopic graspers, forceps, or by gently milking it out via rectal examination.
Placing a speculum into the vagina in a prepubertal girl is rarely necessary and should be avoided if possible, as it can cause unnecessary lacerations, abrasions, and discomfort.
Vaginal foreign bodies are a common cause of vaginal bleeding in prepubertal girls [4,5]. Though foul-smelling dis- charge makes one consider foreign body as a potential eti- ology, most girls with a vaginal foreign body do not, in fact, have a foul-smelling discharge [4,6]. Toilet paper appears to be the most common foreign body; however, other items such as coins, paper clips, safety pins, dice, beads, crayons, and even batteries have been reported. Removal of the foreign body, followed by proper perineal hygiene, should promptly resolve the associated vaginal bleeding. If bleeding persists, investi- gation for other sources (or for another foreign body) must be undertaken. This is particularly true of cases that are treated in the outpatient setting. For example, if vaginal lavage was performed in the office with apparent successful removal of the foreign body, the next step would be an examination under anesthesia with vaginoscopy to evaluate for a persistent foreign body or for a secondary diagnosis.
Key teaching points
A vaginal foreign body is the most common cause of vaginal bleeding in prepubertal girls.
Toilet paper is the most common vaginal foreign body, but other items have been reported.
In cooperative patients, vaginal foreign bodies may be removed in the office setting using vaginal lavage with warm saline.
Patients who are uncooperative with examination in the office may need to be evaluated under anesthesia, in which case, saline vaginoscopy will likely be both diagnostic and therapeutic.
Vaginal bleeding that persists following removal of the foreign body should be further evaluated for other potential etiologies.
Case 72: A seven-year-old girl with vaginal bleeding
References
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