1 What are the best ways to perform a genital examination in a prepubertal girl?

The external genitalia should be examined with the child lying supine in a “frog-leg” position, either on the examining table or on the parent’s lap. Use gentle lateral traction on the labia majora to obtain an adequate view of the introitus. To visualize the vaginal vault, examine the child in the “knee-chest” position. Ask the child to get up on her hands and knees (“like you are going to crawl”), and to rest her head on her folded arms. The labia and buttocks can be separated while the child relaxes her abdominal muscles. An otoscope without speculum can be used as a light source. If discharge or bleeding is noted, return the child to the supine position to take samples/cultures. If there is vaginal bleeding from an injury, it may be necessary to perform a speculum examination under sedation.

Paradise J: Vaginal bleeding. In Fleisher G, Ludwig S, Henretig FM (eds). The Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 669–670.

2 A mother brings her 2-year-old daughter to the emergency department (ED) because she has noticed that her “vagina seems to be closing up.” What could this be caused by?

Labial adhesions are a benign condition occurring in 3–7% of girls between the ages of 3 months and 5 years. The medial epithelial surfaces of the labia minora gradually adhere to one another, and the fusion proceeds anteriorly. Physical examination using labial traction reveals a flat area of adherent tissue, with a characteristic vertical raphe obscuring the introitus. A small opening remains through which urine may pass. Therapy consists of twice-daily applications of estrogen cream at the point of midline fusion. Continue treatment until the lesions resolve. Once the adhesions have separated, zinc oxide or petroleum jelly should be applied for an additional 2 weeks to prevent readherence. Medical therapy may rarely fail when the adhesions are thick (3–4 mm in width) with no evidence of a thin raphe.

Do not confuse labial adhesions with congenital abnormalities of the genitalia, such as ambiguous genitalia or imperforate hymen.

Bacon JL: Prepubertal labial adhesions: Evaluation of a referral population. Am J Obstet Gynecol 187:327–331, 2002.

3 A healthy 14-year-old girl presents with symptoms of urgency, frequency, and dysuria, as well as intermittent lower-abdominal pain. Her urinalysis is normal. Although her sexual development has been normal, she has never menstruated. What might be the problem?

A thorough physical examination, including a genital examination, will reveal the source of her distress. This patient probably has a congenital obstruction of the vagina, either an imperforate hymen or vaginal atresia. If this condition is not noticed during infancy, a young adolescent girl can present as above, with large quantities of menstrual blood accumulated behind the hymen. The collection of blood is termed hematocolpos. Examination of the abdomen may reveal a mass, which might initially be confused with a tumor or even pregnancy. Examination of the genitalia shows a bulging, membranous covering over the introitus, often appearing bluish from the blood behind. Treatment is surgical.

4 How does hydrocolpos differ from hematocolpos?

Vaginal obstruction during infancy leads to vaginal distention that is due to a buildup of mucous. This is called hydrocolpos or mucocolpos. Infants present with an abdominal mass, trouble with urinating, and a bulging membrane at the introitus. When the amount of mucous secretion is large, the uterus also becomes distended and results in hydrometrocolpos. If vaginal obstruction is not recognized until menarchal age, menstrual blood accumulates and distends the vagina, producing hematocolpos. In late puberty the child may present with amenorrhea. Eventually urinary symptoms may develop as the collection of blood increases in size. A lower-abdominal mass is often palpable.

5 How does perineal trauma in young girls occur?

Most perineal trauma in young girls results from a “straddle injury,” wherein the girl falls on a narrow object (e.g., bicycle crossbar, jungle gym, chair arm, fence). The most common injuries are vulvar hematomas and superficial lacerations. Most of these may be treated conservatively with sitz baths several times a day. Ensuring that the patient can void in the ED is crucial.

6 How should urinary retention after a straddle injury be managed?

In most cases urinary retention is mild and brief, and it occurs because of the discomfort of the urine passing over the injured perineum. Girls may be more comfortable urinating while sitting in a tub of warm water.

7 What concerns must you have regarding more complicated perineal trauma?

With a very forceful straddle injury, deep lacerations may occur in the vagina, and may extend into the rectum or urethra. Some hematomas may expand rapidly and become massive, requiring evacuation. These injuries must be explored thoroughly, either with effective sedation or under general anesthesia in the operating room. Consultation should be initiated with colleagues from pediatric gynecology or pediatric urology as appropriate for surgical repair. Concerns are similar for penetrating trauma to the perineum by a foreign object.

8 What are the causes of vaginal bleeding before menarche?

In the prepubertal child, “vaginal bleeding” may originate in the vagina, the vulva, or both. Causes of apparent vaginal bleeding can be divided into nonhormonal and hormonal:

9 A 3-year-old African-American girl presents to the ED with vaginal bleeding and a donut-shaped mass of purplish tissue protruding from her vagina. Her mother is concerned that she might have been abused. What’s your diagnosis?

Although sexual assault must always be in the differential diagnosis of genital trauma, the soft donut-shaped mass in this child is most likely not protruding from the vagina but rather is a urethral prolapse (Fig. 36-1). It is the most common cause of apparent vaginal bleeding in childhood, with the bleeding resulting from ischemia of the protruding urethral mucosa. For reasons that remain obscure, 95% of cases reported in the literature are in African-American girls. If the segment of prolapsed urethra is not necrotic, warm compresses or sitz baths in combination with 2 weeks of topical estrogen may be effective. Dark red necrotic mucosa requires surgical reduction of the prolapse within several days.

Figure 36-1 Urethral prolapse.

10 A mother brings in her 6-year-old daughter and tells you that the girl seems to be urinating more frequently than usual and says that it hurts when she urinates. You are sure she has a urinary tract infection, and you confidently send a sample to the lab. The urinalysis is normal. What could be causing her dysuria and frequency?

Symptoms of vulvovaginitis can include urinary frequency and dysuria. The most frequent reason for vulvovaginitis is simple irritation, either as the result of poor hygiene or cleansing products, such as bubble bath, shampoo, powders, soaps, and some feminine hygiene products. Infectious etiologies include Shigella spp., group A streptococci, Neisseria gonorrhoeae, and Candida spp. Pinworm infections, although rectal in origin, may lead to such intense itching and vigorous scratching that the patient presents with perineal excoriations and bleeding.

Treatment is frequent sitz baths. If the vulva is irritated, the patient may be more comfortable voiding while sitting in a tub of warm water. If symptoms of nonspecific vulvovaginitis persist for 2–3 weeks, consider a 10-day course of oral antibiotics (e.g., amoxicillin). When a specific microbial etiology has been identified in a prepubertal child (such as gonorrhea or chlamydia, coliform bacteria, group A streptococci, Candida albicans, Trichomonas spp., or Gardnerella spp.), give appropriate antimicrobial treatment and alert child protective services.