Abstract
Children and adolescents may present to the urgent care center with complaints such as vaginal bleeding and discharge, trauma, and pregnancy.
Keywords
abnormal uterine bleeding, amenorrhea, dysmenorrhea, labial adhesions, pelvic inflammatory disease, vaginal ulcers, vaginitis
1
What is the best position to perform a genital exam on a prepubertal female?
Girls approximately 2 years and older are best examined in the supine frog-leg ( Fig. 22.1 ) or prone knee-chest position ( Fig. 22.2 ). The patient may be more comfortable lying with her parent (if in supine frog-leg position) and/or keeping her underwear on (can be pulled to the side) during the exam. It is important to explain the procedure prior to examination and allow the girl to stop the exam at any time. Some children may need an exam under sedation.
2
How should you approach vaginitis in prepubertal girls?
The most common signs and symptoms of vaginitis include vulvar erythema, vulvar edema, vaginal bleeding, vaginal discharge, pruritus, vaginal irritation, and/or dysuria ( Table 22.1 ).
| Symptoms/Signs | Testing | Treatment | Special Considerations | |
|---|---|---|---|---|
| Streptococcus pyogenes | Vulvovaginal irritation, discomfort, erythema. Vaginal bleeding and/or discharge. Associated with pharyngitis and/or scarlet fever. Most common in 3–10 years of age. | Vaginal culture; rapid strep of pharynx if signs of pharyngitis. Consider testing for gonorrhea if purulent vaginal discharge without sore throat. | Penicillin, first-generation cephalosporin, clindamycin (PCN allergic) for 10 days or azithromycin x 5 days. | Consider rapid strep of vaginal sample. Labs may refuse to process rapid strep testing from nonpharyngeal specimens as it is not within manufacturer’s guidelines. |
| Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis | Vulvovaginal irritation, discomfort, erythema. Vaginal bleeding and/or discharge. | None | Generally resolves with conservative treatment. | |
| Shigella | Vaginal discharge, sometimes bloody. Inflamed vulvar mucosa, ulcers. Can have associated diarrhea. | Vaginal culture. Consider rectal culture. | Trimethoprim/ sulfamethoxazole bid x 5 days | |
| Candida | Vulvar erythema, edema, and pruritus. External dysuria from urine in contact with inflamed vulva. Vaginal discharge. | Fungal culture if persistent despite past treatment. | Antifungal cream: clotrimazole 1% or miconazole 2% one applicatorful daily x 7 days; clotrimazole 2% or miconazole 4% one applicatorful daily x 3 days; tioconazole 6.5% or butoconazole 2% one applicatorful x 1 dose; fluconazole 150 mg tab po once | Most common cause of vaginitis in pubertal girls. Rare in prepubertal girls, especially without recent antibiotic use, immunocompromised state, or diaper use. |
| Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis | Can be asymptomatic or present with persistent purulent vaginal discharge | Consider NAAT or culture testing. Consult or refer to child abuse specialist, as type of testing accepted for forensic evidence differs by state. | Ceftriaxone or cefotaxime | If outside of newborn period, suspicious for sexual abuse. |
3
What should discharge instructions be for outpatient management of nonspecific vaginitis?
If there is no identifiable treatable cause for vaginitis AND symptoms are acute onset and mild without vaginal bleeding or discharge, consider conservative management. Recommend wearing loose-fitting clothing and cotton underwear, limiting soap to genital area and bubble baths, avoiding long periods in wet swimwear, wiping front to back, soaking in sitz bath or voiding in bathtub for dysuria, and applying cool compresses for vulvar/vaginal pain/swelling. If the patient has progressively worsening symptoms or develops purulent discharge, obtain culture and consider appropriate medications.
4
How do you evaluate prepubertal girls for vaginal foreign bodies?
The knee-chest position for children over 2 years of age generally allows clinicians to visualize the vagina and cervix. Vaginal irrigation using a Foley catheter with a syringe filled with normal saline after a topical anesthetic can be performed if direct visualization and removal with a Calgi swab fails. Rarely, examination under sedation and/or pelvic ultrasound is required.
5
How do you distinguish between labial adhesions and lichen sclerosis? How are they treated?
Labial adhesions are much more common than lichen sclerosis, but both may cause vaginal irritation and bleeding. Labial adhesions present in infancy and in early childhood, likely due to the lack of estrogen, and usually resolve with estrogenization at puberty. They are thin, semitranslucent adhesions between the posterior labia minora and can progress anteriorly, occasionally leaving only a pinpoint opening. In asymptomatic patients, conservative management with a bland ointment, such as A and D ointment, and observation is appropriate. First-line therapy for symptomatic and/or large labial adhesions is estrogen cream applied twice daily to the point of fusion; if no improvement with 2–3 weeks of therapy, low-dose steroid creams can be trialed. Manual separation is only considered if rapid in onset, accompanied by severe symptoms such as urinary retention/obstruction, or in cases where medical management has failed. Classic skin findings of lichen sclerosis include a symmetric hourglass pattern of the vulvar and perianal area with atrophic white plaques. First-line therapy is high-dose topical steroids; if that fails, topical calcineurin inhibitors are a second-line therapy.
6
What is the differential diagnosis for urethral prolapse?
Urethral prolapse presents as a friable, annular mass anterior and separate from the vaginal introitus and can present with bleeding or dysuria. It is unlikely to regress on its own. The peak age of presentation is 5–8 years of age. A urine catheterization can be performed to confirm that the mass is part of the urethra and connected to the bladder. If not necrotic, it usually improves with estrogen cream and sitz baths. Masses that are less annular and more “grapelike” are concerning for sarcoma botryoides. A pelvic ultrasound to assess for pelvic masses and a tissue biopsy would be indicated. If the mass were adjacent to the urethra, white, and found in a neonate, it would be more consistent with a paraurethral cyst. In these cases, a renal ultrasound evaluating for renal pathology would be warranted to evaluate for other anomalies such as urethral diverticula and ectopic ureteroceles.
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