Chapter 544 Bleeding

Vaginal bleeding in infants and prepubescent children is concerning for both the child and the parents and should always be evaluated. Bleeding can be seen as early as the 1st wk of life from maternal estrogen withdrawal until puberty when menstruation occurs. It can occur as light serosanguineous spotting to heavy bleeding with clots. A thorough history and physical must be obtained as the first step in diagnosing the problem. Common causes for vaginal bleeding in children are vulvovaginitis, foreign bodies, dermatologic conditions, and urethral prolapse; less common are endogenous or exogenous estrogenic effects; and, most worrisome, include neoplasms and trauma.

Vulvovaginitis may be caused by respiratory, oral and fecal pathogens, some of which produce a serosanguineous drainage (Streptococcus spp, Shigella) or cause vulvar bleeding due to irritation and excoriation of the skin. Prepubertal girls are at a higher risk for developing these irritations because the protective labia of pubertal girls are not fully developed and thus the vaginal opening and vagina are more exposed to irritants. Further, the mucosa is thin and the pH of the vagina is more alkaline than after menarche from low levels of estrogen. Hand-washing, improved perineal hygiene (wiping front to back, use of wet wipes after bowel movement), and avoidance of topical irritants, chemicals, and perfumed or deodorant soaps and bubble baths will reduce nonspecific vulvovaginitis. If hygiene does not result in improvement, a short course of antibiotics will be required to clear a recurrent or persistent infection (see Table 543-2). External application of bland emollient barriers such as over-the-counter diaper rash medications and petroleum jelly may be helpful.

A potential dermatologic reason for bleeding is lichen sclerosus (see Fig. 543-5 and Table 543-1). This condition is characterized by chronic inflammation, intense pruritus, and thinning and whitening of the vulvar and perianal skin in a keyhole fashion. Petechiae or blood blisters can arise and be mistaken as a sign of sexual abuse. Diagnosis is based on these classic clinical characteristics but may be confirmed by a tissue biopsy if necessary. Potent topical steroids are the first line of treatment and usually improve the appearance and symptoms of pruritus. The steroid should then be tapered and used for the shortest duration necessary; flare-ups can occur and require retreatment.

Foreign bodies are a common cause of vaginal bleeding, and children present with blood-stained and foul-smelling discharge. It can last from days to months until the correct diagnosis is made and the object is removed. The most common objects found are wadded up pieces of toilet paper. A physical exam in knee-chest or frog-leg position can sometimes reveal the object. Vaginal irrigation can then be done in the office using a small feeding tube and warm water. If the object is not visible on exam, irrigation is unlikely to remove it and exam under anesthesia and vaginoscopy are often required. Vaginoscopy not only allows removal of a foreign object but also can facilitate diagnosis of other causes of the bleeding.

Trauma to the vulva or vagina is especially concerning. Most of these injuries are accidental, but physical and sexual abuse must be ruled out (Chapter 37

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