The evaluation of gynecologic problems in prepubertal girls is often a complex, challenging process. This is partly due to the pediatricians’ lack of training in gynecologic examination techniques and the inability to differentiate normal variants from abnormal findings. The rise in concern and incidence of sexual abuse has placed the pediatrician as a central provider in this social, physical, and psychological issue, therefore, mandating an increased knowledge, skills, and comfort in evaluating gynecologic conditions in children. Most girls presenting with genital symptoms have normal findings or a nontraumatic disorder.

When a patient presents with (or her parent describes) a complaint of vaginal bleeding, many questions should come to mind. What is the age of the patient? Is it really blood? What is the sexual maturity rating (SMR) of the patient? A red or brown discoloration present in the diaper or underpants may represent stool, bloody stool, bloody urine, or color-stained urine. The bleeding cannot be due to normal menarche if the patient is only SMR 1 or 2 for breast development because menarche typically occurs at SMR 3 or 4 breast development. It is extremely common to have vaginal bleeding during the first weeks of life (small amounts). This is due to withdrawal bleeding secondary to decreasing maternal estrogen. The differential diagnosis of vaginal bleeding in children is included in Table 195.1.

It is important to note that vaginal bleeding occurs in >90% of cases of vaginal foreign body, as compared to a foul-smelling discharge, which is far less common. The most common foreign body encountered is wadded toilet paper. Also, accidental trauma must be differentiated from abusive trauma. Vaginal trauma, resulting in bleeding that is due to a straddle injury, rarely results in hymenal trauma. Trauma caused by inserted objects or sexual
abuse often results in laceration of the hymen. Urethral prolapse is caused by a weakness in the tissues supporting the urethra. It may present during the toddler years or as late as adolescence; it often presents as painless vaginal bleeding. It is more common in African American girls than white girls. On examination, a bulging, dark red to black mass is seen at the introitus.