Introduction
Prepubertal vaginal bleeding is the onset of vaginal bleeding that occurs before the normal age of puberty and may occur both with and without preceding pubertal milestones. 
Although many etiologies of prepubertal vaginal bleeding are benign and self-limiting, exclusion of malignancy and treatment for nonmalignant but persistent sources of bleeding may be indicated. Common causes of prepubertal vaginal bleeding include trauma, infection, anatomic/structural, hematologic, hormonal, and neoplastic etiologies, which are further delineated in Table 7.1 .
| PREPUBERTAL VAGINAL BLEEDING | |||
|---|---|---|---|
| Etiology | Evaluation | Differential Diagnosis | Treatment |
| Straddle injury/genital trauma | History, physical examination (may include sedated vaginoscopy) | Nonaccidental trauma, failure of midline fusion (perineal groove) | Application of pressure and ice, surgical repair, urethral catheterization, pain control |
| Urethral prolapse | History, physical examination (may include sedated vaginoscopy ± cystoscopy) | Sarcoma botryoides, Skene duct cyst, urethral polyp or caruncle, prolapsed ureterocele, uterine prolapse | Sitz baths, treatment of constipation, topical estrogen therapy, rarely surgical resection |
| Vaginal foreign body | History, physical examination (may include sedated vaginoscopy or in-office vaginal irrigation); rarely plain film, pelvic sonography, or MRI | Vulvovaginitis, müllerian papilloma, vaginal or cervical polyp, malignant vaginal tumor | Vaginoscopy with removal of vaginal foreign body |
| Sarcoma botryoides | History, physical examination, biopsy, imaging (MRI) | Germ cell tumor, carcinoma, müllerian papilloma, urethral polyp or caruncle, urethral prolapse, prolapsed ureterocele, Skene duct cyst, uterine prolapse, adenomyosis, extragonadal yolk sac tumor | Surgical resection, chemotherapy |
| Hemangioma | History, physical examination | Infantile hemangioma, capillary hemangioma, pyogenic granuloma, capillary malformation, macrocystic lymphatic malformation, venous malformation, rhabdomyosarcoma, cutaneous metastatic disease | Observation, topical and/or oral beta-blocker, corticosteroid therapy, laser therapy, surgical excision |
| Precocious puberty | History, physical examination, laboratory evaluation, imaging (x-ray bone age, pelvic sonography, MRI brain), GnRH stimulation test | Premature thelarche, premature adrenarche, isolated premature menarche, poorly controlled congenital adrenal hyperplasia, congenital hypothyroidism, ovarian or adrenal tumors | Central precocious puberty: GnRH analogue treatment |
| Vulvovaginitis | History, physical examination | Vaginal foreign body, vulvar dermatoses, müllerian papilloma, sarcoma botryoides | Improved vulvovaginal hygiene, use of emollients, antibiotics |
Straddle injury/genital trauma
Trauma accounts for up to 45% of cases of prepubertal vaginal bleeding, which is typically accidental. Pediatric perineal injuries account for <1% of all pediatric injuries. A straddle injury is compression of the soft tissues of the perineum between the bony pelvis and an object during trauma. This injury generally involves the mons pubis, clitoris, and labia, and in the absence of a penetrating mechanism of injury, rarely involves the hymen or vagina.
Typically patients will present with some history concerning for accidental trauma. In general, patients complain of pain and bright red vaginal bleeding. Associated symptoms may include pain with urination, an inability to void or defecate, pain with ambulation, and perineal edema and ecchymosis. Evaluation of genital trauma should include an examination of the external genitalia, and analgesia and/or procedural sedation can be considered for patient comfort and cooperation. Any concern for penetration may require a sedated examination with vaginoscopy. Providers should be aware of the possibility of abuse and try to rule this out of the differential diagnosis whenever genital trauma is noted (see Table 7.1 ). In the setting of a superficial straddle injury with well-visualized laceration borders, application of pressure and ice packs can reduce both bleeding and edema. Surgical repair may not be required, and conservative management with sitz baths, oral analgesia, and topical anesthetic may be adequate. Medical skin adhesive can be considered for small lacerations, particularly in settings in which avoidance of sedation is desired.
For injuries that do not achieve hemostasis with the aforementioned conservative management or for deep and/or extensive lacerations, surgical repair is required. Labial hematomas generally tamponade with application of pressure and ice, although incision and drainage may be required for expanding lesions. Consideration should be given to indwelling urethral catheterization in the setting of urinary retention and inability to void until edema and pain improve. Penetrating injuries may require vaginal packing ( Fig. 7.1 ). Refer to Chapter 17 for further information on traumatic genital injury.
Infectious causes of prepubertal vaginal bleeding
Group A beta-hemolytic streptococcus is one of the more common pathogens isolated in the evaluation of vulvovaginitis and prepubertal vaginal bleeding. Concurrent pharyngeal colonization occurs in up to 95% of individuals. Other potential infectious etiologies for prepubertal vaginal bleeding include Shigella, Enterobius vermicularis, and vaginal leeches. Clinicians should be suspicious of this etiology in the face of a recent infection. Evaluation is via vaginal culture with antibiotic treatment geared toward the offending organism.
Urethral prolapse
Urethral prolapse has been reported in 1 in 3000 patients. , Although often seen in prepubertal females, it can also present in postmenopausal women or hypoestrogen states. Urethral prolapse is more common in patients of African descent. ,
Urethral prolapse is prolapse of the redundant urethral mucosa through the meatus. Although the etiology for urethral prolapse is likely multifactorial, episodic increases in intraabdominal pressure in conditions like constipation and chronic cough are likely contributory. The distal female urethra has high concentrations of estrogen receptors and therefore may be more susceptible to prolapse in estrogen deficiency.
Although urethral prolapse may be incidentally noted and otherwise asymptomatic, many patients typically present with painless, bright red vaginal bleeding. Other symptoms may include concurrent constipation. A history should include evaluating for the presence of comorbid conditions that may increase intraabdominal pressure and assess for any other sources of prepubertal vaginal, including the presence of any secondary sexual characteristics.
Examination of the external genitalia is necessary for a diagnosis of urethral prolapse. A protruding donut-shaped mass is typically noted, and care should be taken to evaluate for a distinctly separate hymen and distal vagina. If the origin of the mass is not clear, sedated examination can be considered with cystoscopy and/or vaginoscopy for further clarification. Observation during urination or placement of a small urethral catheter can also be employed to verify urethral origin.
The differential diagnosis of a protruding interlabial mass includes urethral prolapse and sarcoma botryoides. Less common causes include Skene duct cyst, urethral polyp, prolapsed ureterocele, and uterine prolapse.
Conservative management of urethral prolapse includes sitz baths and addressing any underlying cause of increased intraabdominal pressure such as constipation. Application of topical estrogen is usually effective at treatment of the prolapse and resolution in symptoms. Surgical resection of the urethral mucosal edges is rarely needed ( Fig. 7.2 ).
Vaginal foreign body
The presence of a vaginal foreign body should be considered in the setting of persistent vaginal discharge with or without vaginal bleeding. The incidence of a vaginal foreign body has been reported in up to 10% of patients referred to a tertiary care center for persistent blood discharge and up to 25% of patients who required a procedure for evaluation. ,
Patients with a vaginal foreign body typically present with chronic vaginal discharge, which may be bloody. Perineal irritation caused by associated vulvovaginitis may be present. A history assessing for any prior placement of a foreign body in a body orifice should be pursued along with the duration of bloody vaginal discharge, exposure to topical irritants, and review of hygiene techniques.
Examination of the external genitalia should be performed. Labial traction in the supine frog-leg position or knee-chest position may facilitate visualization of the foreign body in the distal vagina ( Fig. 7.3 ) (refer to Chapter 4 for further information on examination of the prepubertal patient). A high index of suspicion in many cases will necessitate a sedated examination with vaginoscopy and removal of a possible foreign body. , Imaging studies may be limited in evaluating for the presence of a vaginal foreign body, but pelvic sonography, pelvic x-ray, or magnetic resonance imaging may be considered. The differential diagnosis of bloody vaginal discharge includes vaginal foreign body, vulvovaginitis, müllerian papilloma, vaginal or cervical polyp, or malignant vaginal tumor. One of the most common vaginal foreign bodies is toilet paper, which typically involves the unintentional migration of toilet paper into the more proximal vagina with toileting. Other vaginal foreign bodies can similarly be unintentional (i.e., blade of grass), but some vaginal foreign bodies are intentionally placed in the vagina. Chronic inflammation of the vaginal mucosa caused by the presence of the foreign object results in symptoms. In severe cases, chronic pressure to the vaginal walls can result in fistula formation and stenosis. Vaginoscopy with removal of the vaginal foreign body remains the mainstay of treatment ( Fig. 7.4 ). This should be considered in all patients with bloody discharge and in patients with chronic discharge recalcitrant to improved perineal hygiene and medical management. Vaginal irrigation, which can be performed with vaginal placement of a pediatric Foley catheter and instillation of a reasonable amount (200 cc) of sterile saline within the vagina using moderate pressure, can also be employed in appropriate patients.
