Vaginal Bleeding
Sara Pentlicky
Courtney Schreiber
INTRODUCTION
The complaint of vaginal bleeding can be concerning to parents, patients and clinicians. The differential diagnosis can be narrowed based on the patient’s age and menarchal status. The clinician should maintain a high index of suspicion for pregnancy-related complications in post-menarchal patients, as these diagnoses can be life-threatening.
DIFFERENTIAL DIAGNOSIS LISTPremenarchal Patients
Infectious Causes
Infectious vulvovaginitis
Genital herpes
Condyloma acuminatum
Toxic Causes
Exogenous estrogens
Neoplastic Causes
Sarcoma botryoides
Adenocarcinoma of the cervix or vagina
Estrogen production from an ovarian cyst or neoplasm
Hemangioma
Traumatic Causes
Accidental trauma
Sexual abuse
Foreign body
Congenital or Vascular Causes
Urethral prolapse
Miscellaneous Causes
Vulvar skin disorders
Neonatal withdrawal bleeding
Precocious puberty
McCune-Albright syndrome
Postmenarchal Patients
Infectious Causes
Infectious vulvovaginitis
Cervicitis
Pelvic inflammatory disease
Neoplastic Causes
Traumatic Causes
Accidental trauma
Sexual abuse
Foreign body
Metabolic or Genetic Causes
Hyperthyroidism or hypothyroidism
Hyperprolactinemia
Gynecologic Causes
Dysfunctional uterine bleeding
Abortion—threatened, incomplete, complete, or missed
Ectopic pregnancy
Polycystic ovarian disease
Hematologic Causes
Idiopathic thrombocytopenic purpura
von Willebrand disease
Miscellaneous Causes
Chronic systemic illness (e.g., liver disease, connective tissue disorder)
DIFFERENTIAL DIAGNOSIS DISCUSSION
Vulvovaginitis
Vulvovaginitis is discussed in detail in Chapter 80, “Vaginal Discharge (Vulvovaginitis).” Bleeding, when present, is usually minimal, although a blood-tinged discharge is common in severe cases. Shigella and group A β-hemolytic streptococci are the most common causes of a bloody vaginal discharge associated with vulvovaginitis.
Vulvar Hemangiomas
Etiology
Bleeding can result following trauma to a vulvar hemangioma. Vulvar hemangiomas are common and generally disappear as the child ages.
Clinical Features
Patients usually present with painless bleeding and a history of vulvar hemangiomas. The bleeding is usually self-limited; however, heavy bleeding can be seen with cavernous hemangiomas, or in a child with a known or unknown bleeding disorder. Careful examination of the external genitalia identifies the source of bleeding. Vaginoscopy is not required if bleeding is limited to the external genitalia.
Treatment
When bleeding does not respond to pressure, surgical ligation may be required.
Trauma
Incidence and Etiology
Genital trauma is a serious and common cause of vaginal bleeding. The incidence is highest in children between 4 and 12 years of age. Most genital trauma results from a straddle injury (e.g., a child landing on the center bar of a bicycle), but sexual abuse, accidental penetration, sudden abduction of the lower extremities, and pelvic fractures must also be considered.
Clinical Features and Evaluation
In patients with straddle injuries (a type of blunt trauma), a small ecchymotic area or a large vulvar hematoma may be noted. Hematomas are tender, tense, and rounded swellings that may enlarge if bleeding continues. Lacerations of the hymen or vagina may occur in association with straddle injuries; however, their presence should alert the physician to other possible sources of trauma.
Accidental penetration with pens and other small objects is common in 2- to 4-year-olds. Lacerations can be superficial or deep and can extend to the peritoneal cavity. Isolated injuries to the hymen alone are rare, and careful examination of the vagina is mandatory, usually under anesthesia.
Lacerations of the vagina can also occur as a result of sudden abduction of the legs, as in gymnastics or water skiing. These injuries can be difficult to
distinguish from injuries sustained secondary to sexual abuse. The paucity of other injuries helps distinguish these injuries from sexual abuse.
In patients with pelvic fractures, injuries to the urinary system are more common than are vaginal lacerations. However, in complex fractures, lacerations of the vagina can be extensive, accounting for significant blood loss. A thorough examination is mandatory, including evaluation of the urinary system and rectum.
If bleeding is noted from the vagina, direct pressure should be applied to the area followed by vaginoscopy under anesthesia.
Treatment
Superficial abrasions and lacerations of the vulva, if not actively bleeding, may be cleaned and left to heal.
Small vulvar hematomas that are not expanding may be managed conservatively with ice packs and pressure.
Large or expanding hematomas should be managed surgically with evacuation and ligation of bleeding vessels. At times, it may prove difficult to locate actively bleeding vessels. In this instance, vaginal packing should be placed and removed after several hours. Perioperative antibiotics are required.
Foreign Body
Foreign bodies placed into the vagina account for 5% of gynecologic visits in childhood. Most children will not remember or admit to placing an object in the vagina. The incidence is highest in children between 2 and 4 years of age. Rolled toilet tissue is one of the most common findings.
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