Differential Diagnosis of Prepubertal Vaginal Bleeding cyclic functioning of the hypothalamic–pituitary–ovarian axis are described in Chapter 7. An understanding of the normal sequence and timing of these events is critical to an appropriate assessment of a girl at the onset of bleeding (see Chapter 29). Menarche typically occurs when an adolescent has reached Tanner stage 3 or 4 of breast development (Fig. 14.1). Bleeding in the absence of breast development must be evaluated.
Slight vaginal bleeding can occur within the first few days of life because of withdrawal from exposure to high levels of maternal estrogen. New mothers of female infants should be informed of this possibility to preclude unnecessary anxiety. After the neonatal period, a number of causes of bleeding should be considered in the prepubertal age group (Table 14.3). Menses rarely occur before breast budding (5,6). Vaginal bleeding in the absence of secondary sexual characteristics should be evaluated carefully.
The causes of bleeding in this age group range from the medically mundane to malignancies that may be life threatening. The source of the bleeding is sometimes difficult to identify, and parents who observe blood in a child’s diapers or panties may be unsure of the source— whether from the urinary tract, the vagina, or the rectum. Pediatricians usually look for urinary causes of bleeding, and gastrointestinal factors such as constipation and or anal fissure or inﬂammatory bowel disease should be considered. The possibility of abuse should always be considered in girls with any vulvovaginal symptoms, particularly if bleeding is present. Failure to diagnose sexual abuse may leave a child in significant danger.
Vulvar Lesions Vulvar irritation can lead to pruritus with excoriation, maceration of the vulvar skin, or fissures that can bleed. Other visible external causes of bleeding in this age group include urethral prolapse, condylomas, lichen sclerosus, or molluscum contagiosum. Urethral prolapse can present acutely with a tender mass that may be friable or bleed slightly; it is most common in African American girls and may be confused with a vaginal mass (Fig. 14.2). The classic presentation is a mass symmetrically surrounding the urethra. This condition can be managed medically with the topical application of estrogens (7). The presence of condyloma should prompt questioning about abuse, although it was suggested that condyloma that appears during the first 2 to 3 years of life may be acquired perinatally from maternal infection with human papillomavirus (Fig. 14.3) (8,9). Excoriation and subepithelial hemorrhage (“blood blisters”) into the skin can cause external bleeding in the presence of prepubertal lichen sclerosus; this finding may mistakenly be identified as abuse, and the conditions are not mutually exclusive (Fig. 14.4) (10). Although most gynecologists recognize the appearance of lichen sclerosus in postmenopausal women, the condition can occur in prepubertal girls and may not be recognized by clinicians who are unfamiliar with this condition. As with adults, the cause of lichen sclerosus remains uncertain; a familial incidence was identified (11).
Figure 14.1 Tanner breast stage at menarche.
Foreign Body A foreign body in the vagina is a common cause of vaginal discharge, which may appear purulent or bloody. Young children explore all orifices and may place all varieties of small objects inside their vaginas (Fig. 14.5). An object, such as a small plastic toy, can sometimes be palpated on rectal examination, and occasionally “milked” toward the vaginal introitus to allow removal. The most common foreign bodies found in the vagina are small pieces of toilet paper (12). Although it was suggested that the presence of vaginal foreign bodies might be a marker for sexual abuse, this is not always the case; but the possibility of abuse should always be considered.