Precocious Puberty Vaginal bleeding in the absence of other secondary sexual characteristics may result from precocious puberty (see Chapter 29), although as with normal puberty, the onset of breast budding or pubic hair growth are more likely to occur before vaginal bleeding. A large observational study suggested that the onset of pubertal changes—breast budding and pubic hair—might occur earlier than previously thought (2). Evaluation for precocious puberty was recommended for girls with pubertal development younger than age 8 years. Guidelines proposed evaluation of white girls younger than age 7 years and African American girls younger
Table 14.3 Causes of Vaginal Bleeding in Prepubertal Girls
Vulvitis with excoriation
Trauma (e.g., accidental injury [straddle injury] or sexual abuse)
Trauma (abuse, penetration)
Figure 14.2 Urethral prolapse in prepubertal girl.
Figure 14.3 Perianal condyloma in prepubertal girl.
than age 6 years who have either breast development or pubic hair, rather than the traditional age of 8 (13). An expert panel concluded that there is reasonable evidence that pubertal milestones are occurring at a younger age in girls (3).
Trauma Trauma can be a cause of genital bleeding. A careful history should be obtained from one or both parents or caretakers and the child herself, because trauma caused by sexual abuse often is not recognized. Trauma can be characterized as accidental or nonaccidental, which is described as child abuse. Physical findings that are inconsistent with the description of the alleged accident should prompt consideration of abuse and appropriate consultation or referral to an experienced social worker or sexual abuse team. All states impose a mandatory legal obligation to report suspected child physical abuse; most states specifically require reporting child sexual abuse, but even in those that do not, the laws are broad enough to encompass sexual abuse implicitly (14,15). Notification is required even with the suspicion of sexual abuse. In general, a straddle injury occurring with accidental trauma affects the anterior and lateral vulvar area, whereas penetrating injuries with lesions of the fourchette or lesions that extend through the hymenal ring are less likely to occur as a result of accidental trauma (Fig. 14.6) (16).
Abuse The medical evaluation of suspected child sexual abuse is best managed by individuals who have experience in assessing the physical findings, laboratory results, and the children’s statements and behaviors. Genital findings are categorized as follows (17): 1.
Normal, normal variants, and other conditions 2.
Nonspecific findings that may be the result of abuse, depending on the timing of the examination, but that may be due to other causes 3.
Concerning for abuse or trauma, including findings that were noted with documented abuse and that may be concerning for abuse, but for which insufficient data exist to determine that abuse is the only cause 4.
Clear evidence of blunt force or penetrating trauma.
The overall classification of the likelihood for abuse can be categorized as follows (17): 1.
No evidence of abuse 2.
3.
4.
Definitive evidence of abuse or sexual contact.
Figure 14.4 Prepubertal lichen sclerosus.
Most cases of child sexual abuse do not come to light with an acute injury and instead are associated with normal or nonspecific genital findings (17,18). Forms of abuse such as fondling or digital penetration may not result in visible genital lesions.
Other Causes Other serious but rare causes of vaginal bleeding include vaginal tumors. The most common tumor in the prepubertal age group is a rhabdomyosarcoma (sarcoma botryoides), which is associated with bleeding and a grapelike clustered mass (see Chapter 36). Other forms of vaginal tumor are rare but should be ruled out with a thorough examination under anesthesia with vaginoscopy if no other obvious external source of bleeding is found.
Figure 14.5 Foreign body (plastic toy) in the vagina of an 8-year-old girl.