Figure 14.6 Straddle injury—vulvar hematoma in a 13-year-old girl.
Figure 14.7 Pelvic ultrasound (transabdominal) of a premenarchal 10-year-old girl.
Diagnosis of Prepubertal Bleeding
Hormonally active ovarian tumors can cause endometrial proliferation and bleeding. Likewise, exogenously administered estrogens can result in bleeding. Rarely, bleeding can result from the prolonged use of topical estrogens prescribed as therapy for vulvovaginitis or labial adhesions or from accidental ingestion of prescription estrogens.
Examination A careful examination is indicated when a child has genital symptoms. The technique of examining the prepubertal child is described in Chapter 1. If no obvious cause of bleeding is visible externally or within the distal vagina, an examination can be performed using anesthesia with vaginoscopy to completely visualize the vagina and cervix. This examination should be performed by a clinician who has experience in pediatric and adolescent gynecology.
Imaging If an ovarian or vaginal mass is suspected, a transabdominal pelvic ultrasonographic examination can provide useful information. The appearance of the ovaries (normal prepubertal size and volume, follicular development, cystic, or solid) can be noted, as well as the size and configuration of the uterus. The prepubertal uterus has a distinctive appearance, with equal proportions of cervix and fundus and a size of approximately 2 to 3.5 cm in length and 0.5 to 1 cm in width (Fig. 14.7). The uterine fundus enlarges with estrogen stimulation, resulting in the postmenarchal appearance in which the uterine fundus is larger than the cervix (19). An ultrasonographic examination should be the first imaging study performed; more sophisticated imaging techniques, such as magnetic resonance imaging (MRI) or computed tomography (CT) scanning, are rarely indicated as initial diagnostic modalities, and they add unnecessary expense and radiation exposure with CT.
Management of Prepubertal Vaginal Bleeding
The management of bleeding in prepubertal-age girls is directed toward the cause of bleeding. If bloody discharge believed to result from nonspecific vulvovaginitis persists despite therapy, further evaluation may be necessary to rule out the presence of a foreign body. Skin lesions (chronic irritation) and lichen sclerosus may be difficult to manage but can be treated with a course of topical steroids; lichen sclerosus often requires the use of ultrahigh-potency topical steroids and ongoing maintenance therapy. Vaginal and ovarian tumors should be managed in consultation with a gynecologic oncologist.
Table 14.4 Causes of Pelvic Mass by Approximate Frequency and Age
Functional cyst Functional cyst Functional cyst Functional cyst Fibroids Ovarian tumor (malignant of benign)
Presentation of Prepubertal Pelvic Masses