Genital Bleeding in Prepubertal Girls

Genital bleeding is a common complaint in the pediatric population. Data on the incidence is hard to find because most cases are taken care of as outpatients and statistics aren't available. Although most cases are not serious, it usually causes parental anxiety and prompt evaluation is recommended and warranted.

Important Questions to Ask in Your History

  1. Has there been any history of trauma?
  2. Are there any indications of possible sexual abuse or molestation?
  3. Has there been any discharge, foul smell, or dysuria?
  4. Does the child grab at her genitals or scratch all the time?
  5. Does the child take any medications or use bubble bath?
  6. Are there any signs or symptoms of precocious puberty?

Causes of Vaginal Bleeding

  1. Trauma- Straddle injuries and falls off a bicycle are common. Vulvar trauma can cause significant bleeding due to the high vascularity and loose subcutaneous tissue of the area, as well as the absence of labial fat pads that protect the vulvar area of adult women. The extent of injury can be determined by inspecting the vulvovaginal area. Unintentional straddle injuries are typically superficial and involve the anterior portion of the genitalia (mons, clitoral hood, and labia minora anterior or lateral to the hymen); an injury to the hymen or posterior fourchette is less common and should raise concern for possible abuse. Once bleeding has stopped after accidental trauma, reassurance and suggestions for local care with sitz baths or ice packs are all that is necessary. You also must make sure that there are no penetrating injuries that would require referral to a gynecologist or pediatric surgeon for possible repair.
  2. Sexual Abuse- May be accompanied by a vague/inconsistent history or an inappropriate lapse of time before the child comes to be evaluated. Physical examination may demonstrate findings of abuse, such as tears in the hymen or posterior fourchette; however, it is important to note that a majority of victims of sexual abuse will not show abnormalities on physical exam.
  3. Pruritus- Scratching may lead to breaks in the skin and cause bleeding. Causes include pinworms, atopic dermatitis, contact dermatitis, tight undergarments, wet bathing suits, and bites.
  4. Foreign Bodies- The most common foreign body in the vaginal canal is toilet paper. Most objects can be removed in the office with a swab or with warm water irrigation after applying a topical anesthetic agent like xylocaine jelly to the introitus. If the foreign body is large or cannot be removed with irrigation, special instruments and sedation/anesthesia may be necessary. Foreign bodies are often (but not always) associated with foul smelling discharge that will disappear after removal. Suspect a foreign body if there are WBCs in the urine but a negative urine culture.
  5. Vulvovaginitis- The vulvar tissue of prepubertal girls is hypoestrogenic and atrophic, resulting in increased susceptibility to infection and irritation.
  6. Hemangiomas- May be suspicious if there are hemangiomas in other parts of the body
  7. Tumors- Benign polyps may protrude from the vagina and cause bleeding. There are rare malignancies associated with bleeding including sarcoma botyroides (a type of embryonal rhabdomyosarcoma that may occur in the vaginas of girls < 8 years old). Daughters of mothers who took DES are at risk for vaginal/cervical cancers that may present with bleeding. Evidence of these rare malignancies may sometimes be found by noninvasive tests (such as CT scans), or may require more complicated techniques such as vaginal exam under anesthesia, vaginoscopy, and cystoscopy.
  8. Rectal bleeding- May be confused with vaginal bleeding. Anal fissures are often not recognized by the parents and the presence of blood on diaper may be confusing
  9. Urethral Prolapse- Characterized by a circular eversion of the mucosa at the distal end of the urethra that may present as vaginal bleeding, dysuria, and/or difficulty with urination.
  10. Neonatal withdrawal bleeding- Female neonates may present soon after birth with a mini-period, a normal response of the infant’s endometrium to the loss of maternal estrogen present in utero. This most commonly occurs during the 2nd or 3rd week of life and lasts only a couple of days. Parental reassurance is appropriate.
  11. Urate crystals- These urine crystals may be confused with bleeding from the vagina. The diaper appears pink.
  12. Precocious Puberty- With true precocious puberty, there will be a growth spurt, advanced bone age, thelarche, and adrenarche prior to vaginal bleeding. True (idiopathic) precocious puberty is due to early activation of the hypothalamic-pituitary-gonadal axis. Important considerations include potential compromise of adult height due to premature closure of the epiphyseal plates and possible social implications of developing secondary sex characteristics at an extremely young age.
  13. Prepubertal Menarche- After careful evaluation including ultrasound, examination under anesthesia, and laboratory investigation, no abnormalities are found. Unlike precocious puberty, other features of puberty are not present along with the premature bleeding. These children will go on to normal puberty.

References

  1. Baldwin, Duane, and Landa, Howard. Pediatric gynecology: Evaluation and treatment. Contemporaty Pediatrics. November 1995
  2. Hill, N.C.W, Oppenheimer, L.W., and Morton, K.E. The aetiology of vaginal bleeding in children. A 20-year review. British Journal of Obstetrics and Gynecology. April 1989.
  3. Fishman, A. and Paldi, E. Vaginal Bleding in Premenarchal Girls :A Review. Obstetrics and Gynecological Survey. 1991
  4. Gray S. and Emans J. Abnormal Vaginal Bleeding in Adolescents.  Pediatrics in Review May 2007.
  5. Pinto S, Garden A. Prepubertal Menarche:A Defined Clinical Entity.  American Journal of Obstetrics and Gynecology.  2006 327-329
  6. Merrit D. Vulvar and genital trauma in pediatric and adolescent gynecology. Current Opinion in Obstetrics and Gynecology. Oct 2004.
  7. Striegal A, Myers J, Sorensen M, Furness P, and Koyle M. Vaginal Discharge and Bleeding in Girls Younger than 6 Years. Journal of Urology. Dec 2006.

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