Pediatric emergency medicine trisk 1539 1539
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CHAPTER 79 ■ VAGINAL BLEEDING
MAMATA V. SENTHIL, ALISON ROCKEY, LAUREN E. ZINNS, JENNIFER H. CHUANG, JILL C.
POSNER
INTRODUCTION
Vaginal bleeding can be either a normal event or a sign of disease. Pathologic
vaginal bleeding may indicate a local genital tract disorder, systemic
endocrinologic or hematologic disease, or a complication of pregnancy. During
childhood, vaginal bleeding is abnormal after the first few weeks of life until
menarche. After menarche, abnormal vaginal bleeding must be differentiated
from menstruation.
When evaluating patients with vaginal bleeding, it is important to distinguish
between three types of bleeding: (1) prepubertal bleeding, (2) bleeding in
nonpregnant adolescent females, and (3) bleeding associated with pregnancy.
VAGINAL BLEEDING IN THE PREPUBERTAL PATIENT
Evaluation and Decision
Important elements of the history include symptom onset, prior history of
bleeding, associated abdominal pain, concern for foreign body, recent infections
such as sore throat or diarrhea, rashes, masses, perineal skin changes, urinary
and/or bowel symptoms, and estrogen-containing medications. When trauma is
suspected, questions pertaining to the mechanism of injury and concerns for
sexual abuse guide management ( Fig. 79.1 ).
During the physical examination, the emergency clinician should note signs of
hormonal stimulation (i.e., breast development, pubic hair growth, a dull pink
vaginal mucosa, or physiologic leukorrhea), thyroid enlargement, and skin
findings such as petechiae, excessive bruising, or café-au-lait spots. Next, it is
important to determine the source of bleeding. For the initial examination of the
genitalia, an infant or child should be placed in frog-leg position with heels near
the buttocks while holding the legs flexed on the parent’s lap or examining table (
Fig. 79.2A ). After inspecting the external genitalia, the left and right labia
majora should be gently grasped by the examiner in an outward and downward
direction to visualize the introitus and identify the source of bleeding. If the
vaginal tissues cannot be observed adequately, the knee-chest position is an
alternative examination technique, allowing for relaxation of the abdominal
