Pediatric emergency medicine trisk 1540 1540
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musculature ( Fig. 79.2B ). This position, however, may be uncomfortable,
especially for patients with suspected sexual abuse or trauma. Utilizing a child
life specialist to assist in preparing the patient before the examination and aid
with positioning may be beneficial. A vaginal speculum should never be used in a
young, awake child.
As genital injuries can be associated with peritonitis and/or rectal perforation, a
careful abdominal examination and consideration for rectal examination is
warranted. Occasionally, a need for a more thorough examination under
anesthesia by a pediatric surgeon, urologist, or gynecologist is necessary.
Laboratory evaluation for prepubertal patients is based upon the most likely
diagnoses.
Vulvar Bleeding
The vulva consists of several structures: the labia majora, labia minora, clitoris,
and vaginal introitus. A premenarcheal girl with the complaint of vaginal
bleeding whose vulva looks abnormal may have a vaginal disorder, vulvar
disorder, or both.
Trauma
Most vaginal trauma results from a blunt straddle injury from a fall onto a hard
surface causing an abrasion, a laceration, or a hematoma of the anterior genital
tissues (labia, urethra, or clitoris). Penetrating trauma and sexual assault may
damage the posterior tissues as well (hymen, vagina, rectum). Even a minor
vulvar injury should alert the emergency physician to the possibility of
concurrent, potentially serious vaginal, rectal, or abdominal injuries. An upright
abdominal X-ray should be obtained to evaluate for free air if there is concern for
a penetrating abdominal injury.
Vulvar lacerations do not often bleed excessively and usually do not require
repair. However, resulting hematomas can extend widely through the tissue
planes, forming large, painful masses that occasionally produce enough pressure
to cause necrosis of the overlying vulvar skin. Pressure dressings and ice packs
can aid with healing. Since minor periurethral injuries can produce urethral spasm
and acute urinary retention, the injured child’s ability to void should be assessed.
Consider the possibility of sexual assault in every child with a genital injury.
Genital Warts
Similar to vulvar trauma, genital warts are recognized by inspection and can
produce bleeding from minor trauma when they are located on the mucosal
surface of the introitus. They appear as flesh-colored papules and are usually due
