Pediatric emergency medicine trisk 1541 1541
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to the human papilloma virus (HPV). Nonsexual transmission is more likely in
children <4 years, however age alone does not exclude the possibility of sexual
abuse. Careful evaluation includes history and physical examination, screening
for concurrent sexually transmitted infections, and reporting to the State Child
Protective Services Agency when appropriate (see Chapter 127 Sexual Assault:
Child and Adolescent ). Topical imiquimod or podophyllin may be used to treat
the warts, though the practitioner should be aware that podophyllin can produce
systemic toxicity if absorbed in large amounts. Other treatment options include
cryotherapy, laser therapy, and surgery. A dermatologist or other knowledgeable
clinician should be consulted to select an appropriate treatment for bleeding
genital warts.
Vulvovaginitis
Vulvar inflammation can be seen in patients with bacterial or fungal
vulvovaginitis (see also Chapter 80 Vaginal Discharge ). Infections caused by
Shigella species, group A hemolytic streptococci, Staphylococcus epidermidis,
Neisseria gonorrhoeae, and Candida albicans produce vaginal bleeding or
bloody discharge in a number of cases. Cultures to guide therapy can be collected
by inserting a cotton swab in the vagina; avoid contact with the hymenal tissues
to reduce pain. Nucleic acid amplification tests (NAATs) on urine have replaced
culture for identification of N. gonorrhoeae and Chlamydia. Enterobius
vermicularis (pinworm) infestations, though typically rectal, may also involve the
vagina. Vigorous scratching may cause excoriation and resultant bleeding in the
perineal area. Emergency physicians should recommend sitz baths, avoidance of
bubble baths, thorough drying after bathing, and front-to-back wiping in all
patients with vulvovaginitis. Occasionally, antibiotics or anthelmintics may be
necessary depending on the organism isolated.
