Pediatric emergency medicine trisk 1545 1545
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urinary tract infection, weak pelvic floor muscles, and increased intra-abdominal
pressure associated with chronic cough or constipation. Some patients with
urethral prolapse complain of dysuria or urinary frequency but most have painless
bleeding as their only symptom. Prolapse is diagnosed by its characteristic
nontender, soft, doughnut-shaped mass anterior to the vaginal introitus. The ring
of protruding urethral mucosa is swollen and dark red with a central dimple that
indicates the meatus. When the child is supine, the prolapse is often large enough
to cover the vaginal introitus and appears to protrude from the vagina. Bleeding
comes from the ischemic mucosa. Urethral prolapse is sometimes mistaken for a
urethral cyst or polyp, which may lead to vaginal bleeding; these lesions do not
surround the entire urethral orifice symmetrically. If the diagnosis of urethral
prolapse is in doubt, one may safely catheterize the bladder through the prolapse
to obtain urine. Most patients will improve with the use of sitz baths and topical
estrogen creams applied twice daily. In rare circumstances where the patient has
difficulty voiding or if estrogen therapy fails, referral for surgical evaluation and
possible excision of the prolapsed tissue is necessary.
BLEEDING IN THE NONPREGNANT ADOLESCENT PATIENT
Normal Menstrual Cycle
When an adolescent girl presents with a chief complaint of irregular menses, the
emergency department (ED) physicians must first differentiate between normal
and abnormal bleeding. In most cases, a comprehensive history and physical
examination, along with minimal ancillary testing, will uncover the etiology and
guide management. An understanding of the menstrual cycle and its hormones is
key to treating the most common cause of adolescent uterine bleeding,
anovulatory cycles.
Menstrual patterns during the first 2 years after menarche vary. The normal
menstrual cycle averages 28 days but varies from 21 to 35 days. Ninety-five
percent of young adolescents’ menstrual periods last between 2 and 8 days;
duration of 8 days or more is considered abnormal. An occasional interval of less
than 21 days from the first day of one menstrual period to the first day of the next
is normal for teenagers, but several short cycles in a row are abnormal. Typical
bleeding requires adolescents to change a pad or tampon four to five times daily
without resultant anemia but this number may vary depending on individual
hygiene practices.
During puberty, the hypothalamic–pituitary–ovarian axis regulates the
development of secondary sexual characteristics and menstruation. During the
