The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.11.075
Clinical Communications: Pediatrics PREPUBERTAL GIRL WITH VAGINAL BLEEDING Noah P. Kondamudi, MD, FAAP, FACEP,* Ayush Gupta, MD,† Amina Watkins, MD,‡ and Amy Bertolotti, RN§ *Division of Pediatric Emergency Medicine, Department of Pediatrics, Rutgers New Jersey Medical School, Newark, New Jersey, †Department of Pediatrics, The Brooklyn Hospital Center, Brooklyn, New York, ‡Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, and §Department of Nursing, University Hospital, Newark, New Jersey Reprint Address: Noah P. Kondamudi, MD, FAAP, FACEP, Division of Pediatric Emergency Medicine, Department of Pediatrics, 185 South Orange Avenue, Newark, NJ 07103
, Abstract—Background: Prepubertal children with vaginal bleeding are frequently brought in to the Emergency Department (ED) for evaluation with the primary concern of sexual abuse. Appropriate history and physical examination can help recognize the specific cause and allay anxiety of parents and reduce unnecessary work-up. Objective: The purpose of this report is to describe a frequently unrecognized cause of vaginal bleeding that is unrelated to sexual abuse. Case Report: We report the case of a 6-year-old African-American girl referred to our ED as a case of vaginal bleeding with suspicion of sexual abuse. She was clinically diagnosed to have urethral prolapse. Conclusion: In prepubertal girls with vaginal bleeding, urethral prolapse should be strongly considered as a diagnostic possibility. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary examinations and patient anxiety and prevents misdiagnosis as sexual abuse. Ó 2014 Elsevier Inc.
evaluation. Common causes of vaginal bleeding in prepubertal girls are neonatal withdrawal bleeding, trauma, foreign bodies, infections, lichen sclerosus, urethral prolapse, and precocious puberty. The biggest concern of both parents and health care providers is the possibility of sexual abuse (1,2). We report a case of a prepubertal child that was referred to the Emergency Department (ED) for evaluation of vaginal bleeding with the suspicion of sexual abuse. CASE REPORT A 6-year-old African American girl was referred by a pediatrician to the Pediatric ED with chief complaints of painless vaginal bleeding for 2–3 days. Her mother and her pediatrician were concerned about the possibility of sexual abuse. She denied any other problems such as pain, fever, lethargy, distension of the abdomen, dysuria, or urgency. She had no history suggestive of sexual abuse or trauma to the genital area. The past history was unremarkable. The patient lived with her mother along with the grandmother, and there were no male children or adults living in the household. The child had normal developmental milestones and attended the local elementary school. Her vital signs were normal and her general physical examination was unremarkable. Examination of the genitalia revealed a round doughnut-shaped reddish colored
, Keywords—urethral prolapse; prepubertal; vaginal bleeding; sexual abuse
INTRODUCTION Vaginal bleeding after the first month of life until menarche is always abnormal and warrants diagnostic Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals. elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 18 March 2013; FINAL SUBMISSION RECEIVED: 2 August 2013; ACCEPTED: 16 November 2013 1
2
N. P. Kondamudi et al.
mass protruding from the urethral opening (Figure 1). The mass was soft and nontender. There was no active bleeding or discharge and there were no signs of bruising or hematoma. It was difficult to visualize the hymen. The patient was observed passing urine through the opening of the mass as shown in Figure 2 and Video 1. This confirmed the diagnosis of urethral prolapse, and she was discharged with advice to apply estrogen cream and follow up with her pediatrician. DISCUSSION Vaginal bleeding in prepubertal children is an alarming symptom for many parents and often evokes concern for sexual abuse among both parents and providers. Though sexual abuse is not infrequent, there are several causes that can present with vaginal bleeding. Sugar and Graham classified the etiology according to examination findings of a visible lesion (3). If a lesion was found, the differential diagnosis included lichen sclerosis et atrophicus, trauma (straddle injury), penetrating injury (accident or abuse), genital warts, external hemangioma, neoplasm—vulva or lower vagina (sarcoma botryoides)—and urethral prolapse. If there are any secondary sexual characteristics, the possibility of precocious or pseudoprecocious puberty Figure 2. Passage of urine through the opening of the mass suggestive of urethral prolapse.
Figure 1. Reddish-colored mass protruding from the urethral opening.
should be entertained. If no visible lesion is seen on examination, an evaluation for hematuria, rectal bleeding, infectious vaginitis, vaginal foreign body, exogenous hormone withdrawal, neoplasm in the upper vagina or uterus, or blood dyscrasia should be considered. Isolated premature menarche is considered on the rare occasions when a thorough evaluation and work-up fail to reveal a plausible cause. Other causes reported in the literature are polyps, condyloma acuminate, ureterocele, hydrometrocolpos, and ectopic ureter (4). Urethral prolapse is a condition in which the urethral mucosa evaginates beyond urethral meatus, resulting in vascular congestion and edema of the prolapsed tissue (5,6). It is a rare condition, with a bimodal age distribution mostly affecting prepubertal girls and postmenopausal women and a suggested incidence of one in 3000 (7). It occurs almost exclusively in black girls younger than 10 years, with an average age at presentation of 4 years. The exact cause of urethral prolapse remains unknown; however, several theories have been proposed. These theories may be divided into congenital or acquired defects. Congenital defects include weak pelvic floor structures such as inadequate pelvic attachments and urethral hypermobility. Proposed theories include intrinsic
Prepubertal Girl with Vaginal Bleeding
abnormalities of the urethra (e.g., an abnormally patulous urethra, a wide urethra, redundant mucosa). Other hypotheses include neuromuscular disorders, urethral malposition, submucosal weakness, or deficient elastic tissue. Acquired defects in children are less likely and include trauma, debility, and malnutrition. Risk factors for urethral prolapse in children include increased intraabdominal pressure as a result of chronic coughing or constipation (8). Prepubertal urethral prolapse is predominantly asymptomatic. Often, urethral prolapse is an incidental finding during routine examination. When symptomatic, typical patients are between 2 and 10 years old with vaginal bleeding, even though it doesn’t actually involve the vagina. Genital examination reveals a reddish purple annular mass between the labia majora. Hematuria is uncommon. Until urethral prolapse is definitively diagnosed, the presence of blood in the genital area should raise the suspicion of sexual abuse. Voiding disturbances are typically rare in the pediatric population, but when they are present, patients may report dysuria, urinary frequency, or introital pain. Again, hematuria is uncommon. Children may report genital pain if the prolapsed mucosa becomes very large or if thrombosis and gangrene have developed (9). Furthermore, although reportedly a nonobstructive lesion, acute urinary retention secondary to urethral prolapse has been reported in a young girl (10). Because urethral prolapse is so rarely seen by emergency physicians, the rate of misdiagnosis can be high. The diagnosis of urethral prolapse is made by verifying that a central opening is present within the prolapsed tissue and that this opening is the urethral meatus. In children, observation during voiding or catheterization of the central opening is diagnostic. Routine evaluation with intravenous pyelograms and voiding cystourethrograms is unnecessary except in cases in which there is doubt concerning malignancy, prolapsed ectopic ureterocele, or abnormalities of the ureterovesical junction (9). Current recommended regimen consists of the application of estrogen cream to the prolapsed urethra two to three times daily for 2 weeks in combination with sitz baths. Topical antibiotics can be used if local secondary infection is suspected. Failure of medical therapy or the
3
presence of strangulated urethral prolapse mandates surgical excision (11,12). CONCLUSION Urethral prolapse is one of the rare causes of vaginal bleeding in children. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary Child Protection Services referrals, parent and patient anxiety, and prevents misdiagnosis as sexual abuse.
REFERENCES 1. Akani CI, Pepple DK, Ugboma HA. Urethral prolapse: a retrospective analysis of hospitalized cases in Port Harcourt. Niger J Med 2005;14:396–9. 2. Vunda A, Vandertuin L, Gervaix A. Urethral prolapse: an overlooked diagnosis of urogenital bleeding in pre-menarcheal girls. J Pediatr 2011;158:682–3. 3. Sugar NF, Graham EA. Common gynecologic problems in prepubertal girls. Pediatr Rev 2006;27:213–23. 4. Lang ME, Darwish A, Long MA. Vaginal bleeding in the prepubertal child. CMAJ 2005;172:1289–90. 5. Shurtleff BT, Barone JG. Urethral prolapse: four quadrant excisionnal technique. J Pediatr Adolesc Gynecol 2002;15:209–11. 6. Shavit I, Solt I. Urethral prolapse misdiagnosed as vaginal bleeding in a premenarchal girl. Eur J Pediatr 2008;167:597–8. 7. Holbrook C, Misra D. Surgical management of urethral prolapse in girls: 13 years’ experience. BJU Int 2012;110:132–4. 8. Pouya M, Van Cangh PJ, Wese FX, Opsomer RJ, Saleh M. Mucous prolapse of the urethra. Acta Urol Belg 1995;63:23–9. 9. Aprile A, Ranzato C, Rizzotto MR, Arseni A, Da Dalt L, Facchin P. ‘‘Vaginal’’ bleeding in prepubertal age: a rare scaring riddle, a case of the urethral prolapse and review of the literature. Forensic Sci Int 2011;210:e16–20. 10. Philippot D, Lacoste J, Bouchot O, Gle´main P, Buzelin JM. Dysuria in women and bladder hypocontractibility. J Urol (Paris) 1988;94: 19–20. 11. Hillyer S, Mooppan U, Kim H, Gulmi F. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology 2009;73:1008–11. 12. Fernandes ET, Dekermacher S, Sabadin MA, Vaz F. Urethral prolapse in children. Urology 1993;41:240–2.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10. 1016/j.jemermed.2013.11.075.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
http://dx.doi.org/10.1016/j.jemermed.2013.11.075
Clinical Communications: Pediatrics PREPUBERTAL GIRL WITH VAGINAL BLEEDING Noah P. Kondamudi, MD, FAAP, FACEP,* Ayush Gupta, MD,† Amina Watkins, MD,‡ and Amy Bertolotti, RN§ *Division of Pediatric Emergency Medicine, Department of Pediatrics, Rutgers New Jersey Medical School, Newark, New Jersey, †Department of Pediatrics, The Brooklyn Hospital Center, Brooklyn, New York, ‡Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, and §Department of Nursing, University Hospital, Newark, New Jersey Reprint Address: Noah P. Kondamudi, MD, FAAP, FACEP, Division of Pediatric Emergency Medicine, Department of Pediatrics, 185 South Orange Avenue, Newark, NJ 07103
, Abstract—Background: Prepubertal children with vaginal bleeding are frequently brought in to the Emergency Department (ED) for evaluation with the primary concern of sexual abuse. Appropriate history and physical examination can help recognize the specific cause and allay anxiety of parents and reduce unnecessary work-up. Objective: The purpose of this report is to describe a frequently unrecognized cause of vaginal bleeding that is unrelated to sexual abuse. Case Report: We report the case of a 6-year-old African-American girl referred to our ED as a case of vaginal bleeding with suspicion of sexual abuse. She was clinically diagnosed to have urethral prolapse. Conclusion: In prepubertal girls with vaginal bleeding, urethral prolapse should be strongly considered as a diagnostic possibility. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary examinations and patient anxiety and prevents misdiagnosis as sexual abuse. Ó 2014 Elsevier Inc.
evaluation. Common causes of vaginal bleeding in prepubertal girls are neonatal withdrawal bleeding, trauma, foreign bodies, infections, lichen sclerosus, urethral prolapse, and precocious puberty. The biggest concern of both parents and health care providers is the possibility of sexual abuse (1,2). We report a case of a prepubertal child that was referred to the Emergency Department (ED) for evaluation of vaginal bleeding with the suspicion of sexual abuse. CASE REPORT A 6-year-old African American girl was referred by a pediatrician to the Pediatric ED with chief complaints of painless vaginal bleeding for 2–3 days. Her mother and her pediatrician were concerned about the possibility of sexual abuse. She denied any other problems such as pain, fever, lethargy, distension of the abdomen, dysuria, or urgency. She had no history suggestive of sexual abuse or trauma to the genital area. The past history was unremarkable. The patient lived with her mother along with the grandmother, and there were no male children or adults living in the household. The child had normal developmental milestones and attended the local elementary school. Her vital signs were normal and her general physical examination was unremarkable. Examination of the genitalia revealed a round doughnut-shaped reddish colored
, Keywords—urethral prolapse; prepubertal; vaginal bleeding; sexual abuse
INTRODUCTION Vaginal bleeding after the first month of life until menarche is always abnormal and warrants diagnostic Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals. elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 18 March 2013; FINAL SUBMISSION RECEIVED: 2 August 2013; ACCEPTED: 16 November 2013 1
2
N. P. Kondamudi et al.
mass protruding from the urethral opening (Figure 1). The mass was soft and nontender. There was no active bleeding or discharge and there were no signs of bruising or hematoma. It was difficult to visualize the hymen. The patient was observed passing urine through the opening of the mass as shown in Figure 2 and Video 1. This confirmed the diagnosis of urethral prolapse, and she was discharged with advice to apply estrogen cream and follow up with her pediatrician. DISCUSSION Vaginal bleeding in prepubertal children is an alarming symptom for many parents and often evokes concern for sexual abuse among both parents and providers. Though sexual abuse is not infrequent, there are several causes that can present with vaginal bleeding. Sugar and Graham classified the etiology according to examination findings of a visible lesion (3). If a lesion was found, the differential diagnosis included lichen sclerosis et atrophicus, trauma (straddle injury), penetrating injury (accident or abuse), genital warts, external hemangioma, neoplasm—vulva or lower vagina (sarcoma botryoides)—and urethral prolapse. If there are any secondary sexual characteristics, the possibility of precocious or pseudoprecocious puberty Figure 2. Passage of urine through the opening of the mass suggestive of urethral prolapse.
Figure 1. Reddish-colored mass protruding from the urethral opening.
should be entertained. If no visible lesion is seen on examination, an evaluation for hematuria, rectal bleeding, infectious vaginitis, vaginal foreign body, exogenous hormone withdrawal, neoplasm in the upper vagina or uterus, or blood dyscrasia should be considered. Isolated premature menarche is considered on the rare occasions when a thorough evaluation and work-up fail to reveal a plausible cause. Other causes reported in the literature are polyps, condyloma acuminate, ureterocele, hydrometrocolpos, and ectopic ureter (4). Urethral prolapse is a condition in which the urethral mucosa evaginates beyond urethral meatus, resulting in vascular congestion and edema of the prolapsed tissue (5,6). It is a rare condition, with a bimodal age distribution mostly affecting prepubertal girls and postmenopausal women and a suggested incidence of one in 3000 (7). It occurs almost exclusively in black girls younger than 10 years, with an average age at presentation of 4 years. The exact cause of urethral prolapse remains unknown; however, several theories have been proposed. These theories may be divided into congenital or acquired defects. Congenital defects include weak pelvic floor structures such as inadequate pelvic attachments and urethral hypermobility. Proposed theories include intrinsic
Prepubertal Girl with Vaginal Bleeding
abnormalities of the urethra (e.g., an abnormally patulous urethra, a wide urethra, redundant mucosa). Other hypotheses include neuromuscular disorders, urethral malposition, submucosal weakness, or deficient elastic tissue. Acquired defects in children are less likely and include trauma, debility, and malnutrition. Risk factors for urethral prolapse in children include increased intraabdominal pressure as a result of chronic coughing or constipation (8). Prepubertal urethral prolapse is predominantly asymptomatic. Often, urethral prolapse is an incidental finding during routine examination. When symptomatic, typical patients are between 2 and 10 years old with vaginal bleeding, even though it doesn’t actually involve the vagina. Genital examination reveals a reddish purple annular mass between the labia majora. Hematuria is uncommon. Until urethral prolapse is definitively diagnosed, the presence of blood in the genital area should raise the suspicion of sexual abuse. Voiding disturbances are typically rare in the pediatric population, but when they are present, patients may report dysuria, urinary frequency, or introital pain. Again, hematuria is uncommon. Children may report genital pain if the prolapsed mucosa becomes very large or if thrombosis and gangrene have developed (9). Furthermore, although reportedly a nonobstructive lesion, acute urinary retention secondary to urethral prolapse has been reported in a young girl (10). Because urethral prolapse is so rarely seen by emergency physicians, the rate of misdiagnosis can be high. The diagnosis of urethral prolapse is made by verifying that a central opening is present within the prolapsed tissue and that this opening is the urethral meatus. In children, observation during voiding or catheterization of the central opening is diagnostic. Routine evaluation with intravenous pyelograms and voiding cystourethrograms is unnecessary except in cases in which there is doubt concerning malignancy, prolapsed ectopic ureterocele, or abnormalities of the ureterovesical junction (9). Current recommended regimen consists of the application of estrogen cream to the prolapsed urethra two to three times daily for 2 weeks in combination with sitz baths. Topical antibiotics can be used if local secondary infection is suspected. Failure of medical therapy or the
3
presence of strangulated urethral prolapse mandates surgical excision (11,12). CONCLUSION Urethral prolapse is one of the rare causes of vaginal bleeding in children. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary Child Protection Services referrals, parent and patient anxiety, and prevents misdiagnosis as sexual abuse.
REFERENCES 1. Akani CI, Pepple DK, Ugboma HA. Urethral prolapse: a retrospective analysis of hospitalized cases in Port Harcourt. Niger J Med 2005;14:396–9. 2. Vunda A, Vandertuin L, Gervaix A. Urethral prolapse: an overlooked diagnosis of urogenital bleeding in pre-menarcheal girls. J Pediatr 2011;158:682–3. 3. Sugar NF, Graham EA. Common gynecologic problems in prepubertal girls. Pediatr Rev 2006;27:213–23. 4. Lang ME, Darwish A, Long MA. Vaginal bleeding in the prepubertal child. CMAJ 2005;172:1289–90. 5. Shurtleff BT, Barone JG. Urethral prolapse: four quadrant excisionnal technique. J Pediatr Adolesc Gynecol 2002;15:209–11. 6. Shavit I, Solt I. Urethral prolapse misdiagnosed as vaginal bleeding in a premenarchal girl. Eur J Pediatr 2008;167:597–8. 7. Holbrook C, Misra D. Surgical management of urethral prolapse in girls: 13 years’ experience. BJU Int 2012;110:132–4. 8. Pouya M, Van Cangh PJ, Wese FX, Opsomer RJ, Saleh M. Mucous prolapse of the urethra. Acta Urol Belg 1995;63:23–9. 9. Aprile A, Ranzato C, Rizzotto MR, Arseni A, Da Dalt L, Facchin P. ‘‘Vaginal’’ bleeding in prepubertal age: a rare scaring riddle, a case of the urethral prolapse and review of the literature. Forensic Sci Int 2011;210:e16–20. 10. Philippot D, Lacoste J, Bouchot O, Gle´main P, Buzelin JM. Dysuria in women and bladder hypocontractibility. J Urol (Paris) 1988;94: 19–20. 11. Hillyer S, Mooppan U, Kim H, Gulmi F. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology 2009;73:1008–11. 12. Fernandes ET, Dekermacher S, Sabadin MA, Vaz F. Urethral prolapse in children. Urology 1993;41:240–2.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10. 1016/j.jemermed.2013.11.075.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
