Pediatric emergency medicine trisk 385

children unable to provide a clean-catch specimen. A pregnancy test should be
obtained in all menstruating females presenting with a urinary complaint, and
sexually transmitted infection (STI) testing (including urine gonococcal and
chlamydial testing) is warranted for sexually active adolescents. Additional
urinary studies, such as urine chemistries, may be indicated if renal parenchymal
or tubular diseases, such as Fanconi syndrome, are suspected. Serum testing
should be undertaken if the diagnosis is not readily apparent or if indicated by the
potential diagnosis implied by the urinalysis. If there is concern for renal
parenchymal disease, then electrolytes, blood urea nitrogen, creatinine, and
calcium should be obtained. Serum electrolytes should be evaluated when
concern exists for either central or nephrogenic DI, and a venous blood gas, in
addition to a hemoglobin A1C, should be collected when concern for DM exists.
Inflammatory markers can be helpful if appendicitis is suspected.

FIGURE 78.1 Interpretation of urinalysis.

Imaging studies obtained emergently should be guided by the differential
diagnosis. A renal and bladder ultrasound is useful in assessing for
nephrolithiasis, and is indicated nonemergently for UTIs that occur in infants.
Ultrasounds of the appendix and pelvis are warranted if appendicitis or ovarian
torsion, respectively, are being considered. An abdominal radiograph to assess
stool burden can be obtained if constipation is suspected as the etiology of urinary
frequency. If a neurogenic bladder (related to a spinal cord lesion such as a
tethered cord) or a space-occupying lesion (leading to central DI) is suspected,
emergent neuroimaging, either via CT scan or MRI, is warranted. A specialty
consultation by a nephrologist is indicated if underlying renal parenchymal


disease is suggested by history, physical examination, or laboratory studies; or by
a urologist if obstructive urolithiasis or urethral disease is suspected.
Suggested Readings and Key References

Balighian E, Burke M. Urinary tract infections in children. Pediar Rev
2018;39:3–12.
Bergmann M, Corigliano T, Ataia I, et al. Childhood extraordinary daytime
urinary frequency—a case series and a systematic literature review. Pediatr
Nephrol 2009;24:789–795.
Fernandez-Ibieta M, Ayuso-Gonzalez L. Dysfunctional voiding in pediatrics: a
review of pathophysiology and current treatment modalities. Curr Pediatr Rev
2016;12:292–300.
Muhammad S, Nawaz G, Jamil I, et al. Constipation in pediatric patients with
lower urinary tract symptoms. J Coll Physicians Surg Pak 2015;25:815–818.
Parekh DJ, Pope JC IV, Adams MC, et al. The role of hypercalciuria in a
subgroup of dysfunctional voiding syndromes of childhood. J Urol
2000;164:1008–1010.
Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in
childhood: a meta-analysis. Pediatr Infect Dis J 2008;27:302–308.


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


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