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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.


FIGURE 79.1 Diagnostic approach to vaginal bleeding before normal menarche.

Lichen Sclerosis

Although bleeding per se is not common, ecchymoses, fissures, and
telangiectasias are frequent clinical manifestations of lichen sclerosis, a chronic,
idiopathic skin disorder in children that most often affects the vulva. In this
condition, white, flat-topped papules gradually coalesce to form atrophic plaques
that involve the vulvar and perianal skin in a symmetric hourglass pattern. Topical
treatment with corticosteroids or an immunomodulator is helpful in most cases.
Consultation with a specialist is suggested for management of this uncommon
disorder.

Vaginal Bleeding
Bleeding in the Neonate
During the first 2 weeks of life, hormonal fluctuations may produce physiologic
endometrial bleeding. Before female infants are born, high levels of placental
estrogen from the mother stimulate growth of both the uterine endometrium and
the breast tissue. As this hormonal support decreases after birth, some infants
have an endometrial slough that results in a few days of light vaginal bleeding.
The bleeding will stop spontaneously and requires no treatment except parental
reassurance. A further workup is necessary if the bleeding persists after 3 weeks.


FIGURE 79.2 A: Girl in the frog-leg position for the examination of the external genitalia. B:
Girl in the knee-chest position with exaggerated lordosis and relaxed abdominal muscles. The
examiner can inspect the interior of her vagina by gently separating her buttocks and labia,
using an otoscope without an attached speculum for illumination.

Precocious Puberty
Precocious puberty is characterized by cyclic bleeding with or without associated
breast development (thelarche), pubic hair growth (adrenarche), or accelerated
linear growth in girls less than 8 years of age. Always consider possible exposure
to exogenous feminizing hormones (e.g., creams or medications containing

estrogen). An ultrasound may be considered to identify an abdominal mass such
as an endocrinologically active ovarian tumor or cyst affecting the gonads. A
careful examination should also be performed to assess for a central nervous
system mass, symptoms/signs of hypothyroidism, blood or coagulation disorders,
or the presence of unilateral café-au-lait spots that may suggest McCune–Albright
syndrome. The evaluation for precocious puberty is rarely emergent and best
referred to a pediatrician and/or pediatric endocrinologist.
Foreign Body
Although a chronic, foul-smelling discharge is often considered the hallmark of a
vaginal foreign body, many girls have intermittent vaginal bleeding or scant
vaginal discharge. Direct inspection of the vaginal vault using the frog-leg or
knee-chest position ( Fig. 79.2B ) usually reveals the foreign body easily. While
the most common foreign body—toilet paper—is not radiopaque, pelvic
ultrasound may be useful when toy parts, crayons, or coins are suspected. If a
foreign body is strongly suspected but cannot be seen, vaginal irrigation often
successfully flushes out the foreign body. Instill normal saline via gravity using a
Foley catheter and a 50-mL syringe with the plunger discarded. Application of
2% viscous lidocaine to the introital tissues reduces discomfort and the majority
of children tolerate the procedure well. An examination under procedural sedation
or general anesthesia with a pediatric gynecologic specialist is sometimes


necessary to ensure that a retained foreign body is removed to prevent
complications such as fistula formation and vaginal stenosis.
Infections
About half of all patients with Shigella vaginitis have bleeding that may be more
noticeable than vaginal discharge. Most patients do not have concurrent diarrhea.
Vaginal infections with group A streptococci, N. gonorrhoeae, and C. albicans
also cause bleeding in some cases. A vaginal culture will provide the diagnosis
and guide the selection of appropriate therapy. The manifestations and treatment

of vaginal infections in children are discussed in more detail in Chapters 80
Vaginal Discharge and 92 Gynecology Emergencies .
Tumors
Malignant tumors, such as endodermal sinus tumors and rhabdomyosarcomas
including sarcoma botryoides are a rare cause of vaginal bleeding in young
females. Sarcoma botryoides presents as a polypoid, “grape-like” mass protruding
from the introitus and often has metastasized to the lungs, pericardium, liver,
kidney, and bones when initially diagnosed. Peak incidence is 2 years of age but
this can present between 1 and 5 years old. Pelvic ultrasound can aid with this
diagnosis. A pediatric gynecologist and oncologist should be consulted
immediately because treatment requires surgical excision, chemotherapy, and
radiation therapy after a tissue biopsy.
Vascular Anomalies
Vascular anomalies, such as malformations or tumors, may cause vaginal
bleeding in young children. Infantile hemangiomas, which can appear anywhere
along the body, are the most common vascular tumor, occurring in up to 10% of
white, non-Hispanic females. They are often associated with prematurity and
infants of mothers with multiple gestation, advanced maternal age, placenta
previa, or preeclampsia. They typically present in the first weeks of life and tend
to regress spontaneously. Infrequently, they may lead to ulceration and bleeding.
Treatment with corticosteroids, laser therapy, and possible excision may be
necessary.

Urethral Bleeding
Urethral prolapse (see Chapter 92 Gynecology Emergencies ) is a common cause
of prepubertal vaginal bleeding. Urethral prolapse more commonly affects
school-aged African-American children. The etiology remains unknown. Factors
contributing to urethral prolapse might include estrogen deficiency, trauma,