Pediatric emergency medicine trisk 387

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


early teenage years, the menstrual cycles may be irregular due to immaturity of
the hypothalamic–pituitary–ovarian axis. Occasionally, an adolescent girl is
brought to the ED by her parents to confirm their belief that she is having her first
menstrual period. About 65% of girls are in sexual maturity stage 4 (Tanner stage
4) for breast development when menarche occurs ( Table 79.1 ). Of the remaining
girls, about 25% are in breast development stage 3 and 10% are in stage 5. If the
adolescent’s chronologic age and degree of pubertal development are consistent
with this expected pattern of maturation, no further evaluation is necessary.
The normal menstrual cycle is divided into three phases based on the
physiologic processes occurring in the ovary and uterus. The ovarian cycle
consists of the follicular phase, ovulation, and luteal phase, whereas the uterine
cycle is divided into menstruation, proliferative phase, and secretory phase. By
convention, the cycle is counted in days beginning with the first day of bleeding.
During the follicular phase, ovarian follicles are stimulated by the release of
pituitary follicle-stimulating hormone (FSH), one or two of the follicles become
dominant, and the nondominant follicles atrophy. The predominant hormone
secreted from the ovary during the follicular phase is estrogen and induces
proliferation within the uterine lining. Approximately midcycle, there is a surge
in secretion of luteinizing hormone (LH) from the pituitary stimulating ovulation,
the release of an egg from the dominant follicle. In the absence of fertilization,
the ovum becomes the corpus luteum and secretes large amounts of progesterone.
Progesterone counteracts the estrogen effects on the endometrium, inhibiting its

proliferation and producing glandular changes to prepare the lining for
implantation of a fertilized ovum. Estrogen and progesterone exert a negative
feedback on FSH and LH secretion and these levels subsequently decrease. In the
absence of implantation, the corpus luteum involutes, progesterone and estrogen
levels fall, the endometrium sloughs away and menstruation ensues, starting the
cycle over again.


TABLE 79.1
DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING
I. At any time
A. Trauma
B. Tumor
II. Before normal menarche
A. Hormonal
1. Neonatal bleeding
2. Exogenous estrogen
3. Precocious puberty
B. Nonhormonal
1. Urethral prolapse
2. Genital warts
3. Lichen sclerosus
4. Infectious vaginitis
5. Foreign body
III. After menarche
A. Bleeding diathesis
B. Pelvic infection
C. Endocrinologic problem
1. Midcycle spotting
2. Abnormal uterine bleeding

a. Hormonal contraception
b. Axis immaturity
c. Polycystic ovarian syndrome
d. Hypothyroidism
e. Ovarian cyst
D. Ectopic pregnancy
E. Spontaneous abortion
F. Placenta previa
G. Abruptio placentae
Terminology


The American College of Obstetrics and Gynecology has recommended replacing
the phrase dysfunctional uterine bleeding (DUB) with the phrase abnormal
uterine bleeding (AUB) when describing an adolescent with prolonged vaginal
bleeding. Abnormal bleeding may be characterized as menorrhagia, defined as
bleeding that occurs at regular intervals but lasts more than 7 consecutive days or
in excess of 80 mL. Metrorrhagia is defined as bleeding that occurs at irregular
intervals. Menometrorrhagia denotes heavy and irregular bleeding.

Evaluation and Decision in the Nonpregnant Adolescent
A comprehensive history and physical examination, along with minimal ancillary
testing, usually points to an etiology to guide management (see Fig. 79.3 ). The
detailed history includes a review of the patient’s menstrual history including age
at menarche, usual cycle duration, a relative estimate of usual blood loss, and how
the current symptoms may differ from baseline. Heavy bleeding from the first
period may indicate an underlying bleeding disorder, most commonly von
Willebrand disease. Abdominal cramping may occur at the time of ovulation due
to progesterone secreted in the luteal phase. Prostaglandins released from the
endometrium at the time of menstruation may contribute to uterine cramping,

nausea, vomiting, or diarrhea, which are all common features of dysmenorrhea.
NSAIDs may alleviate the discomfort of dysmenorrhea by inhibiting
prostaglandin release. The presence of dysmenorrhea is not usually a feature of
anovulatory bleeding. Other pertinent historical details include the presence or
absence of trauma, fainting, dizziness, fever, easy bruising, and excessive
bleeding at other sites. Postural dizziness and other signs of anemia can be
elicited. Questions regarding sexual activity, the possibility of pregnancy, sexual
abuse, and/or sexually transmitted infection should be asked with the teen alone.
An opportunity for private conversation between a teen and her physician without
parent(s) is a routine and necessary part of the adolescent medical evaluation
regardless of chief complaint.
The physical examination helps the clinician determine the severity of blood
loss in order to narrow the differential diagnosis. The ED physician begins with
an assessment of vital signs and the patient’s hemodynamic status. Tachycardia,
hypotension, orthostatic changes, and/or signs of anemia may indicate more
significant blood loss. The mucous membranes, conjunctiva, and palms of the
hands/feet should be assessed for pallor. The skin should be examined for signs of
androgen excess such as acne, hirsutism, or acanthosis nigricans as well as
purpura or petechiae to suggest an underlying bleeding disorder. The thyroid
should be palpated for nodules or enlargement. Presence of a soft systolic flow
murmur may be noted during the cardiac examination in the setting of anemia.