Evaluation of vaginal bleeding in children and adolescents
- Jan Paradise, MD
Jan Paradise, MD
- Department of Pediatrics
- Signature Medical Group - Easton, MA
- Section Editor
- Stephen J Teach, MD, MPH
Stephen J Teach, MD, MPH
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics and Emergency Medicine
- George Washington University School of Medicine and Health Sciences
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The causes of vaginal bleeding in children differ substantially from the causes in adolescents. During childhood, vaginal bleeding after the first week or so of life but before menarche is always abnormal and warrants diagnostic evaluation. After menarche, pregnancy is a consideration; abnormal vaginal bleeding must be differentiated from menstruation; and menstrual bleeding must be categorized as either normal or excessive.
This topic offers an approach to the evaluation of vaginal bleeding in children and adolescents. The evaluation of the specific condition abnormal uterine bleeding in adolescents and the differential diagnosis of vaginal bleeding in adult women are discussed separately. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis" and "Differential diagnosis of genital tract bleeding in women".)
The causes of vaginal bleeding in children and adolescents organized by patients' menarcheal status are presented in the table (table 1). Trauma as a cause of vaginal bleeding is discussed below (see 'Trauma' below). In non-injured children, the clinician should first consider the patient's chronological age and stage in puberty (Tanner or sexual maturity stage) (picture 1 and picture 2). When evaluating adolescents who have passed menarche, the clinician must first establish whether or not the patient is pregnant (see "Clinical manifestations and diagnosis of early pregnancy"). In adolescents who are not pregnant, the clinician will need to distinguish abnormal vaginal bleeding from normal menstruation. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Terminology'.)
Trauma — The home, and especially the bathroom, is a common location for both blunt and penetrating vaginal injuries in girls . Bed frames, falls onto narrow objects like pencils, and protruding bathtub fixtures can pose hazards to girls who jump, fall, or slip on wet surfaces. Although sexual assault is an important consideration in children and adolescents with genital trauma, most injuries that cause vaginal bleeding are unintentional. Conversely, most sexual assault of children does not produce any genital trauma . A discussion of how to distinguish between unintentional genital injury and sexual assault is presented separately. (See "Evaluation of sexual abuse in children and adolescents", section on 'Differential diagnosis' and "Straddle injuries in children: Evaluation and management", section on 'Findings suggesting child abuse'.)
Life-threatening vaginal trauma — Penetrating injuries that lacerate the vaginal wall can cause life-threatening hemorrhage and can be associated with concomitant rectal injury or peritonitis. Mechanisms reported to produce major vaginal trauma include coitus [3,4], high-pressure water jets from fountains or water slides , and recreational misadventures involving water or jet skiing [6,7]. In patients whose visible perineal injuries are minor, a history of impalement or water jet injury should alert the clinician to the possibility of inapparent but severe vaginorectal trauma .
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- - Life-threatening vaginal trauma
- - Vulvar and vaginal trauma
- Vaginal bleeding before normal menarche
- - Life-threatening conditions
- - Common conditions before normal menarche
- - Uncommon conditions before menarche
- Vaginal bleeding during adolescence
- - Life-threatening conditions during adolescence
- - Common conditions related to pregnancy during adolescence
- - Common conditions in non-pregnant adolescents
- - Uncommon conditions during adolescence
- Premenarcheal patients
- - History
- - Physical examination
- - Diagnostic evaluation
- - Approach
- Postmenarcheal patients
- - Approach