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)
- 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 .
- Sugar NF, Feldman KW. Perineal impalements in children: distinguishing accident from abuse. Pediatr Emerg Care 2007; 23:605.
- DeLago C, Deblinger E, Schroeder C, Finkel MA. Girls who disclose sexual abuse: urogenital symptoms and signs after genital contact. Pediatrics 2008; 122:e281.
- Hoffman RJ, Ganti S. Vaginal laceration and perforation resulting from first coitus. Pediatr Emerg Care 2001; 17:113.
- Bhagat M. Coital injury presenting in a 13 year old as abdominal pain and vaginal bleeding. Pediatr Emerg Care 1996; 12:354.
- Aho T, Upadhyay V. Vaginal water-jet injuries in premenarcheal girls. N Z Med J 2005; 118:U1565.
- Perlman SE, Hertweck SP, Wolfe WM. Water-ski douche injury in a premenarcheal female. Pediatrics 1995; 96:782.
- Goldberg J, Horan C, O'Brien LM. Severe anorectal and vaginal injuries in a jet ski passenger. J Trauma 2004; 56:440.
- Grisoni ER, Hahn E, Marsh E, et al. Pediatric perineal impalement injuries. J Pediatr Surg 2000; 35:702.
- Scheidler MG, Schultz BL, Schall L, Ford HR. Mechanisms of blunt perineal injury in female pediatric patients. J Pediatr Surg 2000; 35:1317.
- Lacy J, Capra M, Allen L. Endodermal sinus tumor of the infant vagina treated exclusively with chemotherapy. J Pediatr Hematol Oncol 2006; 28:768.
- Handel LN, Scott SM, Giller RH, et al. New perspectives on therapy for vaginal endodermal sinus tumors. J Urol 2002; 168:687.
- Fernandez-Pineda I, Spunt SL, Parida L, et al. Vaginal tumors in childhood: the experience of St. Jude Children's Research Hospital. J Pediatr Surg 2011; 46:2071.
- Heller ME, Savage MO, Dewhurst J. Vaginal bleeding in childhood: a review of 51 patients. Br J Obstet Gynaecol 1978; 85:721.
- Hill NC, Oppenheimer LW, Morton KE. The aetiology of vaginal bleeding in children. A 20-year review. Br J Obstet Gynaecol 1989; 96:467.
- Striegel AM, Myers JB, Sorensen MD, et al. Vaginal discharge and bleeding in girls younger than 6 years. J Urol 2006; 176:2632.
- Perlman SE. Management quandary. Premenarchal vaginal bleeding. J Pediatr Adolesc Gynecol 2001; 14:135.
- Paradise JE, Willis ED. Probability of vaginal foreign body in girls with genital complaints. Am J Dis Child 1985; 139:472.
- Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health 2004; 40:205.
- Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women. Arch Gynecol Obstet 2011; 284:95.
- Straumanis JP, Bocchini JA Jr. Group A beta-hemolytic streptococcal vulvovaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis J 1990; 9:845.
- Ginsburg CM. Group A streptococcal vaginitis in children. Pediatr Infect Dis 1982; 1:36.
- Mogielnicki NP, Schwartzman JD, Elliott JA. Perineal group A streptococcal disease in a pediatric practice. Pediatrics 2000; 106:276.
- Gryngarten MG, Turco ML, Escobar ME, et al. Shigella vulvovaginitis in prepubertal girls. J Pediatr Adolesc Gynecol 1994; 7:86.
- Murphy TV, Nelson JD. Shigella vaginitis: report of 38 patients and review of the literature. Pediatrics 1979; 63:511.
- Bogaerts J, Lepage P, De Clercq A, et al. Shigella and gonococcal vulvovaginitis in prepubertal central African girls. Pediatr Infect Dis J 1992; 11:890.
- Poindexter G, Morrell DS. Anogenital pruritus: lichen sclerosus in children. Pediatr Ann 2007; 36:785.
- Bercaw-Pratt JL, Boardman LA, Simms-Cendan JS, North American Society for Pediatric and Adolescent Gynecology. Clinical recommendation: pediatric lichen sclerosus. J Pediatr Adolesc Gynecol 2014; 27:111.
- Maronn ML, Esterly NB. Constipation as a feature of anogenital lichen sclerosus in children. Pediatrics 2005; 115:e230.
- Isaac R, Lyn M, Triggs N. Lichen sclerosus in the differential diagnosis of suspected child abuse cases. Pediatr Emerg Care 2007; 23:482.
- Wood PL, Bevan T. Lesson of the week child sexual abuse enquiries and unrecognised vulval lichen sclerosus et atrophicus. BMJ 1999; 319:899.
- Smith YR, Quint EH. Clobetasol propionate in the treatment of premenarchal vulvar lichen sclerosus. Obstet Gynecol 2001; 98:588.
- Patrizi A, Gurioli C, Medri M, Neri I. Childhood lichen sclerosus: a long-term follow-up. Pediatr Dermatol 2010; 27:101.
- Chi CC, Kirtschig G, Baldo M, et al. Topical interventions for genital lichen sclerosus. Cochrane Database Syst Rev 2011; :CD008240.
- Goldstein AT, Thaçi D, Luger T. Topical calcineurin inhibitors for the treatment of vulvar dermatoses. Eur J Obstet Gynecol Reprod Biol 2009; 146:22.
- Anveden-Hertzberg L, Gauderer MW, Elder JS. Urethral prolapse: an often misdiagnosed cause of urogenital bleeding in girls. Pediatr Emerg Care 1995; 11:212.
- Valerie E, Gilchrist BF, Frischer J, et al. Diagnosis and treatment of urethral prolapse in children. Urology 1999; 54:1082.
- Hillyer S, Mooppan U, Kim H, Gulmi F. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology 2009; 73:1008.
- Van Wyk JJ, Grumbach MM. Syndrome of precocious menstruation and galactorrhea in juvenile hypothyroidism: an example of hormonal overlap in pituitary feedback. J Pediatr 1960; 57:416.
- Sanjeevaiah AR, Sanjay S, Deepak T, et al. Precocious puberty and large multicystic ovaries in young girls with primary hypothyroidism. Endocr Pract 2007; 13:652.
- Jackson MG, Simms-Cendan J, Sims SM, et al. Vaginal bleeding due to an infantile hemangioma in a 3-year-old girl. J Pediatr Adolesc Gynecol 2009; 22:e53.
- Yalamanchili V, Entezami P, Langenburg S, Stockmann P. Consider benign Müllerian papilloma: a rare cause of vaginal bleeding in children. Pediatr Surg Int 2014; 30:1285.
- Hostetler BR, Muram D, Jones CE. Capillary hemangiomas of the vulva mistaken for sexual abuse. J Pediatr Adolesc Gynecol 1994; 7:44.
- Mierau GW, Lovell MA, Wyatt-Ashmead J, Goin L. Benign müllerian papilloma of childhood. Ultrastruct Pathol 2005; 29:209.
- Goodpasture M. A 4-year-old girl who presents with repeated episodes of vaginal bleeding found to have anogenital warts. J Emerg Med 2013; 45:e177.
- Nella AA, Kaplowitz PB, Ramnitz MS, Nandagopal R. Benign vaginal bleeding in 24 prepubertal patients: clinical, biochemical and imaging features. J Pediatr Endocrinol Metab 2014; 27:821.
- Pinto SM, Garden AS. Prepubertal menarche: a defined clinical entity. Am J Obstet Gynecol 2006; 195:327.
- Seravalli V, Linari S, Peruzzi E, et al. Prevalence of hemostatic disorders in adolescents with abnormal uterine bleeding. J Pediatr Adolesc Gynecol 2013; 26:285.
- Hoffman L, Ma OJ, Gaddis G, Schwab RA. Cervical infections in emergency department patients with vaginal bleeding. Acad Emerg Med 2002; 9:781.
- Eyvazzadeh AD, Smith YR, Lieberman R, Quint EH. A rare case of vulvar endometriosis in an adolescent girl. Fertil Steril 2009; 91:929.e9.
- Paradise JE, Campos JM, Friedman HM, Frishmuth G. Vulvovaginitis in premenarcheal girls: clinical features and diagnostic evaluation. Pediatrics 1982; 70:193.
- Zinns LE, Chuang JH, Posner JC, et al. Vaginal bleeding. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG (Eds), Wolters Kluwer, Philadelphia 2016. p.513.
- Smorgick N, Padua A, Lotan G, et al. Diagnosis and treatment of pediatric vaginal and genital tract abnormalities by small diameter hysteroscope. J Pediatr Surg 2009; 44:1506.
- - 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