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儿童和青少年阴道出血的评估

Author
Jan Paradise, MD
Section Editor
Stephen J Teach, MD, MPH
Deputy Editor
James F Wiley, II, MD, MPH
Translators
陈庄, 教授

引言

儿童与青少年的阴道出血的原因有着很大差别。在儿童期，出生约1周之后至月经初潮之前的阴道出血一定是不正常的，须行诊断性评估。月经初潮后的阴道出血需考虑妊娠；异常阴道出血须与月经相鉴别。月经出血必须考虑血量正常还是过量。

本文提供了评估儿童和青少年阴道出血的方法。青少年异常子宫出血的具体情况的评估和成年女性阴道出血的鉴别诊断将单独讨论。 (参见“青春期异常子宫出血的定义和评估”和“女性生殖道出血的鉴别诊断”)

原因

附表根据患者月经初潮的情况对儿童和青少年阴道出血的原因进行了分类(表 1)。外伤性阴道出血将在下文讨论(参见下文‘创伤’)。对于非外伤性阴道出血儿童，临床医生首先应考虑患者的实足年龄和青春期阶段(Tanner分期，即性成熟分期)(图片 1和图片 2)。评估月经初潮后的青少年时，临床医生必须首先确定患者是否妊娠。(参见“早期妊娠的临床表现和诊断”)对于未妊娠的青少年，临床医生需要区分异常阴道出血与正常月经。 (参见“青春期异常子宫出血的定义和评估”，关于‘青春期异常子宫出血’一节)

创伤 — 在家中，尤其是洗手间，是女孩发生钝性和穿透性阴道损伤的常见地点[1]。女孩在跳跃、摔倒或在湿滑表面滑倒时，床框、窄小物体(如铅笔)和浴缸突出的固定装置都会对其造成伤害。虽然在儿童和青少年生殖器外伤时性侵犯是重要考虑因素，但大多数引起阴道出血的损伤是无意的。相反，大多数受到性侵犯的儿童未发生任何生殖器外伤[2]。关于如何鉴别生殖器无意损伤和性侵犯的内容见其他专题。 (参见“Evaluation of sexual abuse in children and adolescents”, section on ‘Differential diagnosis’和“儿童骑跨伤的评估和处理”，关于‘提示儿童虐待的表现’一节)  

危及生命的阴道外伤 — 穿透伤撕裂阴道壁可能造成危及生命的出血，还可能合并直肠损伤或腹膜炎。据报道，引起重要阴道外伤的机制包括性交[3,4]和娱乐性事故(由喷泉或水滑梯的高压水流[5]和滑水或喷气式滑水艇引起[6,7])。如果患者可见的会阴损伤较轻微，并有刺穿或水射流损伤史，临床医生应注意患者可能存在不明显但严重的阴道直肠损伤[8]。  

                    

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Literature review current through: 2017-06 . | This topic last updated: 2017-07-11.
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