NEUROUROLOGY & FEMALE UROLOGY

Vaginal Discharge and Bleeding in Girls Younger than 6 Years
Striegel AM, Myers JB, Sorensen MD, Furness PD, Koyle MA
Department of Urology, Children’s Hospital, Denver, Colorado, USA
J Urol. 2006; 176: 2632-5

• Purpose: Persistent unexplained vaginal discharge or bleeding in the pediatric population may be the only manifestation of a serious underlying medical or social problem. Therefore, these symptoms require careful and complete evaluation to identify the primary pathology accurately. We retrospectively reviewed charts of patients who presented for evaluation of persistent vaginal discharge or bleeding to determine if noninvasive imaging was a sensitive means of screening for gynecological pathology.
• Materials and Methods: The records of 24 girls younger than 6 years who presented with vaginal discharge or bleeding were reviewed retrospectively. All patients were evaluated with noninvasive imaging, a pelvic examination while under anesthesia, vaginoscopy and cystoscopy.
• Results: Noninvasive imaging was useful in identifying 5 of 7 vaginal foreign bodies. However, noninvasive imaging identified only 2 of 6 malignancies. These malignancies consisted of rhabdomyosarcoma (3 patients) and endodermal sinus tumor (3). Two girls also had benign vaginal mullerian papillomas that were not identified by noninvasive imaging. Noninvasive imaging did not aid in the diagnosis of sexual abuse.
• Conclusions: Based on these data, we recommend that all girls younger than 6 years who present with persistent vaginal discharge or bleeding be evaluated with pelvic examination while under anesthesia, to be followed by vaginoscopy and cystoscopy if no readily identifiable pathology is found by simple genital examination alone, regardless of the results of noninvasive imaging studies.
  
  
• Editorial Comment
  The authors reviewed the efficacy of non-invasive imaging (including abdominal x-ray, ultrasound, CT scan and MR of the pelvis) in the population of females younger than 6 years old who presented to their clinic with vaginal discharge and bleeding as opposed to a physical examination with potential endoscopy under anesthesia; in addition, notation was made of the diagnoses found after evaluation. The patients had for the most part already been treated with antibiotic therapy prior to presentation to the authors. The study found that approximately half of the patients with vaginal discharge had a vaginal vault foreign body while one-third of the patients had no identifiable cause of the discharge. Of the patients with vaginal bleeding, almost half had a vaginal malignancy while approximately 15% had a foreign body within the vagina. The authors thus highlight the difference of potential diagnosis of vaginal discharge versus vaginal bleeding in this young population. Based on their findings, the presentation of vaginal bleeding in a female younger than 6 years old should engender an evaluation without hesitation under anesthesia since there is a high likelihood of the presence of malignancy.

Dr. Steven P. Petrou
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA