Vaginal bleeding, Ureterocele, Prolapsed urethra, sarcoma botyroides,
condyloma acuminata

There are multiple causes of vaginal bleeding in prepubescent girls, some of which are specific to this age group. Many causes, however, can be seen in both preadolescent and adolescent girls and are associated with vulvovaginitis or a vaginal discharge. In most cases, a comprehensive history and thorough external genital examination without direct visualization of the cervix will lead to the appropriate diagnosis. 

Common causes of vaginal bleeding in prepubescent girls include foreign bodies in the vagina, such as small pieces of toilet paper, and some bacterial infections (eg, group A Streptococcus and Shigella sp). Other, less common causes of vaginal bleeding are vascular lesions such as a hemangioma, trauma from sexual abuse, and estrogen withdrawal (eg, the child ingested the mother's or sister's oral contraceptives). Straddle injuries may cause small perineal lacerations, but rarely produce intervaginal bleeding. Urethral bleeding may be confused with vaginal bleeding.

Vaginal Bleed - Prepubescent
Top 3 causes:
•  vulvovaginitis
•  scratching because of pinworm
•  vaginal foreign body

Questions to ask:
- onset, duration, previous, cyclic
- trauma? foreign body? topical or systemic meds?
- history of foreign body in ears/vagina predispose.
- abdominal/pelvic pain? itch? discharge? odor?
- urinary frequency? hematuria?
- diarhhea? hematochezia?
- easy bruising? bleeding?
- dizziness? weakness? syncope?
- mother's hormone pills? OCP?
- wipe back to front? bubble baths? tight underwear? polyester vs cotton?

PE:
- anus to posterior fourchette = median raphe
- posterior fourchette to vaginal introitus = fossa navicularis
- injuries to anterior/superior half of vaginal introitus more c/w innocent causes ie straddle injury
- injuries to posterior/inferior half: more c/w anterio-posterior penetrating forces ie sexual abuse
- want to get a cx from the rugated vaginal tissue (stay away from hymen, very sensitive), but can also culture the fossa navicularis.

Differential
- Trauma
- Vulvovaginitis: poor hygeine, irrit/pinworms, nonspecific, if bloody (GABHS pyogenes, Shigella). Vaginitis in prepubertal girls: Mycoplasma, Gardnerella, Candida, nongonorrheal Neisseria. The following are almost exclusively assoc with sexual activity: chlamydia, N. gonorrhea (the most common one in abuse kids), trichomonas. Vaginal cx from girls with vaginitis usually shows normal flora, i.e. lactobacillus, diphteroids...
- Endocrine: maternal estrogen w/drawal  (in week one only), precocious puberty, exogenous hormones ie OCP, hypothyroid
- Dermatoses: Condyloma acuminata (HPV), lichen sclerosis
- Foreign body
- Urethral prolapse
- Blood dyscrasia (ask about epistaxis? petechiae? hematomas?)
- Tumor

Hygiene
- wipe front to back
- No tight underwear. Use cotton.
- can do warm water soak baths 10 min bid-tid for a week or two

  
Urethral prolapse.

The donut-shaped erythematous mass is prolapsed urethral mucosa that bleeds from local irritation. It is seen more commonly in prepubescent African-American girls and is self-limited. Rarely, surgical treatment is indicated, although medical therapies often are tried initially, such as topical estrogen cream or sitz baths. 

Condyloma acuminata (venereal warts) appear as flesh-colored, pedunculated growths with multiple finger-like projections and are transmitted sexually. They occur most frequently in moist areas, such as the vaginal introitus and vagina, and bleed with minor trauma. Hemangiomas can be seen in the vaginal area, but they do not appear as donut-shaped erythematous masses extruding from the urethra. Although sarcoma botryoides can present with vaginal bleeding in a prepubescent girl, the mass typically is described as grape-like clusters originating from the vagina. A ureterocele is a congenital anomaly that includes cystic dilation of the terminal (intramural) part of the ureter and can be seen as a mass in the urethral area. Approximately 90% are associated with a duplex collecting system.

References:
Emans SJ, Laufer MR, Goldstein DP. Vulvovaginal problems in the
prepubertal child. In: Pediatric and Adolescent Gynecology. 4th ed.
Philadelphia, Pa: Lippincott-Raven; 1998:75-107
Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent.
Pediatr Rev. 1993;14:141-147