Chapter 136 Pediatric Urologic and Gynecologic Disorders

SCROTUM
o Scrotal pain  one  most common urologic emergencies seen in boys.
o Although  causes of scrotal pain  not require an immediate organ-preserving procedure, some causes can lead to
rapid and permanent loss of testicular function without timely intervention.
o Thus, clinician must identify patients who need emergent diagnostic and/or therapeutic procedures and those who need
observation and reassurance.

TESTICULAR TORSION
 Consider testicular torsion  males with acute scrotal pain, because torsion  urologic emergency.
 estimated incidence  torsion  U.S. males younger than 18 years is 3.8 per 100,000 children.
 Testicular torsion  bimodal age presentation, with one peak  immediate neonatal period and another peak during
early puberty.
 Because  testicle  neonates with true prenatal torsion  not salvageable, many urologists agree that neonates can
be taken to the operating room on a semi-elective basis when the infant is a few months of age to decrease the
anesthesia risk.
 However, neonates who experience postnatal torsion, salvage rate  likely similar to adolescent testicular torsion,
making early surgical detorsion a priority.
 clinical distinction between prenatal and postnatal torsion, however, sometimes difficult to elucidate.
 Most boys with testicular torsion present between 12 and 18 years of age.
 Classically, pain is abrupt in onset and severe and is usually associated with nausea or vomiting. The testicle is
extremely painful, and often the patient will walk with a wide-based gait to minimize the contact of the scrotum to the
thigh. There may be a preceding history of a sports activity or even minor trauma to the area, which may lead the
clinician to a misdiagnosis of traumatic injury. In some cases, the patient may recall episodes of previous scrotal pain
that rapidly resolved without intervention, which may represent intermittent torsion with spontaneous detorsion.
Patients with intermittent testicular pain should be referred for elective orchiopexy, as such patients with intermittent
torsion are at risk for acute complete testicular torsion.3
 Classic physical examination findings of acute testicular torsion include a swollen, tender, high-riding testis, with an
abnormal transverse lie.
 There  often scrotal skin changes.
 Ipsilateral loss  cremasteric reflex is often noted, but the presence of a normal cremasteric reflex does not rule out
torsion.4
 Doppler US  diagnostic imaging study of choice,5 with radionuclide imaging a distant second.
 If  time to obtain diagnostic imaging may lead to delay of surgical intervention, advocate for emergent surgical
exploration for highly suspected cases of torsion, rather than waiting for an imaging study to be completed.
 Time especially critical  duration of symptoms
 <6 hours, salvage rate is excellent in such cases.
 Beyond 6 hours, salvage rate becomes progressively worse, and after 48 hours of symptoms, the
salvage rate is near zero.
 Patients presenting with equivocal signs of torsion may benefit from a Doppler US, which can
visualize blood flow to the testis.
 In acute torsion, Doppler demonstrates an enlarged testis with decreased or absent flow compared
with the unaffected side.
 In patients with suspected intermittent torsion who have a normal Doppler US and resolution of
pain, counsel the patient and family to seek medical attention immediately should the pain recur,
and recommend urologic follow-up as an outpatient.
 Several recent studies  attempted to develop clinical predictors for acute torsion, with the hopes of decreasing time to
surgical intervention for true cases of torsion, reducing the rate of negative explorations, and decreasing the number of
unnecessary imaging studies.
  TWIST (Testicular Workup for Ischemia and Suspected Torsion) scor ing system was developed in 2013 to predict
testicular torsion based on the following findings:
o testicular swelling (2 points)
o hard testicle (2 points)
o absent cremasteric reflex (1 point)
o nausea/vomiting (1 point)
o high-riding testis (1 point).

This scoring system was retrospectively validated when used by urologists, and it was suggested that
high-risk patients (score of ≥5) should have immediate surgical exploration
intermediate-risk patients (score of 3 or 4) should undergo Doppler US
low-risk patients (score ≤2) do not require any testing.

In 2016, TWIST score validated using non-urologists, but  noted that the trained emergency medical technicians had
different cutoffs for
high risk (score of ≥6)
intermediate risk (score of 1 to 5)
low risk (score of 0).

These studies  provided  more objective framework in management of suspected torsion.

To optimize timeliness and minimize unnecessary testing, advocate for immediate surgery in patients with highly suspected
torsion, obtain emergent Doppler US for patients with equivocal signs of torsion, and consider no testing for patients with very
low suspicion for torsion.

 Manual detorsion  indicated  patients with torsion when there  no surgeon immediately available and when the
duration of symptoms  too long for surgical salvage.
 Administer parenteral opioid analgesia, local anesthesia (infiltrating the spermatic cord near the external ring with
lidocaine), or procedural sedation.
 Because  testis tends  torse in medial direction, manual detorsion  accomplished by holding the testis between
the thumb and index finger and rotating the testis  outward direction toward the thigh (as if opening a book).
 However, spermatic cord  twisted >180 degrees, making  difficult to recognize how many times the testis should be
outwardly rotated.
 Also, very swollen hemiscrotum  isolating the testis between two fingers challenging.
 unsedated, older, verbal patient may be able to describe relatively immediate relief upon successful detorsion.
 Bedside or formal Doppler US useful in determining improvement of flow.
 success rate  manual detorsion  quite variable and not definitive therapy.
 Even after manual detorsion, patients need emergent surgical exploration to confirm complete detorsion and to perform
bilateral orchidopexy.

TORSION OF TESTICULAR APPENDAGE

 appendix testis and appendix epididymis testicular embryologic remnants that can twist, resulting in venous congestion
and subsequent infarction of the appendage.
 Torsion  testicular appendage  most common in males between 7 and 12 years of age, although it can occur at any age.
Typically, the patient’s symptoms are more insidious than true testicular torsion, with less severe pain and lack of systemic
symptoms.
 Early  course before scrotal edema and erythema develop, possible to localize the point of tenderness to the upper pole of
the testis or epididymis.
 In addition, one may observe the infarcted appendage through the scrotal skin (“blue dot sign”). If Doppler US is obtained,
there should be normal testicular flow with a small hyperechoic region adjacent to the testis.
 Management consists 
o scrotal support
o limitation of activity
o oral analgesics (e.g., nonsteroidal anti-inflammatory drugs).
o If torsion  testicular appendage is diagnosed early in its course
 o pain may worsen before ultimate improvement due to ongoing inflammation, and this is an important point of
counseling to prevent return to the ED.

EPIDIDYMITIS

 Epididymitis, or inflammation  epididymis,  common cause of scrotal pain in pre- and postpubertal boys that does not
require surgical intervention.
 In sexually active males, acute epididymitis  result from ascending urethral infection due to Chlamydia trachomatis or
Neisseria gonorrhoeae.
 Epididymitis  result from enterovirus or adenovirus infection.
 Symptoms are insidious 
o onset, with dysuria, frequency, or fever. Prehn’s sign (relief of pain by elevating the scrotum) is not consistently
reproducible in boys.
 Typically, affected testis  mildly enlarged and tender with hemiscrotal erythema and swelling (Figure 136-1).
 Urinalysis  demonstrate pyuria and bacteriuria.
 Obtain urine culture and sensitivity, and suspected sexual transmission, obtain specific testing for C. trachomatis and N.
gonorrhoeae.
 Doppler US  diagnosis is in doubt, shows an enlarged epididymis with increased blood flow, and normal blood flow to the
testis. It is often difficult to differentiate torsion of a testicular appendage from
 FIGURE 136-1. Epididymo-orchitis. A 5-year-old boy with 1 day of left testicular pain and swelling, consistent with
epididymo-orchitis.
 FIGURE 136-2. Hydrocele. A 3-month-old boy with bilateral hydroceles (left greater than right).epididymitis by US, but
neither disorder requires surgical intervention.


 treatment  epididymitis  somewhat controversial, with some advocating analgesics and limited activity only and others
supporting treatment with antibiotics.
 In  era of antibiotic stewardship, consider selectively treating certain cases of epididymitis with empiric antibiotics.
 In  2011, retrospective, single-center, pediatric ED study of 140 patients, the incidence of positive urine culture in acute
epididymitis was only 4.1%.
 authors suggest empiric antibiotics for all young infants regardless of urinalysis results, as well as for all non–sexually active
males with a positive urinalysis.
 Sexually active males should be treated presumptively for C. trachomatis and N. gonorrhoeae.

HYDROCELE
 Hydrocele (Figure 136-2)  accumulation of fluid around the testis
 most common cause of painless scrotal swelling in children.
 Parents often note intermittent swelling  one or both sides of the scrotum.
 painless swelling  resolve when supine or sleeping and become more prominent when awake or crying.
 Hydrocele  termed noncommunicating,  there is residual but static swelling after the processus vaginalis has closed, or
communicating, if swelling increases and decreases through a patent processus vaginalis.
 diagnosis  confirmed by transillumination, whereby an otoscope or other light source is placed on the affected
hemiscrotum and the hydrocele fluid is illuminated like a lantern; by contrast, a thickened scrotal wall or pure testicular
enlargement will not transilluminate.
 Most simple hydroceles resorb by 18 to 24 months of age.
 communicating hydrocele  often associated with inguinal hernia, and as long as the hernia is reducible, it does not require
emergent surgical repair.
 Management  most hydroceles includes outpatient scrotal US with referral to urology.

VARICOCELE

 Varicocele  another cause of painless scrotal swelling and typically presents at onset of puberty.
 due  abnormal dilation of spermatic cord veins, also known as the pampiniform plexus, due to faulty in part to the
acute angle of confluence with the left renal vein and resulting higher venous pressure.
 Classically  mass of enlarged veins can be palpated superior and posterior to the testis (“bag of worms”) and is more
prominent when standing or with the Valsalva maneuver; even large varicoceles may be missed in the supine position.
 Varicoceles  managed on an outpatient basis by urology.
 implications  possible subfertility should be discussed in the urologist’s office.

INTRASCROTAL TUMORS

 Intrascrotal tumors  uncommon in young children; however, testicular tumors are the most common solid tumor among
adolescent males.
 testicular or paratesticular tumor usually presents as a painless, firm, unilateral scrotal mass.
 Evaluation includes
o serum α-fetoprotein
o tumor β-human chorionic gonadotropin levels
o scrotal US
o urgent urologic consultation.

DISORDERS OF THE PENIS

 swollen, red, or painful penis  usually -> categorized as disorder of foreskin or of the shaft of the penis.
 most common abnormalities of foreskin are
o Phimosis
o Paraphimosis
o balanoposthitis.
 Penile shaft disorders occur less commonly and include priapism, tourniquet
syndrome, and zipper injury.

PHIMOSIS

 Phimosis  caused by stenosis of distal aspect of the foreskin, preventing

retraction of the foreskin over the glans.
 history of ballooning  foreskin during urination, with dribbling of
entrapped urine after voiding is complete (Figure 136-3).
 Most uncircumcised infants  normal, physiologic phimosis.
 Nearly all cases of physiologic phimosis spontaneously resolve by 5 years of age and rarely require treatment other than
daily cleaning while bathing.
 patient  persistent phimosis beyond school age and parent desires treatment, topical steroid cream can be effective.
 Several studies  application of a medium-potency topical steroid twice daily for 4 to 8 weeks can be a safe and effective
treatment for phimosis.
 Acquired cases of phimosis  secondary to
o recurrent balanoposthitis
o poor hygiene
o forcible retraction of the foreskin.
 Acquired cases are often refractory to medical management and ultimately require circumcision.
 One  few true emergencies related to phimosis occurs when the foreskin is nearly completely sealed off, causing acute
urinary retention.
 Such cases  require dilation of foreskin under procedural sedation or dorsal penile block to place a Foley catheter.

PARAPHIMOSIS

 Paraphimosis  true urologic emergency.

 occurs when  tight ring of phimotic foreskin  retracted proximal to the glans and becomes trapped in that position.
 Subsequent impairment of venous and lymphatic drainage causes progressive swelling of the glans and foreskin.
 If  paraphimosis  not promptly reduced, arterial blood supply becomes
compromised, and the glans may necrose.
 Symptoms  paraphimosis are pain, erythema, and swelling of the shaft and
glans, distal to the constricting ring of foreskin (Figure 136-4).
 area  shaft proximal to the constriction appears normal. \
 Because delay in reduction  lead to
o worsening edema resulting  more difficult manual reduction
o paraphimosis should be reduced as soon as possible.
 Mild paraphimosis  manually reduced without need for sedation or analgesia.
 More difficult  require either a dorsal penile nerve block or procedural
sedation, depending on the age and degree of cooperativeness of the patient.
 dorsal penile nerve provides most  somatosensory innervation to the shaft and
glans penis. dorsal penile block (Figure 136-5) is useful for minor painful
procedures of the penis, such as paraphimosis reduction, dorsal slit procedure, or
zipper entrapment release.

 Using a 25- or 27-gauge needle, inject lidocaine hydrochloride without
epinephrine into the base of penis, at the junction between the penis and
the suprapubic skin, off the midline to avoid the superficial dorsal vein.
 Inject  lidocaine just deep to Buck fascia, which is located 3 to 5 mm
beneath the skin.
 slight “pop”  usually felt as the needle passes through the fascial
layer.
 Aspirate before injecting the lidocaine, because the dorsal arteries and
veins are within close proximity to the nerve.
 Depending  size of child, between 1 and 5 mL of lidocaine should be
used.
 Half  volume is injected at the 10 o’ clock position, with the other
half injected at the 2 o’ clock position. Another technique involves
injecting only once at the midline through the Buck fascia, with
injection of the full volume directed toward each direction after
negative aspiration of blood.
 Like most nerve blocks, optimal analgesia  achieved after 5 minutes.
 Once analgesia  chieved either by dorsal nerve block or procedural sedation, manual reduction of the paraphimosis may
be attempted.
 decrease penile edema  often helpful to use a bag of ice (for 3-minute increments to avoid cold injury) or manual
compression before attempting reduction.
 Squeezing  glans and swollen foreskin using one’s palm or a compression dressing for 5 minutes usually decreases the
edema to allow successful manual reduction.
 most common technique for manual reduction involves placing both thumbs over the glans, with both index fingers and
long fingers surrounding the trapped foreskin.
 One pushes  glans back into the foreskin while pulling the foreskin back into normal position. This may require a few
minutes of constant pressure before the glans
slips through the paraphimotic ring (Figure

136-6).
 Manual reduction  fail  there is extreme swelling of foreskin and glans from prolonged paraphimosis. Emergent
urologic consultation is necessary for such cases.
 Although more invasive procedures are ideally done by a surgeon, the emergency physician may need to perform such
procedures if necrosis is imminent.
 One commonly used technique involves using a 21-gauge needle to make multiple punctures in the foreskin followed by
gentle compression, thus draining some of the edema.
 Manual reduction  attempted again.
 d orsal slit procedure  necessary if other attempts at reduction fail.
 involves making vertical incision over constricting ring to release the paraphimosis.
 All cases  paraphimosis, whether simple or complicated, require follow-up with urologist to assess healing and the need
for circumcision.

BALANOPOSTHITIS

 Balanitis (cellulitis of the glans), posthitis (cellulitis of the foreskin), and balanoposthitis (cellulitis of the glans and
foreskin) are common diagnoses in young males.
 Poor hygiene and phimosis predispose children to such infections (Figure 136-7).
 On examination, glans,  foreskin, or both glans and foreskin are swollen, tender, and edematous. In most cases, empiric
treatment with oral antibiotics with a first-generation cephalosporin and warm soaks are sufficient.
 cases  which there  associated erythematous papular rash with satellite lesions, antifungal cream may also be indicated.

PRIAPISM

 Priapism  prolonged, unwanted erection not associated with sexual stimulation.

 Low-flow (venous) and high-flow (arterial) priapism  managed differently.
 High-flow (nonischemic) priapism is generally due to an arteriovenous fistula from trauma (i.e., lacerated cavernous
artery shunting blood into the cavernous bodies).
o lead to persistent partial or full erection for days to weeks but is generally not painful. Because of the
continuous inflow of arterial blood, ischemia or impotence does not occur.
o Therefore, high-flow priapism  not a true urologic emergency.
o Most cases  treated conservatively, and only a few cases require angioembolization of the lacerated artery

Low-flow (ischemic) priapism  caused by ]

o sludging  red blood cells, leading to impaired venous drainage, venous congestion, and ischemia. In
children, the most common cause of priapism is sickle cell disease
o Other less common causes in children include
 illicit drugs (cocaine and cannabis)
 antidepressants
 antipsychotics
 leukemia (presenting with extreme hyperleukocytosis).
 Low-flow priapism causes a very rigid and extremely painful erection.
 type of priapism can usually be identified by history and physical examination. Doppler US can distinguish the type of
priapism, with low-flow priapism showing decreased or no blood flow in the cavernosal arteries.
 most reliable method, however, involves testing aspirated blood from the corpus cavernosum for blood gas analysis.
 Aspiration of corpus cavernosum should be done only by an experienced urologist.
 Blood from
o low-flow priapism will be dark in color, with a partial pressure of oxygen (Po2) <30 mm Hg, a partial pressure of
carbon dioxide (Pco2) >60 mm Hg, and a pH <7.25.
o Cavernous blood gas from high-flow priapism  bright red in color with numeric values similar to normal arterial
blood.
 Without a history of pelvic, genital, or perineal trauma, nearly all priapism is low flow and usually secondary to sickle cell
crisis.
 Priapism  occur in all forms of sickle cell disease, including sickle hemoglobin C and the sickle thalassemias.
 Priapism affects 30%  all males with sickle cell disease,with most reporting repetitive painful episodes of prolonged
erections.
 Such recurrent episodes are termed “stuttering” priapism and are unpredictable and of variable duration.
 Obtain a history including the duration of symptoms and any precipitating events (i.e., medications or illicit drugs).
 When low-flow priapism lasts for >4 hours, the risk for permanent damage leading to impotence is significant and requires
emergency urology consultation. While waiting for the urologist, administer IV fluids, opioid analgesics, and supplemental
oxygen, and maintain the patient as NPO (nothing by mouth) for possible procedural sedation or operative management.
 If sickle cell disease  underlying cause, treat with IV venous hydration at 1.5 times maintenance rates and consider red
blood cell exchange transfusion
 Prolonged priapism requires concurrent aggressive urologic management with corporeal aspiration and irrigation,
intracavernous injection of a sympathomimetic drug (such as phenylephrine or epinephrine), or, potentially, surgical
shunting as a last resort.
 Ketamine  established detumescent1 and should be preferentially considered for patients requiring procedural sedation
prior to corporeal aspiration or irrigation.

TOURNIQUET SYNDROME OF THE PENIS

 First reported  literature in 1832, Reinisch and colleagues coined the term hair-thread tourniquet syndrome in 1988, when
they described six cases of young infants with digit strangulation.20 In a 2004 review, among the 90 cases of tourniquet
syndrome found in the literature, toes were affected in 47%, penis in 25%, fingers in 20%, clitoris in 6%, and labia in 2%.
 Tourniquet syndrome  penis presents with
o penile redness
o swelling
o pain.
 Occasionally, presenting sign  irritability  unknown cause, thorough history and physical are crucial to identify a
tourniquet syndrome.
 On physical examination, area  penis distal  strangulation  erythematous, edematous, and tender.
 Edema often obscures the hair or thread itself.
 Treatment includes
o cutting  hair or thread if visualized, or using a depilatory agent, such as Nair®.
 Depilatory creams  not work on synthetic fibers, however, and if unable to remove the constriction, urologic consultation
is necessary.
 Damage from  tourniquet can range from mild penile edema, to glandular disfigurement, urethral transaction, and even
penile amputation.
 Although most cases are unintentional, they can also result from abuse.

ZIPPER INJURY

 Penile zipper entrapment  most often seen 

 school-age boys  most commonly when not wearing underpants.
 patient’s shaft, foreskin,
 skin  trapped between teeth of the zipper, cut  cloth between the locked teeth, and separate the teeth of the zipper.
 However, if  skin is caught within the fastener of the zipper, releasing  skin is more difficult.
 There are several methods described in the literature for zipper release.
 most commonly used method  use sturdy wire cutters or bone cutters to cut the median bar of the zipper (Figure 136-9).

requires  special tool, which may not be

available, and in some cases, the angle  zipper
and type of zipper preclude easy access to the
median bar.
 Other methods include using

mini hacksaw to cut the median bar, dousing the area with liberal amounts of mineral oil and then freeing the
entrapped skin with gentle traction,24 or twisting a small flat-head screwdriver between the two faceplates of the
zipper to widen the gap and allow release of the tissue.25

The age and degree of cooperativeness of the patient will determine type of analgesia and/or sedation needed.
The patient may need oral analgesics, IV analgesics, or a dorsal penile block with or without procedural sedation.
If all attempts fail at bedside zipper release, consult the urologist for removal under general anesthesia in the
operating room.

FEMALE GYNECOLOGIC PROBLEMS

 One  most challenging physical examinations to perform is the gynecologic examination of the young female.
 Provide extra care and attention to create a nonthreatening environment to obtain a thorough, less anxiety-
provoking examination. Tell the child that the parent
approves the examination and that he or she will remain
in the room.
 Tell  child why the examination  necessary and that
everything will be explained to her beforehand. It is
helpful to have the parent stand near the head of the bed
while holding the child’s hand.
 Never forcibly restrain  child for a gynecologic
examination. \
 If  examination is difficult, procedural sedation or an
examination under general anesthesia is an alternative
approach.
 Regardless  practitioner gender, obtain third-party
assistance (such as a nurse or social worker).
 first position  which to examine the young female
external genitalia is the frog-legged position (Figure 136-
10), with the child lying supine (or near-supine on a parent’s lap).

Spread  child’s knees apart.

Sometimes, this position  aided with

the soles of the feet brought together.

vestibule and hymen  seen by gently

pressing the labia majora laterally and
posteriorly. Examine the child in the
knee-chest position (Figure 136-11) for
visualization of the perianal area and the
outer vaginal vault. Ask the child to
position herself on the examination table
on her hands and knees, like a baby
crawling.

With her parent standing at the head of

the bed, ask the child to put her head
down onto her hands, with her elbows
resting on the examination table.

Apply gentle lateral and upward traction over the buttocks and labia majora to inspect the vaginal vault.
 

LABIAL ADHESIONS

 Labial adhesions (Figure 136-12)  fusions of labia minora

 most commonly seen  infant and preschool-aged girls.
 exact cause --> unknown, although they are thought to be related to a girl’s low level of estrogen,
which predisposes the epithelium to irritation.
 Irritation may be due to poor hygiene, harsh soaps, bubble baths, or minor trauma.
 Re-epithelialization occurs  response to irritation, forming the labial adhesions.
 adhesions appear as a flat, connected surface, inferior to the clitoris, with a thin, vertical raphe.
Adhesions may extend from the clitoris over the entire introitus, or they can be partial with some
perforations.
 Labial adhesions  often asymptomatic
o discovered  routine examination or when obtaining a catheterized urine specimen,
although occasionally the child may complain of dysuria.
o Most labial adhesions resolve spontaneously during puberty, or topical estrogen cream
can be applied over the area twice a day for 2 to 4 weeks.
o Topical estrogen  cause transient hyperpigmentation of the area, and prolonged use
may induce reversible secondary sexual characteristics. Once lysis of the adhesions
occurs, the parent should apply petroleum jelly to the area for another 2 to 3 weeks to
maintain labial separation. Do not manually separate adhesions, as they will likely recur.
o 

VAGINAL DISCHARGE

o During  first 2 to 3 weeks of life, many infant girls  normal physiologic vaginal discharge.
o leukorrhea  thin, slippery, and clear or white in color.
o Among older infants and young girls, there are two common causes of vaginal discharge: vaginal foreign
body and vulvovaginitis.
o Also, consider sexual abuse with infection from
o N. gonorrhoeae,
o C. trachomatis
o Trichomonas as a possibility.
o Vaginal foreign bodies present with foul-smelling vaginal discharge, which can be slightly bloody.
o patient  complain of voiding symptoms secondary to local irritation.
o Symptoms are often present for a long period of time before presentation to a physician.
o most common vaginal foreign body in prepubertal females is toilet paper.
 o Examination  patient in knee-chest position (see Figure 136-11) is the best method to visualize the
vaginal vault and possible foreign body.
o foreign body  readily seen, removed using forceps or warm water vaginal lavage. If bedside removal is not
possible, the patient may require examination and removal under procedural sedation or general anesthesia.
o Vulvovaginitis  very common cause of vaginal discharge, pain, and pruritus. Most cases are not associated
with any specific organism, but irritation is secondary to poor hygiene, wiping back to front after urination or
defecation, bubble baths, tight clothing or underwear, or perfumed bathing products.
o Treatment  such cases includes
o proper hygiene habits and eliminating offending agents.
o Among bacterial causes  vaginitis  prepubertal female, most common are group A β-hemolytic
Streptococcus, Staphylococcus aureus, Escherichia coli, and Shigella.
o Candida vaginitis  not common among prepubertal females because of the alkaline pH of the vagina.
o vaginal bleeding  another common complaint  pediatric ED.
o In  first 2 to 3 weeks of life, maternal hormonal levels wane, the newborn female may experience
sloughing of her endometrium with subsequent vaginal bleeding.
o form of nonpathologic bleeding is always self-limited and requires no treatment other than reassurance to the
parents.
o In children, urethral prolapse occurs more commonly  prepubertal black females between the ages of 2 and
10 years old.
o complaint is usually painless blood spotting on the underwear, although some patients may also experience
mild irritation with voiding.
o mucosa  distal urethra prolapses outward beyond the meatus, causing venous congestion of the prolapsed
tissue.
o Prolapse appears  red-purple, doughnut-shaped mass with a central dimple.
o diagnosis  doubt, pass a urinary catheter through the central opening for confirmation. The treatment of
choice is sitz baths and topical estrogen cream for 2 weeks.
o Constipation  exacerbate  prolapse if the child strains with defecation, so providing a stool softener is
often helpful. If conservative medical management fails, or if the prolapsed tissue becomes necrotic, the
tissue may have to be surgically reduced and/or removed.
o Fortunately, most straddle injuries cause only minor superficial abrasions, lacerations, or hematomas of the
perineum.
o Such cases can be treated with supportive care and sitz baths. Pain with voiding can be relieved by allowing
the child to urinate in a bathtub of warm water.
o More significant injuries, such  expanding hematoma, a laceration beyond the superficial layers, a wound
that continues to actively bleed, any rectal bleeding, or inability to urinate, require immediate gynecologic
evaluation.
o In addition, sexual abuse or assault should  considered  possible cause of genital injury and should be
reported to the appropriate state agency as mandated by law.
o vast majority  vaginal bleeding  adolescents  caused by dysfunctional uterine bleeding.
o Irregular menses with or without prolonged bleeding is especially common in females during the first year
after menarche, due to the high number of anovulatory cycles.
o Dysfunctional uterine bleeding  best managed initially with a trial of a combined estrogen-progestin pill.
The estrogen stops the bleeding, and the progestin stabilizes the endometrium.
o There  multiple forms  oral contraceptive pills that would be appropriate as first-line therapy.

IMPERFORATE HYMEN

 Cases  imperforate hymen (Figure 136-13) typically present  ED as a teenage female with chronic,
vague abdominal pain, who has secondary sexual characteristics, yet is still “premenarchal.”
 physical examination reveals  bluish bulging membrane covering the introitus, representing
accumulated menstrual blood and hematocolpos.
 If  hematocolpos  large, patient  have symptoms of urinary urgency, frequency, or dysuria.
 Treatment in adolescents  urgent surgical repair, but in asymptomatic infants and young girls, surgery is
performed on an elective basis