Bleeding

Chapter 544 Bleeding

Vaginal bleeding in infants and prepubescent children is concerning for both the child and the parents and should always be evaluated. Bleeding can be seen as early as the 1st wk of life from maternal estrogen withdrawal until puberty when menstruation occurs. It can occur as light serosanguineous spotting to heavy bleeding with clots. A thorough history and physical must be obtained as the first step in diagnosing the problem. Common causes for vaginal bleeding in children are vulvovaginitis, foreign bodies, dermatologic conditions, and urethral prolapse; less common are endogenous or exogenous estrogenic effects; and, most worrisome, include neoplasms and trauma.

Vulvovaginitis may be caused by respiratory, oral and fecal pathogens, some of which produce a serosanguineous drainage (Streptococcus spp, Shigella) or cause vulvar bleeding due to irritation and excoriation of the skin. Prepubertal girls are at a higher risk for developing these irritations because the protective labia of pubertal girls are not fully developed and thus the vaginal opening and vagina are more exposed to irritants. Further, the mucosa is thin and the pH of the vagina is more alkaline than after menarche from low levels of estrogen. Hand-washing, improved perineal hygiene (wiping front to back, use of wet wipes after bowel movement), and avoidance of topical irritants, chemicals, and perfumed or deodorant soaps and bubble baths will reduce nonspecific vulvovaginitis. If hygiene does not result in improvement, a short course of antibiotics will be required to clear a recurrent or persistent infection (see Table 543-2). External application of bland emollient barriers such as over-the-counter diaper rash medications and petroleum jelly may be helpful.

A potential dermatologic reason for bleeding is lichen sclerosus (see Fig. 543-5 and Table 543-1). This condition is characterized by chronic inflammation, intense pruritus, and thinning and whitening of the vulvar and perianal skin in a keyhole fashion. Petechiae or blood blisters can arise and be mistaken as a sign of sexual abuse. Diagnosis is based on these classic clinical characteristics but may be confirmed by a tissue biopsy if necessary. Potent topical steroids are the first line of treatment and usually improve the appearance and symptoms of pruritus. The steroid should then be tapered and used for the shortest duration necessary; flare-ups can occur and require retreatment.

Foreign bodies are a common cause of vaginal bleeding, and children present with blood-stained and foul-smelling discharge. It can last from days to months until the correct diagnosis is made and the object is removed. The most common objects found are wadded up pieces of toilet paper. A physical exam in knee-chest or frog-leg position can sometimes reveal the object. Vaginal irrigation can then be done in the office using a small feeding tube and warm water. If the object is not visible on exam, irrigation is unlikely to remove it and exam under anesthesia and vaginoscopy are often required. Vaginoscopy not only allows removal of a foreign object but also can facilitate diagnosis of other causes of the bleeding.

Trauma to the vulva or vagina is especially concerning. Most of these injuries are accidental, but physical and sexual abuse must be ruled out (Chapter 37). Straddle injuries such as falling on the top bar of a bicycle or slipping in the bathtub may result in bruising, hematomas, and lacerations. Generally, if the trauma is accidental, the hymen is protected by the labia and defects are not seen. If there is a laceration of the hymen, especially posteriorly, abuse must be suspected. If the injury is penetrating, further exam and imaging are necessary to evaluate the urethra and anus and for internal injuries. General anesthesia may be needed to fully assess injuries and allow repair; minor lacerations can be repaired in a cooperative child under sedation or using local anesthesia. If the patient is able to void spontaneously, nonexpanding hematomas can be observed and treated with ice and with pain medications. Large expanding hematomas should be opened and drained, especially if the overlying skin is becoming ischemic. A Foley catheter should be placed for children who are having difficulty with voiding.

Urethral prolapse (Chapter 538) is another potential cause of bleeding in the prepubertal girl. It occurs when the distal end of the urethra prolapses either partially or completely. Patients may be asymptomatic or present with bleeding, dysuria, or difficulty with urination. Low estrogen state, trauma, chronic cough, and constipation are believed to be predisposing factors. Treatment is conservative, with application of estrogen cream at the area of prolapse twice daily for 2 wk and then, if prolapse is still present, continued use until the prolapse resolves. Surgical excision is very rarely necessary to remove necrotic tissue.

Neoplasms of the vulva and vagina are rare (Chapter 547). Of these, the most common in the prepubertal girl include hemangiomas, polyps, and sarcoma botryoides. The most obvious on exam is the cavernous hemangioma of the vulva. This is a benign growth of blood vessels that can cause bleeding from irritation to the skin from clothing overlying these vessels. Like hemangiomas found elsewhere on the body, these lesions are typically not seen at birth, increase in size over the 1st yr of life, and then begin to regress over the next several years. After this has occurred, there is rarely any evidence of the lesion with the exception of a discoloration of the skin that can sometimes be noted. Treatment is not necessary because these are self-limiting; however, a barrier cream can be applied if bleeding is a concern. Surgery is reserved for very severe cases causing heavy bleeding. Hemangiomas of the perineum may be associated with spinal dysraphism, so a neurologic assessment should be performed.

Like hemangiomas, hymenal polyps are also usually benign. If these polyps are noted at birth, they generally regress after maternal levels of estrogen decrease in the infant. Reassurance to the parents and expectant management are all that is needed. A barrier cream can be applied to the area until it resolves to decrease bleeding from friction with the diaper. Vaginal polyps, especially if they cause bleeding, should be removed and sent for pathologic evaluation.

Rhabdomyosarcoma (RMS) is a rare malignancy that affects <300 children a year in the USA. In children, the most common sites are the head and neck and genitourinary region (Chapter 494). Vaginal tumors tend to occur in young children and produce vaginal bleeding and discharge. The uterine tumors generally occur in older girls and may be extensive at the time of diagnosis. Treatment consists of a multimodal approach including surgery, radiation therapy, and chemotherapy. The survival rate is >90% when an early diagnosis is made.

Vaginal bleeding can be a presenting sign of precocious puberty, which is defined as pubertal development that is 2.5 to 3 standard deviations earlier than the average age. Guidelines for the evaluation of premature development state that pubic hair or breast development requires evaluation only when it occurs before age 7 yr in non–African-American girls and before age 6 yr in African-American girls (Chapters 555 and 556).

The most common etiology is gonadotropin-dependent or central precocious puberty (Chapter 556.1). Gonadotropin-independent and incomplete precocity are less common. A thorough physical exam must be done, looking for secondary sex characters. The child might require observation of progression from one stage of pubertal development to the next in <3-6 mo. Diagnostic studies include measurement of accelerated growth velocity demonstrated by growth charts and advanced bone age. Pelvic ultrasound might show presence of ovarian or adrenal pathology or uterine maturation. Serum estradiol levels >100 pg/mL may be associated with an ovarian cyst or tumor. The gold standard is measurement of gonadotropins after GnRH or GnRH-agonist stimulation. In all cases of central precocious puberty, MRI imaging of the brain is needed to determine if a tumor is present in the hypothalamus.

Another etiology for childhood vaginal bleeding is exogenous exposures to estrogens. These exposures can occur from ingestion of birth control pills, foods, beauty products, and plastics that contain estrogen or estrogen-like components. Several other studies have assessed the risk of bisphenol A (BPA) leaching from plastic cups and bottles. The importance of this is still being studied but BPA is known to have an estrogenic effect and thus could potentially be a cause for vaginal bleeding if ingested in high levels.

Vaginal bleeding in the prepubertal girl or infant can have many causes. A good history and physical must be done to identify the source of bleeding so that treatment can occur. Fortunately, most of these causes are easily treated and the patients do quite well.

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