Clinical Scenario:
A 7-year-old girl is brought to the pediatric clinic with a 2-week history of cloudy, foul-smelling vaginal discharge. Her mother reports that she has also noticed that the child has become withdrawn and unusually quiet over the last few months. On further, sensitive questioning, the mother reports that she found blood stains on the girl’s underwear about 1 month ago, although the child had not reported any trauma or pain.
On examination, there is no breast development or pubic hair. The abdomen is soft, with no palpable mass.
Which of the following should be considered the most important diagnosis to investigate in this child?
A. Nonspecific vulvovaginitis
B. Vaginal foreign body
C. Sexual abuse
D. Peripheral precocious puberty
E. Vaginal rhabdomyosarcoma
Correct answer & Explanation:
Correct answer: C. Sexual abuse
Explanation
Sexual abuse should be strongly considered in a prepubertal child with unexplained genital bleeding, abnormal vaginal discharge and new behavioral changes such as withdrawal or depression.
A foul-smelling or abnormal genital discharge may occur with infection, foreign body or genital trauma. In a prepubertal girl, a combination of genital symptoms and unexplained blood staining of underwear requires careful assessment for possible sexual abuse.
The behavioral change in this case is an additional warning sign, although no single behavioral symptom is diagnostic of abuse. The child should be approached in a calm, non-leading and child-sensitive manner, with appropriate safeguarding procedures followed.
Important differential diagnoses
Nonspecific vulvovaginitis: Common in prepubertal girls and can cause discharge, irritation and occasionally minor bleeding, but does not explain the complete history as well.
Vaginal foreign body: Can cause persistent, foul-smelling discharge and intermittent vaginal bleeding, and should always be considered.
Peripheral precocious puberty: Can cause vaginal bleeding in a prepubertal girl, particularly when associated with estrogen exposure from an ovarian or adrenal disorder. However, one would expect other evidence of estrogen effect, such as breast development, and it would not explain the behavioral history.
Vaginal rhabdomyosarcoma: May present with vaginal bleeding or discharge and should be considered when there is a mass or persistent unexplained bleeding.
Exam point
In a prepubertal girl, vaginal bleeding is never considered normal menstruation. Important causes include trauma/sexual abuse, foreign body, vulvovaginitis, genital tumors and estrogen-mediated peripheral precocious puberty.
Reference
American Academy of Pediatrics. Evaluation of Children When Sexual Abuse Is Suspected. Pediatrics.
Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506–512.
