Case 86

A 4-year-old female had 1 day of bleeding noted in her underpants. Her mother said that when she checked her genitals, the area ‘looked red’. The girl had been afebrile, active and playful, though was recovering from a mild upper respiratory tract infection. She denied any vaginal pain or dysuria. She was a healthy and developmentally normal child, attended school regularly and was toilet trained. She denied any sexual abuse when questioned in the office. Her physical examination is shown in Image 86. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig86.jpg"/>

What was the diagnosis?

What are the next steps in management of this condition?

List other causes of bleeding in prepubertal girls.

194

This patient has a urethral prolapse, a relatively rare occurrence in prepubertal girls and mostly affecting patients of African descent. ¹ The distal urethral mucosa protrudes beyond the urethral meatus, causing bleeding with or without urinary symptoms. Urethral prolapse may be caused by laxity of periurethral ligaments and low levels of oestrogen, and in some it has been shown to be associated with increased intra-abdominal pressure as with episodes of coughing or an asthma exacerbation. ² The appearance of the prolapsed tissue is erythematous or even haemorrhagic and often obscures the anterior vagina (the 12 o’clock position) when the patient is examined supine. A ‘donut-shaped’ urethral opening can often be seen surrounded by prolapsed tissue. In this image, the extruded tissue is erythematous and highly vascular.

The patient can be medically treated with topical oestrogen cream and sitz/salt baths to alleviate symptoms of bleeding and discomfort. ² In some cases, this may resolve the prolapse; however, recurrence after a first episode is common and the patient may need surgical correction. Cases with persistence should be referred to a paediatric urologist. ¹

Bleeding in a prepubertal girl can be distressing to patients and caregivers and should be evaluated thoroughly with a careful history. Child sexual abuse is part of the differential, and if there is concern, a verbal patient should be questioned carefully by a qualified interviewer. Physicians must always consider other non-abusive causes of bleeding, such as infections (Salmonella or group A strep), foreign body (especially toilet paper), accidental trauma such as a straddle injury, precocious puberty, including McCune-Albright syndrome or oestrogen secreting tumour, exogenous exposure to oestrogen and autoimmune conditions such as Behçet disease or lichen sclerosus et atrophicus. ¹