Differential diagnosis of vulvovaginal bleeding in the premenarcheal girl

* Blunt straddle injuries typically cause bruising of the labia majora or lacerations that are anterior or lateral to the hymen. Any one of the following findings should raise concern for sexual abuse: intravaginal bleeding, injury to the hymen or posterior fourchette, or perineal lacerations or tears. However, most children who are sexually abused do not have signs of vulvar or vaginal trauma.

¶ Group A Streptococcus and Shigella species are the two main pathogens associated with vaginitis and bleeding in premenarcheal girls. In patients with appropriate indications (eg, high likelihood of sexual abuse on interview, signs of genital penetration, purulent discharge with or without negative vaginal bacterial culture), testing for sexually transmitted infections should also be obtained.

Δ Genital warts raise concern for sexual abuse, although nonsexual transmission also occurs. Refer to UpToDate topics on condylomata acuminata (anogenital warts) in children.

◊ Urethral prolapse presents with a friable, doughnut-shaped mass with a central urethral dimple that can obscure the vaginal orifice. Examination in the knee-chest position helps to distinguish urethral prolapse from a vaginal tumor.

§ Perineal hypopigmentation in a figure-of-eight pattern is a pathognomonic finding. Features of severe lichen sclerosus variably include telangiectasias, purpura, hematomas, and white atrophic vulvar or perineal skin.