Common gynecologic problems in prepubertal girls

An Unusual Case of Retained Foreign Body in the Vagina With Vaginal Fibrosis

Vaginal foreign bodies can cause long haul, foul-smelling vaginal discharge and vaginal bleeding and are typically found in female youngsters while looking into vaginitis and urinary tract diseases. There are many causes for vaginal discharges. Among them, vaginal foreign bodies are uncommon but not a very rare presentation. We had a case of a 49-year-old female, a widow, with para 2 living 2 and a history of menopause since three years; she was referred from a district hospital with a diagnosis of carcinoma of the cervix and was later found to have a foreign body, which was removed surgically through the vagina. A foreign body in the vagina is usually seen in children than in adults. Foreign bodies are inserted vaginally for treatment purposes, contraception, induced abortion, and sexual stimulation in adults. Here, we report a case of retained vaginal foreign body with vaginal fibrosis.

Vaginal foreign body insertion in a patient with emotionally unstable personality disorder

Insertion of foreign objects into one or more bodily orifice, otherwise known as polyembolokoilamania, occurs as a result of a variety of psychosocial and psychiatric states. Such behaviour exposes the affected individual to the complications of object insertion, surgical removal and its adverse sequelae such as a colovesical fistula. Foreign body insertion into the vagina mainly involves children and can be associated with premenarchal vaginal discharge or sexual abuse. The gynaecological literature describes cases involving adults and can be associated with drug smuggling or sexual gratification. Commonly retrieved foreign bodies from the vagina includes tampons, hair pins, buttons, seeds, toy parts, objects used in foreplay, forgotten pessaries, pen caps, toilet tissue and illicit drugs for trafficking. There is a relative dearth of cases reported in the psychiatric literature. Management of deliberate foreign body insertion [DFBI) in borderline personality disorder patients is challenging, often repetitive and the potential for further self-harm and complex emotional issues may elicit strong countertransference from medical staff. Although there are well-established guidelines for acute medical and surgical management of DFBI, none provide an overview of the management of repeat presentations or consider the role of secondary gain or provide reinforcement strategies for managing this complex patient cohort. The authors present the case of a 23-year-old woman with an emotionally unstable personality disorder presenting to the emergency department after inserting objects in her vagina. This paper will provide an overview of the presentation, investigations and management of individuals presenting after inserting foreign objects into the vagina. In the majority of cases, a carefully obtained history and physical examination will render the diagnosis, although imaging modalities may be required to locate the misplaced objects. Individuals may present with bleeding, blood stained or foul-smelling vaginal discharge. Prompt management can prevent morbidity and mortality resulting from complications.

Is my baby normal? A review of seemingly worrisome but normal newborn signs, symptoms and behaviors

Infant patients are a unique challenge to emergency department (ED) physicians as the spectrum of normal infant signs, symptoms and behaviors are often difficult to differentiate from abnormal and potentially life-threatening conditions. In this article, we address some common chief complaints of neonates and young infants presenting to the ED, and contrast reassuring neonatal and young infant signs and symptoms against those that need further workup and intervention.

Examination of the pediatric adolescent patient

Gynecologic examination of the pediatric adolescent patient provides a valuable opportunity for patient education and diagnosis, yet presents special challenges, including achieving comfort for the patient and guardian and finding equipment that are sized for pediatric patient. Anatomic changes due to the hormonal environment evolve from newborn through pubertal development. As pediatric adolescent gynecology has evolved as a specialty, techniques and training for providing optimal office and surgical examination have emerged. Where possible, the patient should be engaged with the examination through use of a mirror or positioning. Smaller swabs should be used for testing for vaginal infection in prepubertal patients. When speculum or office examination is not possible, use of narrow-caliber, flexible, and rigid hysteroscopes allow vaginoscopy for assessment.

Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management

IMPORTANCE

Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to parents. A variety of practitioners, including obstetrician-gynecologists and pediatricians, may be asked to see patients with this presenting complaint, yet many do not receive adequate training in pediatric gynecology.

EVIDENCE ACQUISITION

Review of the published literature in PubMed, focusing on the last 20 years, regarding the incidence, etiologies, diagnosis, and management strategies for the common causes of prepubertal vaginal bleeding.

RESULTS

Careful history taking and pediatric-specific gynecological examination skills, including awareness of normal anatomy across the age spectrum and the ability to identify an estrogenized hymen, are keys to the appropriate assessment of this clinical problem.

CONCLUSIONS AND RELEVANCE

Prepubertal vaginal bleeding has many causes and requires a thorough targeted history and pediatric genitourinary examination, requiring knowledge of the variants of normal pediatric genitourinary anatomy. Most causes can be easily treated and are less likely to be due to sexual abuse or malignancy.

UriSed - Preliminary reference intervals and optimal method for urine sediment analysis in newborns and infants

OBJECTIVES

The aim of this study was to establish reference intervals for urine sediment in newborns and infants in the second month of life for the UriSed automated analyser and for bright field microscopy. We also aimed to provide an optimal protocol for UriSed analysis, which best corresponds to the results of manual microscopy.

DESIGN AND METHODS

Urine sediment analyses of 75 healthy newborns and infants in the second month of life were performed by manual microscopy and UriSed automated analyser (two modes: 15 and 20 images per sample). Images were then reviewed and manually corrected by an operator when needed.

RESULTS

We observed statistically significant differences between bright-field microscopy and UriSed (when manual correction was not performed) for squamous epithelial cells and red blood cells counts (P<0.0001). There were no differences based on the number of images per sample (P>0.05). Upper reference values for bright-field microscopy and UriSed analyser taking 15 images per sample with manual correction (method we recommend) were as follows: squamous epithelial cells: microscope 8.7×10(6)/l, UriSed 6.4×10(6)/l, non-squamous epithelial cells: microscope 4.3×10(6)/l, UriSed 3.9×10(6)/l; erythrocytes: microscope 5.9×10(6)/l, UriSed: 4.6×10(6)/l; leukocytes: microscope 8.6×10(6)/l, UriSed 9.9×10(6)/l; hyaline casts: microscope 0×10(6)/l, UriSed (no correction) 0.7×10(6)/l.

CONCLUSIONS

We established preliminary reference intervals for urine sediment analysis in newborns and infants for UriSed and bright-field microscopy. We concluded that for routine laboratory examination of non-pathological urine it is enough to use the faster mode, with 15 images per sample, followed by a manual correction.

Menarche? A Case of Abdominal Pain and Vaginal Bleeding in a Preadolescent Girl

Abdominal pain is one of the most common complaints in the pediatric ED. Because of the broad range of potential diagnoses, it can pose challenges in diagnosis and therapy in the preadolescent girl. An 11-year-old previously healthy girl presented to our pediatric ED with fever, decreased appetite, vaginal bleeding, and abdominal pain. Initial evaluation yielded elevated creatinine levels, leukocytosis with bandemia, elevated inflammatory markers, and urine concerning for a urinary tract infection. She began receiving antibiotics for presumed pyelonephritis and was admitted to the hospital. After worsening respiratory status and continued abdominal pain, a computed tomography scan was obtained and a pelvic foreign body and abscess were identified. Adolescent gynecology was consulted for examination under anesthesia for abscess drainage and foreign body removal. A foreign body in the vagina or uterus can present as vaginal discharge, vaginal bleeding, abdominal pain, dysuria, or hematuria. Because symptoms can be diverse, an intravaginal or uterine foreign body should be considered in the preteen female patient presenting to the ED with abdominal pain.

Normal Vulvovaginal Health in Adolescents

As adolescence is often the first time a woman will see a gynecologist, it is important for health care providers to understand and be capable of explaining the changes that occur to a young woman during these years. Many adolescents and their caretakers who seek gynecologic care for what they consider vulvovaginal abnormalities may be misinterpreting completely normal changes; education and reassurance are the best treatment in these cases. Most medical literature on vulvovaginal health focuses on abnormalities and there is a paucity of information on what is considered "normal." This goal of this review is to describe normal anatomic and physiologic vulvovaginal changes that occur during the adolescent years, as well as to offer advice on how to educate and reassure young women during this vulnerable time.

Pyogenic granuloma, an unusual presentation of peripubertal vaginal bleeding. Case report and review of the literature

Pyogenic granuloma, also named lobular capillary hemangioma, is a common proliferative vascular lesion known as a benign condition despite its rapid growth. It may appear in any cutaneous or mucosal surface but is usually restricted to the oral cavity. It is characterized by a friable mulberry-like lesion that can be sessile or pedunculated. Bleeding is usually its first clinical manifestation. Locations on respiratory, digestive and genital tracts are uncommon and sporadic. We describe the occurrence of an intravaginal pyogenic granuloma in a peripubertal girl with recurrent vaginal bleeding. This is the first reported case of a genital tract lobular capillary hemangioma in pediatric age to our knowledge. Therefore, we suggest this entity in the differential diagnosis of an unclear peripubertal vaginal bleeding.

Vaginal foreign bodies and child sexual abuse: an important consideration

Vaginal foreign bodies are a complaint occasionally encountered in pediatric clinics and emergency departments, and when pediatric patients present with a vaginal foreign body sexual abuse may not be considered. We describe two children with vaginal foreign bodies who were found to have been sexually abused. Each child had a discharge positive for a sexually transmitted infection despite no disclosure or allegation of abuse. We recommend that all pre-pubertal girls who present with a vaginal foreign body should be considered as possible victims of sexual abuse and should receive a sexual abuse history and testing for sexually transmitted infections.

Vaginal microbiocoenosis and cytology of prepubertal and adolescent girls: their role in health and disease

BACKGROUND

Clinicians and investigators often do not appreciate the importance of vaginal microbiocoenosis and vaginal cytology in the health of prepubertal and adolescent girls.

DATA SOURCES

Based on recent publications in human medicine and our own experience with vaginal cytology and microbiology in children and adolescent girls, we review the principles of vaginal microbiocoenosis and cytology and their roles in disease prevention in prepubertal and adolescent girls.

RESULTS

The main role of vaginal microbiocoenosis and cytology in diagnosing as well as developing vulvovaginitis is demonstrated. Clinicians can identify states of vaginal health and disease by important well-known diagnostic tools, including vaginal cytology. Lactobacilli are infrequently observed in the prepubertal girls, but become more abundant in adolescent girls. Three basic types of vaginal smears are presented in addition to a classification of inflammatory urogenital diseases. Management of common types of vulvovaginitis is also considered.

CONCLUSIONS

This essential shift in vaginal biocoenosis is important to prevent the growth of potentially pathogenic flora in the vagina. The detection of vaginal microbiocoenosis problems and recognition of changing cytology in vaginal development can provide helpful clues to identifying and preventing vaginal diseases in this pediatric population.

Child sexual abuse: can anatomy explain the presentation?

This article discusses a 4-year-old girl who displayed behavioral symptoms consistent with posttraumatic stress disorder. She was recently placed in foster care due to emotional and physical neglect. During her clinic visit, she disclosed being sexually abused by her father with a knife. Results of her general and anogenital physical examinations were normal. The case discussion proposes an explanation for how a maltreated child (1) develops behavioral problems, (2) has a normal genital examination despite the history of sexual abuse, and (3) has an implausible disclosure of her father hurting her with a knife. As part of the Integrating Basic Science into Clinical Teaching Initiative series, basic science principles are the method of explanation. The case discussion is an attempt to understand the science responsible for the disease that is present and make that understanding useful for future clinical problem solving.