A 5-year-old girl is brought to the emergency department for evaluation of vaginal discharge. She has had malodorous vaginal discharge and a small amount of vaginal bleeding for about a week. Her mother called the patient's primary care provider and was told to stop letting the child take bubble baths; however, the symptoms have not improved. Aside from the discharge, the girl is acting normally. The patient was toilet trained at age 2 and has had no episodes of incontinence. She started kindergarten a month ago. The mother says that she has no fever, abdominal pain, or dysuria. On examination, the labia appear normal. Purulent, malodorous vaginal discharge is noted. Visual inspection with the child in knee-chest position shows a whitish foreign body inside the vaginal introitus. Which of the following is the best next step in management of this patient?

Question

A 5-year-old girl is brought to the emergency department for evaluation of vaginal discharge.  She has had malodorous vaginal discharge and a small amount of vaginal bleeding for about a week.  Her mother called the patient's primary care provider and was told to stop letting the child take bubble baths; however, the symptoms have not improved.  Aside from the discharge, the girl is acting normally.  The patient was toilet trained at age 2 and has had no episodes of incontinence.  She started kindergarten a month ago.  The mother says that she has no fever, abdominal pain, or dysuria.  On examination, the labia appear normal.  Purulent, malodorous vaginal discharge is noted.  Visual inspection with the child in knee-chest position shows a whitish foreign body inside the vaginal introitus.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9f3_72ae_bc81_034a815109f2_MD0003_00 Vaginal foreign bodies are a common cause of vulvovaginitis in prepubertal girls. The most common vaginal foreign body is toilet paper, although other objects (eg, small toys, hair bands) can occasionally be found. The chronic irritation of the foreign body (the whitish foreign body in this case) on the vaginal tissue can result in malodorous vaginal discharge, intermittent vaginal bleeding (eg, spotting), and urinary symptoms (eg, dysuria). When a vaginal foreign body is suspected, an external pelvic examination is performed with the girl in a knee-chest or frog-leg position. In case of an easily visualized small foreign body (eg, toilet paper), an attempt at removal (after application of a topical anesthetic in the vaginal introitus) can be made using vaginal irrigation with warm fluid or a swab. Cases in which the age of the girl or the type of foreign body prohibit adequate clinical evaluation may require the patient to undergo sedation or general anesthesia for examination (eg, vaginoscopy) and foreign body removal. (Choice B) Child Protective Services should be contacted when child abuse or neglect is suspected. Vaginal or rectal foreign bodies can be the initial presentation of sexual abuse; however, the presence of what is likely toilet paper is not immediately concerning for abuse, particularly in otherwise asymptomatic girls (eg, no behavioral changes, urinary symptoms, vulvar or anal trauma). (Choice C) CT scan of the abdomen and pelvis can be used to evaluate pelvic or ovarian masses; it is not indicated in evaluation of a foreign body. (Choice D) Speculum examinations should not be performed in prepubertal girls as these patients have a narrow vaginal introitus and sensitive hymenal tissue (due to low estrogen levels) that can result in significant discomfort and trauma. (Choice E) Topical estrogen is used in the treatment of urethral prolapse, a cause of vaginal bleeding in prepubertal girls. This diagnosis is unlikely because those with urethral prolapse have a beefy red protrusion at the urethra, not material in the vagina. Educational objective: Prepubertal girls with vaginal foreign bodies typically have malodorous vaginal discharge and vaginal spotting, commonly secondary to retained toilet paper. Initial management is topical anesthetic application and either vaginal irrigation with warm fluid or removal with a swab. References: Vaginal foreign body: a delayed diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/24656699) Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies. (http://www.ncbi.nlm.nih.gov/pubmed/12459229)

A 5-Year-Old Girl Is Brought to the Emergency Department for Evaluation