A 7-year-old girl is brought to the clinic by her mother due to vaginal spotting. The mother first noted a small amount of malodorous, yellow discharge on the patient's underwear 2 weeks ago and noticed a small amount of blood yesterday. The patient has no incontinence, dysuria, hematuria, or abdominal pain. She has no chronic medical conditions and takes no daily medications. Vital signs are normal. BMI is at the 60th percentile for age. Physical examination reveals a well-appearing girl in no acute distress. The abdomen is soft, nontender, and nondistended. External pelvic examination reveals purulent vaginal discharge with a small streak of blood. There are no visible lacerations or ecchymoses. The remainder of the examination is unremarkable. Which of the following is the most likely diagnosis in this patient?

Question

A 7-year-old girl is brought to the clinic by her mother due to vaginal spotting.  The mother first noted a small amount of malodorous, yellow discharge on the patient's underwear 2 weeks ago and noticed a small amount of blood yesterday.  The patient has no incontinence, dysuria, hematuria, or abdominal pain.  She has no chronic medical conditions and takes no daily medications.  Vital signs are normal.  BMI is at the 60th percentile for age.  Physical examination reveals a well-appearing girl in no acute distress.  The abdomen is soft, nontender, and nondistended.  External pelvic examination reveals purulent vaginal discharge with a small streak of blood.  There are no visible lacerations or ecchymoses.  The remainder of the examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf18_163f_8f63_d3226f3ffd85_MD0005_00 This prepubertal girl likely has a vaginal foreign body, a common cause of vaginitis in this patient population. Toilet paper is a common vaginal foreign body; other retained objects include small toys and rubber bands. When the foreign body becomes retained in the vagina, it irritates the vaginal mucosa and results in intermittent vaginal bleeding and a chronic, malodorous vaginal discharge. Patients typically have no vulvar symptoms (eg, pruritus, erythema, lacerations) and an otherwise normal examination. Vaginal foreign bodies are typically diagnosed clinically on external pelvic examination with the patient in the knee-chest or frog-leg position. Objects that are easily visualized can be removed in the office with either warm saline irrigation or a cotton swab. For patients who cannot tolerate the procedure or in whom the foreign body cannot be easily removed, vaginoscopy under general anesthesia is performed. (Choice A) Girls with precocious puberty do not have isolated menarche; instead, they have early-onset breast, axillary, and pubic hair development (ie, thelarche, adrenarche) prior to menarche. (Choice B) Sarcoma botryoides can cause a bloody, mucoid vaginal discharge; however, patients have associated grape-like structures protruding through the vagina (not seen in this patient). Sarcoma botryoides (Choice C) Urethral prolapse can present with vaginal spotting due to friable urethral tissue; however, there is also associated dysuria and a red or purple circumferential mass surrounding the urethra (not seen in this patient). Urethral prolapse (Choice E) Vulvovaginal candidiasis is rare in prepubertal girls with no recent antibiotic use or immunosuppression. Patients typically have vulvar pruritus and a thick, white vaginal discharge. Educational objective: Vaginal foreign bodies are a common cause of vulvovaginitis in prepubertal girls and often present with vaginal bleeding and a malodorous vaginal discharge. References: Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. (http://www.ncbi.nlm.nih.gov/pubmed/28927766) Foreign body in vagina: an uncommon cause of vaginitis in children. (http://www.ncbi.nlm.nih.gov/pubmed/23634340) Vaginal foreign body: a delayed diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/24656699)

A 7-Year-Old Girl Is Brought to the Clinic by Her