INTRODUCTION — This topic offers an approach to the evaluation of vaginal bleeding in children and adolescents. The evaluation of the specific condition, abnormal uterine bleeding in adolescents, bleeding during pregnancy, and the differential diagnosis of vaginal bleeding in adults are discussed separately:
●(See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis".)
●(See "Approach to the adult with vaginal bleeding in the emergency department" and "Causes of female genital tract bleeding".)
●(See "Overview of the etiology and evaluation of vaginal bleeding in pregnancy" and "Overview of postpartum hemorrhage".)
CAUSES — The causes of vaginal bleeding in premenarchal children differ substantially from the causes in postmenarchal patients (table 1). During childhood, vaginal bleeding between the first week of life and menarche warrants an evaluation to identify the source (vagina, uterus, or otherwise) and the cause. Near menarche, the differential diagnosis changes. Pregnancy is a consideration, and vaginal bleeding may also arise from normal menstruation or abnormal uterine bleeding.
The causes of vaginal bleeding in children and adolescents organized by the patient's menarchal status are presented in the table (table 1) [1,2].
Trauma is a cause of vaginal bleeding at any age (see 'Trauma' below). The clinician should first consider the patient's chronological age and stage of puberty (Tanner or sexual maturity stage) (picture 1 and picture 2) [3]. When evaluating adolescents who have passed menarche or are well into puberty, the clinician must first establish whether or not the patient is pregnant (see "Clinical manifestations and diagnosis of early pregnancy"). In adolescents who are not pregnant, the clinician will need to distinguish abnormal vaginal bleeding from normal menstruation. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Terminology'.)
Trauma
Blunt trauma — Most vulvovaginal trauma is blunt, nonpenetrating, and produces relatively minor injury. The home, especially the bathroom or poolside, is a common location for straddle injuries to occur [4]. Bed frames, bicycle frames, playground equipment, and protruding bathtub fixtures can pose hazards to females who slip on wet surfaces, jump, or fall. Although sexual assault is an important consideration in children and adolescents with genital trauma, most injuries that cause vaginal bleeding are unintentional. Conversely, most sexual assault of children does not produce any genital trauma [5]. Blunt or straddle injuries typically cause bruising of the labia majora or lacerations that spare the hymen and vagina. Intravaginal bleeding, injury to the hymen or posterior fourchette, or perineal lacerations or tears raise suspicion for sexual abuse. (See "Straddle injuries in children: Evaluation and management", section on 'Findings suggesting child abuse' and "Evaluation of sexual abuse in children and adolescents", section on 'Differential diagnosis'.)
Evaluation and management of superficial vulvar and vaginal wounds and the clinical manifestations and diagnosis of sexual abuse or assault are discussed separately. (See "Straddle injuries in children: Evaluation and management", section on 'Girls' and "Evaluation of sexual abuse in children and adolescents" and "Evaluation and management of adult and adolescent sexual assault victims".)
Penetrating vaginal trauma — In children and adolescents, penetrating injuries from coitus [6-8], narrow sharp objects (eg, pencils), high-pressure water jets found in fountains or water slides [9], and recreational misadventures involving water or jet skiing [10,11] can lacerate the vaginal wall and may result in life-threatening hemorrhage, concomitant rectal injury, and/or peritonitis. In patients whose visible perineal injuries are minor, a history of impalement or water jet injury should alert the clinician to the possibility of inapparent but severe vaginorectal trauma [12].
Hemodynamically unstable patients with penetrating vaginal injuries require resuscitation according to Advanced Trauma Life Support (ATLS) guidance and emergency consultation with a surgeon with pediatric trauma expertise in consultation with a surgeon with pediatric gynecology expertise when possible. Key actions include packing the vagina with sterile gauze to control bleeding and transfusion of blood products to maintain blood volume and coagulation factors. Patients should then rapidly proceed to the operating room for examination under anesthesia to fully characterize the vaginal injury, definitively control hemorrhage, and repair damage to adjacent structures (eg, urethra, bladder, or rectum). (See "Evaluation and management of female lower genital tract trauma", section on 'Vagina' and "Trauma management: Approach to the unstable child", section on 'Blood products'.)
Hemodynamically stable patients with penetrating trauma should undergo careful visual inspection of the perineum but also warrant prompt consultation with a surgeon who has the pediatric gynecologic expertise to perform an examination under anesthesia if indicated. In patients with a history of water jet injury or signs of significant injury, an upright abdominal film is warranted to identify free air under the diaphragm caused by penetration into the peritoneum.
Patients who have penetrating vaginal trauma without a plausible mechanism or due to sexual assault also require forensic evidence collection and reporting. (See "Evaluation of sexual abuse in children and adolescents" and "Evaluation and management of adult and adolescent sexual assault victims".)
Nontraumatic causes before menarche
Common conditions — The most common causes of vaginal bleeding in prepubertal females are blunt trauma, foreign bodies, infections, lichen sclerosus, urethral prolapse, and neonatal withdrawal bleeding. In some cases, a specific etiology cannot be identified despite complete evaluation [13-16]. Among prepubertal females referred to specialists, the most commonly reported causes of vaginal bleeding have been precocious puberty, foreign bodies, sexual abuse, and genital tumors [13,14,17]. However, these series likely reflect referral bias. In primary care practice, precocious puberty is uncommon, and genital tumors are rare.
Neonatal withdrawal bleeding — During intrauterine life, maternal estrogen crosses the placenta and stimulates growth of the female fetus's endometrial lining. As this hormonal support wanes, some neonates, typically during the first week of life, have an endometrial slough that results in a few days of bloody mucoid discharge or light vaginal bleeding [18,19]. The bleeding is self-limited and requires no treatment. This phenomenon may be delayed in extremely premature infants [20].
Vaginal foreign bodies — Vaginal bleeding with or without associated discharge is the most common symptom in prepubertal females who have vaginal foreign bodies [21]. Conversely, vaginal foreign body is a likely diagnosis in females who present with vaginal bleeding but no history of trauma [22]. The bleeding is typically light, spotty, and/or intermittent, and may be associated with a foul odor. With the child in the knee-chest position (figure 1), examination of the vaginal vault frequently provides visualization of the foreign body. Occasionally, examination under anesthesia is required to establish the diagnosis. Management of vaginal foreign bodies is discussed separately. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vaginal foreign body'.)
Infection (vaginitis) — Of the bacteria that cause vaginitis, two are particularly associated with bleeding: Streptococcus pyogenes (group A beta-hemolytic streptococci) and Shigella species. Infections with group A streptococci occur mainly in prepubertal females. Similarly, Shigella vaginitis has not been reported in females over the age of 10 years. Lack of estrogen, which results in a thin vaginal mucosa, an alkaline pH, and a relative paucity of protective microorganisms are risk factors for these and other vaginal infections [23].
●Group A streptococcal vaginitis – This infection is characterized by purulent vaginal discharge that is blood-tinged in about half of the cases [24]. Additional symptoms include pruritus, dysuria, or pain. A clinical hallmark of group A streptococcal perineal infection is a fiery or beefy red appearance of the perineal skin, often with a sharp margin (picture 3) [25]. Perineal streptococcal infection most often produces vulvar and/or perineal inflammation; true vaginitis with discharge is less common [26]. Most patients with perineal streptococcal infection do not have symptomatic pharyngitis, but throat cultures are positive in about 75 percent of cases [24]. Thus, treatment as for streptococcal pharyngitis with penicillin V; amoxicillin; or, in penicillin-allergic patients, cephalosporins, macrolides, or clindamycin for 10 days should result in resolution of the infection (table 2). (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Respiratory and enteric flora'.)
●Shigella vaginitis – Shigella infection produces mucopurulent and sometimes bloody vaginal discharge and often produces concomitant vulvitis [27,28]. Only about one-fourth of patients have a history of recent or concurrent diarrhea [28]. Nearly all reported cases of this uncommon infection have been caused by Shigella flexneri. Culture of vaginal secretions is necessary to establish the diagnosis; stool cultures are generally negative [27,29]. (See "Shigella infection: Clinical manifestations and diagnosis", section on 'Other manifestations'.)
Treatment of Shigella infection in children is discussed separately. (See "Shigella infection: Treatment and prevention in children", section on 'Oral therapy'.)
Lichen sclerosus — Bleeding, purpura, telangiectasias, and hematomas occur in 20 to 60 percent of females with lichen sclerosus [30]. Lichen sclerosus is a chronic, mucocutaneous inflammatory disorder of unknown etiology that principally affects the vulva and perineum [31]. Ninety percent of cases are in females, and the onset is most common in early childhood, although diagnosis is often delayed. Misdiagnosis of lichen sclerosus as sexual abuse is a recognized cause of intense distress to patients and families [32-34].
The most common presenting symptoms are vulvar and perineal itching, soreness, dysuria, and pain with defecation. The perineal discomfort can lead to constipation in severe or undiagnosed cases [32]. On examination, the labia majora and minora, clitoris, introitus, and perineal skin show, to varying extent, the characteristic white, atrophic, "cigarette-paper" appearance (picture 4). This fragile skin may bleed and create superficial hemorrhages. Perineal hypopigmentation in a figure-of-eight pattern is a pathognomonic finding (picture 5). Loss of normal vulvar architecture can occur with disease progression.
First-line treatment consists of topical emollients and application of superpotent steroid ointments; most children do well with this therapy when medication adherence is optimized and maintenance therapy considered [35-37]. Concerns regarding side effects of topical calcineurin inhibitors (eg, tacrolimus, pimecrolimus) make them a second-line treatment for children who do not respond to first-line treatment [31,38].
Lichen sclerosus in adults is discussed separately. (See "Vulvar lichen sclerosus".)
Urethral prolapse — Although this condition does not actually involve the vagina, the typical presentation is "vaginal" bleeding in a 2- to 10-year-old female. Some patients complain of dysuria or urinary frequency as well. Predisposing conditions are obesity, cough, constipation, and other circumstances that increase intra-abdominal pressure. On examination, a dusky red or purplish annular mass is seen between the labia majora. Although the vaginal orifice can be obscured by the mass, and clinicians and parents/caregivers may worry about malignancy, gentle caudolateral retraction of the labia majora will generally reveal the diagnostic appearance of a prolapse: a smooth doughnut shape with a central urethral dimple (picture 6).
Treatment of urethral prolapse is discussed in more detail separately. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Urethral prolapse'.)
Genital tract malignancies — Genital tract malignancy is a rare cause of vaginal bleeding in children and adolescents [39,40]. Endodermal sinus tumors and rhabdomyosarcomas (including sarcoma botryoides) of the vagina are rare, accounting for approximately 8 percent of all pediatric germ cell tumors and approximately 0.3 percent of all childhood malignancies. The majority of cases occur before age five years [41] (see "Rhabdomyosarcoma in childhood and adolescence: Epidemiology, pathology, and molecular pathogenesis" and "Vaginal cancer", section on 'Sarcoma'). Benign papillomas can mimic these tumors [42,43]. (See 'Uncommon conditions' below.)
Uncommon conditions — A variety of conditions can cause vaginal bleeding in children and premenarchal adolescents:
●Precocious puberty – Experts differ on the precise age that should mark the separation between abnormally early puberty and early but physiologic puberty in females (see "Definition, etiology, and evaluation of precocious puberty", section on 'Threshold for evaluation'). The Lawson Wilkins Pediatric Endocrine Society modified the definition of precocious puberty to be the appearance of secondary sexual characteristics younger than age seven in White and younger than six in African American females [44]. Evaluation is also warranted for females who progress to Tanner stage 3 breast development prior to age eight; those who have both pubic hair and breast development prior to age eight; females who are short with puberty younger than age eight; and those with neurologic issues suggesting a central process.
In a girl who has already begun puberty, the clinician must assess whether bleeding that is presumed to be menstrual is consistent with the patient's pubertal progression. On average, menarche occurs approximately two years after the onset of breast development, typically when a girl reaches Tanner stage 4 or 5 for breast development (picture 1). Bleeding out of synchrony with other signs of pubertal development (figure 2) or in a girl under the age of eight years warrants evaluation. The evaluation of females with precocious puberty is discussed separately. (See "Definition, etiology, and evaluation of precocious puberty".)
●Hypothyroidism – Hypothyroidism can produce premature menstruation in association with growth delay, premature thelarche, galactorrhea, and ovarian cysts, in varying combinations (Van Wyk-Grumbach syndrome) [45]. Notably, in some cases, the massive size of the associated multicystic ovaries has distracted clinicians' attention away from the underlying, causal hypothyroidism [46]. (See "Definition, etiology, and evaluation of precocious puberty", section on 'Causes of central precocious puberty'.)
●Hemangiomas and papillomas – Intravaginal and perineal hemangiomas and Müllerian papillomas (benign intravaginal and/or intracervical tumor) can produce vaginal bleeding in infancy or childhood [42,47] and should not be mistaken for sexual abuse [48]. Histopathology is required to differentiate benign Müllerian papilloma from malignant botryoid rhabdomyosarcoma [42,49]. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications".)
●Genital warts – Genital warts are caused by human papillomavirus and can produce bleeding in children when they are located on the mucosal surface of the introitus or just inside the hymenal ring (picture 7) [50]. Children acquire genital warts by vertical transmission (birth through an infected lower genital tract), autoinoculation of common warts, nonabusive contact, or sexual contact. (See "Condylomata acuminata (anogenital warts) in children", section on 'Transmission'.)
The diagnosis of condyloma acuminatum is usually made via clinical examination. Biopsies are rarely required and are usually reserved for patients in whom the diagnosis is uncertain or when the warts demonstrate atypical features, such as ulceration. When there is any concern for sexual abuse or consensual sexual activity, condylomata lata (secondary syphilis) should be in the differential. (See "Condylomata acuminata (anogenital warts) in children", section on 'Diagnosis and evaluation'.)
Although it is likely that many children with condyloma acuminatum acquire the disorder through nonsexual means, the possibility of sexual abuse warrants serious consideration during patient evaluation. Children under four years of age with condyloma acuminatum are less likely to be victims of sexual abuse than older children, but the possibility of sexual abuse cannot be definitively excluded based upon age. (See "Condylomata acuminata (anogenital warts) in children", section on 'Assessment for sexual abuse'.)
Treatment of anogenital warts is discussed separately. (See "Condylomata acuminata (anogenital warts) in children", section on 'Treatment'.)
●Estrogen exposure – The possibility that a child with vaginal bleeding has been exposed chronically to exogenous estrogen in a topical agent (cream or shampoo), oral medication (estrogen-containing prescriptions), or dietary supplement should be explored. Lavender and tea tree oil are in common use and associated with estrogen-like activity [51]. Evidence-based summaries of many dietary supplements and herbal remedies can be found on websites provided by the National Library of Medicine and the National Institutes of Health.
●Female genital cutting – Hemorrhage is a recognized complication of female genital cutting, which is practiced mainly by individuals from parts of East Africa, the Middle East, and Southeast Asia; it is less common in resource-rich countries. (See "Female genital cutting".)
●Isolated premature menarche – Prepubertal females may have uterine bleeding once or in cycles for a few months, without other evidence of endocrine abnormalities, pubertal advancement, or estrogen effects [52,53]. All other causes of bleeding, especially intravaginal foreign body and intravaginal tumor should be excluded before settling on this diagnosis.
Nontraumatic postmenarchal conditions
Pregnancy and its complications — Bleeding during pregnancy can indicate a life-threatening condition. In addition to identifying and treating hypovolemic shock when present, it is essential for the clinicians managing the postmenarchal adolescent with abnormal vaginal bleeding to perform a rapid pregnancy test. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Detection of human chorionic gonadotropin'.)
The causes and evaluation of vaginal bleeding during pregnancy are discussed separately and include (see "Overview of the etiology and evaluation of vaginal bleeding in pregnancy"):
●Ectopic pregnancy (see "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Clinical presentation')
●Placenta previa (see "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality")
●Placental abruption (see "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences")
●Spontaneous, threatened, incomplete, or missed abortion, and therapeutic abortion or its complications (see "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology")
Conditions not related to pregnancy — The preferred general term for abnormal bleeding in nonpregnant patients of reproductive age is abnormal uterine bleeding (formerly referred to as dysfunctional uterine bleeding). When the patient reports that their menstrual bleeding is excessive in quantity, frequency, duration, or any combination of these, the currently preferred term for this symptom is heavy menstrual bleeding (HMB) [54].
●Common conditions – The most common causes of HMB in adolescents are disorders of ovulation and side effects of hormonal contraceptive methods. (See "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception".)
In turn, the most common causes of ovulatory dysfunction in adolescence are delayed pubertal maturation and polycystic ovary syndrome. (See "Definition, clinical features, and differential diagnosis of polycystic ovary syndrome in adolescents".)
●Uncommon conditions — A bleeding disorder, in particular thrombocytopenia, von Willebrand disease, or a factor deficiency, should be considered in the adolescent whose menstrual bleeding is cyclic but unusually heavy or prolonged, especially if the HMB had its onset close to the time of menarche, is associated with a past or family history of excessive bleeding, or produces anemia. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Bleeding disorders'.)
Vaginal foreign bodies, cervicitis, genital warts, and infections (eg, pelvic inflammatory disease, endometritis, Chlamydia trachomatis) can cause irregular bleeding in adolescents [55]. Vulvar endometriosis is a rare cause of vaginal bleeding [56]. (See "Causes of female genital tract bleeding" and "Acute cervicitis" and "Desquamative inflammatory vaginitis" and "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis".)
EVALUATION
Trauma — With the exception of patients with penetrating trauma causing extensive vaginal lacerations and hemorrhage, most children and adolescents with vulvovaginal trauma are hemodynamically stable.
Initial evaluation and stabilization of penetrating vaginal injuries are discussed separately. (See 'Penetrating vaginal trauma' above and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management", section on 'Initial assessment'.)
Premenarchal patients
Diagnostic approach — The algorithm summarizes an approach to diagnosis for patients with vaginal bleeding before menarche (algorithm 1). In many premenarchal children, the physical examination findings will provide or suggest a diagnosis (see 'Physical examination' below). Endocrinologic evaluation is indicated for patients with early signs or an abnormal sequence of puberty (figure 2). (See "Definition, etiology, and evaluation of precocious puberty", section on 'Threshold for evaluation'.)
If the patient has a nondiagnostic examination and no signs of puberty, then vaginal culture for bacterial infection typically caused by Group A Streptococcus or Shigella species, and, in patients with appropriate indications (eg, high likelihood of sexual abuse on interview, signs of genital penetration, or patients with persistent purulent discharge with or without negative vaginal bacterial culture), testing for sexually transmitted infections should be obtained. If results are negative, the patient should be referred to a surgeon with pediatric gynecologic expertise to perform vaginoscopy to look for foreign bodies, trauma, hemangiomas, and tumors. (See 'Diagnostic evaluation' below.)
History — In prepubertal children, the history has low predictive value; diagnosis will depend primarily on the patient's physical examination findings [1,57]. However, it can be helpful to elicit a history of associated vaginal discharge; recent sore throat or streptococcal infection in a household member; diarrhea; pain with defecation; or previous vaginal foreign bodies.
Physical examination — The clinician will tend to focus on the external genital examination, but the skin, thyroid gland, and chest also require attention. Children's underwear should be removed completely to facilitate careful inspection of the external genitalia and perineum.
Important findings include:
●Thyroid enlargement can suggest hypothyroidism.
●The presence of breast or pubic hair development (picture 1 and picture 2) suggests either abnormal vaginal bleeding in a girl with normally progressing puberty, first menarche in a girl whose age and pubertal progression are appropriate, or, much less commonly, precocious puberty.
●Lichen sclerosus (picture 5 and picture 8) and urethral prolapse (picture 6) usually present pathognomonic appearances.
●A fiery or beefy red appearance of infected skin points to perineal group A streptococcal infection (picture 3).
●Cafe-au-lait spots can suggest neurofibromatosis or McCune-Albright syndrome (picture 9), rare causes of precocious puberty.
If the general physical examination and inspection of the external genitalia do not permit a confident diagnosis, the vaginal vault should be inspected. Although speculum examination was recommended historically, this procedure is not commonly performed in the awake premenarchal patient. Most children over three years of age can cooperate for prone knee-chest examination (figure 1). The keys to successful visualization of the vaginal vault using this position are adequate lateral and cephalad retraction of the child's buttocks and labia majora (accomplished by a parent/caregiver or assistant) and relaxation of the abdominal muscles sufficient to ensure that air enters the vaginal vault. An otoscope provides focused illumination and magnification and can help with visualization.
Diagnostic evaluation — The selection of diagnostic tests should be guided by findings from the child's history and physical examination (algorithm 1). (See 'Diagnostic approach' above.)
If the physical examination was not diagnostic, vaginal secretions, if present, warrant appropriate testing for bacterial pathogens. A vaginal culture for enteric and respiratory organisms can be sent with treatment determined by results (see "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Respiratory and enteric flora'). The clinician should alert the microbiology laboratory staff in advance to use culture media appropriate for the suspected pathogens, namely group A Streptococcus and Shigella species. Otherwise, a report of "Group B Strep not present" is likely to be obtained and not be useful to the clinician. (See "Gynecologic examination of the newborn and child", section on 'How to obtain cultures and other specimens from children'.)
In prepubertal females with appropriate indications (eg, high likelihood of sexual abuse on interview, signs of genital penetration, or patients with purulent discharge with or without negative vaginal bacterial culture), testing for sexually transmitted infections is also required. Consultation with the child abuse team may inform specimen collection choice. (See "Gynecologic examination of the newborn and child", section on 'How to obtain cultures and other specimens from children' and "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims'.)
Females whose breast development is inappropriately advanced for their chronologic age (figure 2) warrant further evaluation for precocious puberty or potential exogenous estrogen exposure. The diagnostic evaluation of the child with precocious puberty is discussed separately. (See "Definition, etiology, and evaluation of precocious puberty", section on 'Evaluation'.)
In females with no pubertal development, if the vaginal culture is negative and vaginal bleeding remains unexplained, then vaginoscopy by a surgeon with pediatric gynecology expertise should be undertaken [58]. Studies suggest that vaginoscopy has considerably better diagnostic sensitivity than does noninvasive imaging (ultrasound, computed tomography, magnetic resonance imaging) for the diagnoses of foreign body and malignancy [14]. (See "Vaginoscopy".)
Serum alpha-fetoprotein is a sensitive and specific marker for endodermal sinus tumors and should be obtained if there is any suspicion that a malignancy might be present. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis", section on 'Tumor markers'.)
Differential diagnosis — The clinician should use history and physical examination to determine that the source of the bleeding is vaginal and not from the skin, the urinary or gastrointestinal tract. Parents'/caregivers' assessments about the source are usually informative based upon observations at home during toileting or diaper changes. Asking about the location of the blood in the child's underwear can also be revealing. For patients with rectal mucosal lesions (eg, anal fissures) or hematochezia caused by a juvenile polyp or a Meckel diverticulum, bright red blood on the toilet paper is often reported. Physical examination, including examination in the knee-chest position, usually definitively demonstrates the bleeding site. However, if, after physical examination of the child, the bleeding source is still uncertain, urinalysis collected by catheterization to prevent external blood contamination of the specimen, and/or stool guaiac testing is suggested. Guaiac testing may be used to confirm that the 'blood' is truly blood.
Postmenarchal patients — Management of hemodynamically unstable postmenarchal patients with vaginal bleeding and the evaluation of adolescents who could be pregnant are presented separately:
●(See "Approach to the adult with vaginal bleeding in the emergency department".)
●(See "Clinical manifestations and diagnosis of early pregnancy".)
●(See "Overview of the etiology and evaluation of vaginal bleeding in pregnancy".)
For nonpregnant adolescents who are hemodynamically stable, a complete blood count and assessment of iron stores should be obtained to assess for blood loss, thrombocytopenia, and replacement needs. Whether and which laboratory investigations should be undertaken next will depend upon the diagnoses suggested by the individual patient's clinical circumstances. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Initial evaluation'.)
SUMMARY AND RECOMMENDATIONS
●Causes – The causes of vaginal bleeding in children and adolescents are presented in the table (table 1) and include (see 'Causes' above):
•Trauma – Although the possibility of sexual assault should be considered, most blunt injuries that cause vaginal bleeding are unintentional. Conversely, most sexual abuse or assault of children does not produce genital trauma or bleeding. In particular, the clinician should be careful not to confuse lichen sclerosus (picture 5) with sexual abuse. (See 'Blunt trauma' above and "Straddle injuries in children: Evaluation and management", section on 'Findings suggesting child abuse' and "Evaluation of sexual abuse in children and adolescents", section on 'Differential diagnosis' and 'Lichen sclerosus' above.)
Penetrating vaginal injuries can cause life-threatening hemorrhage, rectal injury, or peritonitis. The possibility of intravaginal injury should be considered even if a patient's visible perineal injuries are minor (see 'Penetrating vaginal trauma' above). Patients who have penetrating vaginal trauma without a plausible mechanism or due to sexual assault also require forensic evidence collection and reporting. (See "Evaluation of sexual abuse in children and adolescents" and "Evaluation and management of adult and adolescent sexual assault victims".)
•Premenarchal patients – Neonatal withdrawal bleeding, foreign bodies, noninfectious vulvovaginitis, infectious vulvovaginitis due to Streptococcus pyogenes (group A beta-hemolytic streptococci) or Shigella species, and urethral prolapse (picture 6) are common causes of actual or apparent vaginal bleeding. Although bleeding is not common, purpura, telangiectasias, and hematomas frequently occur in patients with lichen sclerosus (picture 10) and may be mistaken for sexual abuse. (See 'Common conditions' above.)
Uncommon causes of vaginal bleeding before normal menarche include precocious puberty, hypothyroidism, intravaginal hemangiomas and papillomas, genital warts, exogenous estrogen exposure, and female genital cutting. Benign prepubertal vaginal bleeding is a diagnosis of exclusion. (See 'Uncommon conditions' above.)
Life-threatening genital malignancies such as endodermal sinus tumors and rhabdomyosarcomas (including sarcoma botryoides) of the vagina are rare; they present almost exclusively in patients <3 years old. (See 'Genital tract malignancies' above.)
•Postmenarchal patients – For postmenarchal patients with vaginal bleeding, the most urgent issues are to establish whether the patient is pregnant and to manage hemorrhagic shock, as needed. (See "Clinical manifestations and diagnosis of early pregnancy" and "Approach to the adult with vaginal bleeding in the emergency department", section on 'Diagnostic approach, initial management, and disposition'.)
In adolescents who are not pregnant, the clinician needs to distinguish normal menstruation from hormonal, infectious, hematologic, and other causes of abnormal bleeding. (See 'Conditions not related to pregnancy' above and "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis".)
The emergency management of postmenarchal adolescents and adult patients with vaginal bleeding is presented in detail separately (algorithm 2). (See "Approach to the adult with vaginal bleeding in the emergency department".)
●Diagnostic approach for premenarchal patients – The diagnostic approach to vulvovaginal bleeding in premenarchal patients is provided in the algorithm (algorithm 1). In many premenarchal children, the physical examination findings will provide or suggest a diagnosis (see 'Physical examination' above). Endocrinologic evaluation is indicated for patients with early signs or an abnormal sequence of puberty (figure 2). (See 'Premenarchal patients' above.)
If the patient has a nondiagnostic examination and no signs of puberty, then vaginal culture for bacterial infection typically caused by Group A Streptococcus or Shigella species, and, in patients with appropriate indications (eg, high likelihood of sexual abuse on interview, signs of genital penetration, or patients with purulent discharge with or without negative vaginal bacterial culture), testing for sexually transmitted infections should be obtained. If results are negative, the patient should be referred to a surgeon with pediatric gynecologic expertise to perform vaginoscopy to look for foreign bodies, trauma, hemangiomas, and tumors. (See 'Diagnostic evaluation' above.)
ACKNOWLEDGMENT — We are saddened by the death of Jan Paradise, MD, who passed away in April 2021. UpToDate gratefully acknowledges Dr. Paradise's outstanding work as an author for this topic.
