What is the appropriate workup for a 7-year-old with vaginal bleeding?

Evaluation of Vaginal Bleeding in a 7-Year-Old Child

Vaginal bleeding in a 7-year-old child requires prompt and thorough evaluation with examination under anesthesia and vaginoscopy as the gold standard diagnostic approach, as noninvasive imaging alone may miss serious pathology including malignancies. 1

Initial Assessment

History

• Duration and pattern of bleeding
• Associated symptoms (pain, discharge, odor)
• Trauma history
• Foreign body insertion possibility
• Medication use
• Signs of precocious puberty
• Concerning behaviors suggesting abuse

Physical Examination

• External genital inspection (without digital examination)
• Assessment for:
  • Signs of trauma
  • Vulvovaginitis
  • Foreign bodies visible at introitus
  • Lesions, masses, or warts
  • Urethral abnormalities
  • Signs of precocious puberty

Diagnostic Approach

First-Line Evaluation

• External genital examination in a comfortable setting
• Avoid digital pelvic examination before ruling out serious pathology 2
• Laboratory tests:
  • Complete blood count
  • Urinalysis
  • Vaginal cultures if discharge present

Imaging Studies

• Pelvic ultrasound (transabdominal)
  • Can identify some foreign bodies and structural abnormalities
  • Note: Ultrasound alone identified only 5 of 7 foreign bodies and only 2 of 6 malignancies in one study 1

Definitive Evaluation

• Examination under anesthesia with vaginoscopy is essential for:
  • Thorough visualization of vagina and cervix
  • Identification and removal of foreign bodies
  • Evaluation of mucosal damage
  • Biopsy of suspicious lesions
  • Ruling out malignancy 3, 1

Common Etiologies to Consider

Most Common Causes

• Vulvovaginitis (most common cause in prepubertal girls) 4
• Foreign bodies (plastic toys, toilet paper, etc.) 5
• Trauma (accidental or non-accidental)
• Urethral prolapse

Less Common but Serious Causes

• Malignancies:
  • Rhabdomyosarcoma
  • Endodermal sinus tumor 1
• Precocious puberty
• Genital lesions (polyps, tumors)
• Sexual abuse

Management Approach

1. Initial external examination in a comfortable setting
2. Noninvasive imaging (pelvic ultrasound)
3. Examination under anesthesia with vaginoscopy regardless of imaging results 1
4. Treatment based on findings:
   • Antibiotics for infections
   • Foreign body removal
   • Referral to specialists for tumors or endocrine disorders
   • Involvement of child protection services if abuse suspected

Important Considerations

• Providers specifically trained in pediatric gynecology should be involved 3
• Ensure patient safety and comfort throughout evaluation
• While most causes are benign, malignancy and abuse must always be ruled out 3
• Noninvasive imaging alone is insufficient for diagnosis 1
• Examination under anesthesia is warranted even with normal imaging findings

Pitfalls to Avoid

• Relying solely on noninvasive imaging (may miss malignancies) 1
• Performing digital examination before ruling out serious pathology 2
• Assuming benign etiology without thorough evaluation
• Failing to consider child abuse in the differential diagnosis
• Delaying examination under anesthesia when diagnosis is unclear

Remember that while vulvovaginitis and foreign bodies are the most common causes of vaginal bleeding in this age group, the evaluation must be thorough enough to rule out more serious conditions, particularly malignancies which may not be detected on imaging alone.