What is the appropriate evaluation and treatment for an 8-year-old girl experiencing vaginal bleeding and itching?

Evaluation and Management of Vaginal Bleeding and Itching in an 8-Year-Old

This child requires immediate evaluation by an experienced clinician with visual inspection of the genital area, consideration of sexual abuse, and STD testing if indicated, while deferring presumptive treatment until proper specimens are obtained. 1

Immediate Mandatory Actions

Legal Reporting Requirement

• If you have reasonable cause to suspect child abuse based on your evaluation, you must report to child protective services immediately - this is legally mandated in all U.S. states and territories. 1

Initial Clinical Assessment

The examination should include: 1

• Visual inspection of the genital, perianal, and oral areas specifically looking for:
  • Discharge characteristics (color, odor, consistency)
  • Evidence of bleeding or its source
  • Signs of trauma or penetrative injury
  • Presence of foreign bodies
  • Erythema, irritation, or lesions
  • Hypopigmentation suggesting lichen sclerosus

Critical caveat: Examinations and specimen collection in prepubertal children can be very uncomfortable and should be performed by an experienced clinician to avoid psychological and physical trauma. 1

STD Testing Indications

Because this child has signs or symptoms of STDs (vaginal bleeding, genital itching), STD testing is indicated before initiating any treatment. 1 The CDC specifically lists "vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital lesions or ulcers" as factors requiring STD screening. 1

Additional factors that strengthen the need for STD testing include: 1

• Evidence of penetration or penetrative injury
• Abuse by a stranger or high-risk perpetrator
• Household member with an STD
• High STD prevalence in the community
• Parent or child requests testing

Specific Testing Protocol

Use only tests with high specificity due to legal and psychosocial consequences of false-positive results: 1, 2

• Culture for N. gonorrhoeae from pharynx, anus, and vagina
• Culture for C. trachomatis from vagina and anus
• Syphilis testing if gonococcal infection is identified
• Vaginal pH measurement (normal prepubertal pH ≤4.5)
• Microscopic examination with saline and 10% KOH preparations

Defer presumptive treatment until specimens are obtained - the potential benefit of a reliable STD diagnosis justifies this delay. 1

Differential Diagnosis Algorithm

Most Common Causes (in order of frequency):

1. Vulvovaginitis (82% of cases) 3

• Often responds to hygiene measures alone
• May be nonspecific or infectious

2. Foreign Body (3% of cases) 3, 4

• Can cause purulent, bloody, foul-smelling discharge
• May require vaginoscopy for removal
• Important: Plain radiography or ultrasound should be considered before invasive procedures 4

3. Sexual Abuse (5% of cases) 3

• Must be evaluated in consultation with specialists trained in pediatrics
• Any STD diagnosis in a prepubertal child requires mandatory reporting 2

4. Lichen Sclerosus 5, 2

• Presents with intense vulvar itching and hypopigmentation
• Requires topical steroids as first-line treatment
• Mandatory regular long-term follow-up

5. Less Common: Genital tumors, precocious puberty, labial adhesions 6, 3, 7

Treatment Based on Etiology

For Vulvovaginal Candidiasis (if confirmed):

Use clotrimazole 1% cream applied to affected area twice daily for up to 7 days 5, 2 - this has moderate strength of evidence from the Infectious Diseases Society of America.

Do NOT use oral fluconazole in children under 12 years - safety data is limited. 5

For Nonspecific Vulvovaginitis:

Implement proper hygiene measures: 5, 2

• Gentle cleansing with warm water only (no soap)
• Front-to-back wiping after toileting
• Avoid tight-fitting clothing and synthetic underwear
• Cotton underwear changed daily

For Lichen Sclerosus:

Topical steroids are first-line treatment with mandatory regular follow-up. 5, 2

When to Proceed to Examination Under Anesthesia

If the child is reluctant to undergo examination, or if the extent of injury or source of bleeding cannot be determined, examination under anesthesia with vaginoscopy is recommended. 6 This allows:

• Clear visualization without distorting hymenal anatomy
• Diagnosis and removal of foreign bodies
• Evaluation of mucosal damage
• Complete assessment when office examination is inadequate

Follow-Up Requirements

• Schedule follow-up if symptoms persist or recur within 2 months 5, 2
• If sexual abuse is suspected and initial exposure was recent, schedule a second visit approximately 2 weeks after the most recent exposure to repeat examination and collect additional specimens for infections that might not have been detected initially 1
• For lichen sclerosus, regular long-term monitoring is essential 2

Common Pitfalls to Avoid

• Do not assume bleeding/itching is benign without proper evaluation - while most causes are benign, malignancy and abuse must be excluded 6
• Do not start empiric treatment before obtaining specimens if STD testing is indicated - this can interfere with diagnosis 1
• Do not perform speculum examination routinely - it should only be done when medically necessary and by experienced providers 8
• Do not overlook foreign bodies - always consider this diagnosis in prepubertal vaginal bleeding with discharge 4