Diagnosing and Managing Common Genital Emergencies in Pediatric Girls

Table of Contents

 

The presentation of genital injuries and emergencies in pediatric girls can be misleading. While a straddle injury may present with excessive bleeding yet require only conservative management, an impalement injury may present with no external findings yet require extensive surgery. This issue describes the workup and management of common traumatic genital injuries and nontraumatic genital emergencies in pediatric girls. You will learn:

Typical presentations of a straddle injury, hematoma, impalement/penetrating injury, imperforate hymen, and urethral prolapse in pediatric girls

Key questions to ask during the history

Recommended patient positions and examination techniques to use during the physical examination

How to determine when interventions are needed and what types of interventions are recommended

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology, Etiology, and Pathophysiology
   1. Physiologic Differences in the Genitalia of Young Girls
   2. Traumatic Genital injuries
      1. Blunt Trauma/Straddle Injuries
      2. Penetrating Injuries
      3. Injuries Caused by Insufflation or Hydrodistension
   3. Nontraumatic Genital Emergencies
      1. Imperforate Hymen
      2. Urethral Prolapse
6. Differential Diagnosis
7. Emergency Department Evaluation
   1. History
      1. Traumatic Genital Injuries
      2. Nontraumatic Genital Emergencies
         • Imperforate Hymen
         • Urethral Prolapse
   2. Physical Examination
      1. Examination Techniques
      2. Traumatic Genital Injuries
      3. Nontraumatic Genital Emergencies
8. Diagnostic Studies
   1. Traumatic Genital Injuries
      1. Laboratory Studies
      2. Imaging Studies and Endoscopy
      3. Urinalysis and Urine Culture
   2. Nontraumatic Genital Emergencies
      1. Laboratory Studies
      2. Imaging Studies
9. Treatment
   1. Traumatic Genital Injuries
      1. Lacerations and Hematomas
      2. Penetrating Injuries
   2. Nontraumatic Genital Emergencies
      1. Hematocolpos
      2. Urethral Prolapse
10. Special Circumstances
    1. Large Expanding Genital Hematomas
    2. Genital Injuries Caused by Insufflation or Hydrodistension
    3. Alternate Etiologies of Hematocolpos
11. Controversies and Cutting Edge
    1. Management of Lacerations After Straddle Injuries
    2. Management of Patients with Urethral Prolapse
12. Disposition
    1. Traumatic Genital Injuries
       1. Lacerations, Hematomas, and Penetrating Injuries
    2. Nontraumatic Genital Emergencies
       1. Hematocolpos
       2. Urethral Prolapse
13. Summary
14. Risk Management Pitfalls in the Management of Genital Injuries and Emergencies in Pediatric Girls
15. Time- and Cost-effective Strategies
16. Case Conclusions
17. Clinical Pathways
    1. Clinical Pathway for the Management of a Genitourinary Laceration in a Pediatric Girl
    2. Clinical Pathway for the Management of a Genitourinary Hematoma in a Pediatric Girl
    3. Clinical Pathway for the Management of a Hematocolpos in a Pediatric Girl
    4. Clinical Pathway for the Management of a Urethral Prolapse in a Pediatric Girl
18. Tables and Figures
    1. Table 1. Differential Diagnosis of Genital Anomalies
    2. Table 2. Classification of Genitoanal Injury Severity
    3. Figure 1. Ecchymosis After a Straddle Injury
    4. Figure 2. Laceration After a Straddle Injury
    5. Figure 3. Bulging Imperforate Hymen
    6. Figure 4. Hematocolpos
    7. Figure 5. Urethral Prolapse
    8. Figure 6. Supine/Frog-Leg and Prone/Knee-Chest Examination Positions
    9. Figure 7. Female Anatomy
    10. Figure 8. Techniques for Examination of the Female Anatomy
19. References

Abstract

The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery. This issue reviews the most common traumatic genital injuries in girls presenting to the emergency department, including straddle injuries, hematomas, and impalement injuries. Nontraumatic emergencies, including hematocolpos and urethral prolapse, are also discussed. Evidence-based recommendations are presented for identifying and managing these common genital injuries and emergencies in pediatric girls.

Case Presentations

A 15-year-old adolescent girl is brought into the ED by her mother for severe abdominal and pelvic pain with dysuria. The patient is otherwise healthy, with no significant past medical history. She is not sexually active and denies any trauma. Upon questioning, the patient states that she has had cyclical abdominal pain over the past year and a half, which typically lasts 2 to 3 days, and then self resolves. She has not yet started her menses. This is the first time that the pain has been 10/10 in severity, and she has new urinary urgency, with inability to fully empty her bladder. On physical examination, she is Tanner stage V for breast and pubic hair development, her abdomen is soft with no palpable mass, and she has no costovertebral angle tenderness. On visual inspection of her perineum, she is noted to have a large, bulging purplish mass in her vaginal area with a small leak of blood. Are there any laboratory tests that you should order? What imaging—if any—would be the best choice for confirming the diagnosis? Should you try to release the pressure and evacuate the blood?

Your next patient is a 3-year-old girl who has come in for fever. Two days prior, her brother had injured her with a coat hanger while playing “swords.” According to the patient’s brother, the coat hanger had gone into her “bottom,” but he removed it. Since she had no bleeding or obvious injury, they thought it was okay not tell their mother. During the physical examination, the girl has no abdominal tenderness with palpation and no bloody drainage on limited visual rectal examination. You begin to consider how you should manage this patient. Is her fever related to the injury, or is this a viral illness? Would laboratory studies be helpful? What imaging would be best for evaluating her potential injury?

A concerned mother brings her 7-year-old daughter into your ED after noticing the girl's underwear had blood on it. The girl appears to be uncomfortable. The mother states that the girl attends daycare but that the staff of the school said there was no violence or trauma that occurred there. The girl says that no one examined or touched her “private parts.” The girl’s mother states that her daughter had previously been healthy except for a history of asthma with a recurrent cough. The girl says that she has not had any prior vaginal bleeding. You begin to wonder whether the daycare staff is telling the truth. How worried should you be regarding sexual abuse or undisclosed trauma? What conditions can cause this type of bleeding in a young girl?

Introduction

Traumatic genital injuries are rare in girls and can range from minor skin abrasions to severe injuries of the genitourinary tract or pelvic compartment. Physicians at the Leicester Royal Infirmary in the United Kingdom reviewed a retrospective case series of girls aged 0 to 15 years with genital injuries who presented to the emergency department (ED) between 2002 and 2010. Over the 8 years reviewed, there were 181 genital injuries reported. Of these, 76.2% of the patients were discharged without any significant intervention, demonstrating that the majority of genital injuries can be treated conservatively.¹ Although some injuries or emergencies may appear to be significant because of the severity of bleeding, most pediatric girls who present to the ED with genital complaints can be treated without surgical intervention.

This issue of Pediatric Emergency Medicine Practice describes the workup and management of common traumatic genital injuries in pediatric girls, including how to determine when interventions are needed and what types of interventions are recommended. Nontraumatic genital concerns including an imperforate hymen and urethral prolapse will also be discussed, as will how to approach the different stages of these diagnoses.

Critical Appraisal of the Literature

A literature search was performed in PubMed using the following search terms: perineal injuries, labial lacerations, hematocolpos, impalement injuries, perineal trauma, female genital and urogenital abnormalities, vulvovaginal complaints, pediatric genital exam abnormalities AND children, child, or pediatrics. 120 articles were reviewed, ranging in publication date from 1980 to the present; however, there were limited data regarding management of these conditions in the ED setting.

The majority of the publications were retrospective reviews and case reports. Gynecologists, surgeons, and emergency physicians published the majority of the case reports and retrospective reviews. Currently, there are few published guidelines based on qualified multicenter research studies.

Risk Management Pitfalls in the Management of Genital Injuries and Emergencies in Pediatric Girls

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. Roland D, Lewis G, Rowlands R, et al. Female perineal injuries in children and adolescents presenting to a paediatric emergency department. Emerg Med J. 2016;33(1):73-75. (Retrospective study; 181 patients)
2. Saxena AK, Steiner M, Hollwarth ME. Straddle injuries in female children and adolescents: 10-year accident and management analysis. Indian J Pediatr. 2014;81(8):766-769. (Retrospective review; 91 patients)
3. Merritt DF. Management quandary. Vulvar trauma in a young girl. J Pediatr Adolesc Gynecol. 2003;16(5):325-326. (Review article)
4. Jacobs AM, Alderman EM. Gynecologic examination of the prepubertal girl. Pediatr Rev. 2014;35(3):97-104. (Review article)
5. Merritt DF. Genital trauma in children and adolescents. Clin Obstet Gynecol. 2008;51(2):237-248. (Review article)
6. McCann J, Miyamoto S, Boyle C, et al. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics. 2007;120(5):1000-1011. (Retrospective study; 113 patients)
7. Liuzzi C, Carabellese F, Vinci F. Perineal-vaginal injuries in children: accident or abuse? J Forensic Sci. 2010;55(4):1120-1122. (Case report)
8. Heppenstall-Heger A, McConnell G, Ticson L, et al. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003;112(4):829-837. (Prospective observational study; 94 patients)
9. Spitzer RF, Kives S, Caccia N, et al. Retrospective review of unintentional female genital trauma at a pediatric referral center. Pediatr Emerg Care. 2008;24(12):831-835. (Retrospective review; 105 patients)
10. Scheidler MG, Schultz BL, Schall L, et al. Mechanisms of blunt perineal injury in female pediatric patients. J Pediatr Surg. 2000;35(9):1317-1319. (Retrospective study; 358 patients)
11. Onen A, Ozturk H, Yayla M, et al. Genital trauma in children: classification and management. Urology. 2005;65(5):986-990. (Retrospective review; 116 patients)
12. Berkenbaum C, Balu L, Sauvat F, et al. Severe vaginal laceration in a 5-year-old girl caused by sudden hydro-distention. J Pediatr Adolesc Gynecol. 2013;26(6):e131-e132. (Case report)
13. McCann J, Wells R, Simon M, et al. Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics. 1990;86(3):428-439. (Review article)
14. Dane C, Dane B, Erginbas M, et al. Imperforate hymen-a rare cause of abdominal pain: two cases and review of the literature. J Pediatr Adolesc Gynecol. 2007;20(4):245-247. (Case report, review article)
15. Ballouhey Q, Galinier P, Gryn A, et al. Benefits of primary surgical resection for symptomatic urethral prolapse in children. J Pediatr Urol. 2014;10(1):94-97. (Retrospective study; 19 patients)
16. Rudin JE, Geldt VG, Alecseev EB. Prolapse of urethral mucosa in white female children: experience with 58 cases. J Pediatr Surg. 1997;32(3):423-425. (Retrospective study; 58 cases)
17. Ninomiya T, Koga H. Clinical characteristics of urethral prolapse in Japanese children. Pediatr Int. 2017;59(5):578-582. (Retrospective study; 77 patients)
18. Hillyer S, Mooppan U, Kim H, et al. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology. 2009;73(5):1008-1011. (Retrospective study; 34 patients)
19. Bronkhorst MW, Wilde JC, Hamming JF, et al. Anorectal impalement in a pediatric patient with transanal evisceration of small bowel. J Pediatr Surg. 2007;42(9):E23-E25. (Case report)
20. Hong HR, Hwang KR, Kim SA, et al. A case of vulvar hematoma with rupture of pseudoaneurysm of pudendal artery. Obstet Gynecol Sci. 2014;57(2):168-171. (Case report)
21. Merritt DF. Genital trauma in prepubertal girls and adolescents. Curr Opin Obstet Gynecol. 2011;23(5):307-314. (Review article)
22. Merritt DF. Vulvar and genital trauma in pediatric and adolescent gynecology. Curr Opin Obstet Gynecol. 2004;16(5):371-381. (Review article)
23. Mwampagatwa IH, Mponda BA. Imperforate hymen presenting with massive haematocolpos and acute urinary retention in a teenage girl: a case report. Tanzan J Health Res. 2012;14(4):293-296. (Case report)
24. Nazir Z, Rizvi RM, Qureshi RN, et al. Congenital vaginal obstructions: varied presentation and outcome. Pediatr Surg Int. 2006;22(9):749-753. (Review article)
25. Kondamudi NP, Gupta A, Watkins A, et al. Prepubertal girl with vaginal bleeding. J Emerg Med. 2014;46(6):769-771. (Case report)
26. Kim S, Linden B, Cendron M, et al. Pediatric anorectal impalement with bladder rupture: case report and review of the literature. J Pediatr Surg. 2006;41(9):E1-E3. (Case report, review article)
27. Price J. Injuries in prepubertal and pubertal girls. Best Pract Res Clin Obstet Gynaecol. 2013;27(1):131-139. (Review article)
28. Hewitt G. Examining pediatric and adolescent gynecology patients. J Pediatr Adolesc Gynecol. 2003;16(4):257-258. (Review article)
29. Jones JG, Worthington T. Genital and anal injuries requiring surgical repair in females less than 21 years of age. J Pediatr Adolesc Gynecol. 2008;21(4):207-211. (Retrospective review; 44 patients)
30. Jona JZ. Accidental anorectal impalement in children. Pediatr Emerg Care. 1997;13(1):40-43. (Case reports; 4 patients)
31. Ameh EA, Mshelbwala PM, Ameh N. Congenital vaginal obstruction in neonates and infants: recognition and management. J Pediatr Adolesc Gynecol. 2011;24(2):74-78. (Review article)
32. Holbrook C, Misra D. Surgical management of urethral prolapse in girls: 13 years’ experience. BJU Int. 2012;110(1):132-134. (Retrospective study; 21 patients)
33. McCann J, Miyamoto S, Boyle C, et al. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics. 2007;119(5):e1094-e1106. (Retrospective study; 239 patients)
34. Kim K, No JH, Kim YB, et al. Patterns of accidental genital trauma and factors associated with surgical management in girls visiting the emergency department of a referral center. J Pediatr Adolesc Gynecol. 2014;27(3):133-137. (Retrospective study; 159 patients)
35. Iqbal CW, Jrebi NY, Zielinski MD, et al. Patterns of accidental genital trauma in young girls and indications for operative management. J Pediatr Surg. 2010;45(5):930-933. (Retrospective review; 167 patients)
36. Vincent MV, Abel C, Duncan ND. Penetrating anorectal injuries in Jamaican children. Pediatr Surg Int. 2012;28(11):1101-1107. (Retrospective study; 14 patients)
37. Grisoni ER, Hahn E, Marsh E, et al. Pediatric perineal impalement injuries. J Pediatr Surg. 2000;35(5):702-704. (Case reports, review)
38. Ameh EA. Anorectal injuries in children. Pediatr Surg Int. 2000;16(5-6):388-391. (Retrospective study; 7 patients)
39. Bonnard A, Zamakhshary M, Wales PW. Outcomes and management of rectal injuries in children. Pediatr Surg Int. 2007;23(11):1071-1076. (Retrospective study; 9 patients)
40. Himmelman RG, Martin M, Gilkey S, et al. Triple-contrast CT scans in penetrating back and flank trauma. J Trauma. 1991;31(6):852-855. (Prospective study; 88 patients)
41. Mahapatra RS, Priyadarshi V, Madduri VK, et al. Transrectal impalement of an incense stick in a child presenting as foreign body in the urinary bladder. BMJ Case Rep. 2014. DOI: https://doi.org/10.1136/bcr-2014-204689 (Case report)
42. Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg. 1999;34(10):1555-1556. (Case report)
43. Kumar A, Mittal M, Prasad S, et al. Haematocolpos--an uncommon cause of lower abdominal pain in adolescent girls. J Indian Med Assoc. 2002;100(4):240-241. (Case report)
44. Boudhraa K, Ouhibi J, Kassaaoui A, et al. Hematocolpos with imperforate hemi-vagina and duplicated uterus: diagnosis and treatment. Tunis Med. 2007;85(11):970-974. (Retrospective study; 4 patients)
45. Kushnir O, Garde K, Blankstein J. Rectal sonography for diagnosing hematocolpometra. A case report. J Reprod Med. 1997;42(8):519-520. (Case report)
46. Kapsalaki E DA, Deligeoroglou E, Zavos A, et al. The role of MRI in young adolescent girls with hematocolpos. Eur J Rad Ext. 2011;78(2):e97-e100. (Case report)
47. Leeman L, Spearman M, Rogers R. Repair of obstetric perineal lacerations. Am Fam Physician. 2003;68(8):1585-1590. (Review article)
48. Propst AM, Thorp JM Jr. Traumatic vulvar hematomas: conservative versus surgical management. South Med J. 1998;91(2):144-146. (Retrospective study; 29 patients)
49. Ernest A, Knapp G. Severe traumatic vulva hematoma in teenage girl. Clin Case Rep. 2015;3(12):975-978. (Case report)
50. Steinman E, Cunha JC, Branco PD, et al. [Traumatic rectal injuries]. Arq Gastroenterol. 1990;27(3):120-125. (Retrospective study; 45 patients)
51. Hashish AA. Perineal trauma in children: a standardized management approach. Ann Pediatr Surg. 2011;7:55-60. (Prospective study; 34 patients)
52. Mittal S, Pittalwala R. Transverse vaginal septum causing hematocolpos: an uncommon condition mimicking a UTI. Consultant 360. 2015;14(9):422-424. (Case report)
53. Kunishima K, Takao H, Kato N, et al. Transarterial embolization of a nonpuerperal traumatic vulvar hematoma. Radiat Med. 2008;26(3):168-170. (Case report)
54. Scott SM, Schlaff W. Hematocolpos associated with a remote history of chronic vaginitis and a diagnostic vaginal biopsy: a case report. J Pediatr Adolesc Gynecol. 2004;17(5):347-349. (Case report)
55. Okeke T, Anyaehie U, Ezenyeaku C. An overview of female genital mutilation in Nigeria. Ann Med Health Sci Res. 2012;2(1):70-73. (Review article)
56. Leslie JA, Cain MP. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006;53(3):513-527. (Review article)
57. Dickson CA, Saad S, Tesar JD. Imperforate hymen with hematocolpos. Ann Emerg Med. 1985;14(5):467-469. (Case reports; 2 cases)