A 7-year-old girl is brought to the emergency department for evaluation of vaginal discharge. She has had malodorous vaginal discharge for about a week and a small amount of vaginal bleeding for the past day. The patient's mother called the primary care clinic on the first day of symptoms and was advised to come in if the symptoms persisted. Aside from the discharge, the girl is acting normally. The patient was toilet trained at age 2 and has had no episodes of incontinence. She started second grade a month ago. The mother says that she has no fever, abdominal pain, or dysuria. On examination, the girl is well appearing, interactive, and cooperative. The labia appear normal. Purulent, malodorous vaginal discharge is noted. Visual inspection with the child in knee-chest position shows a friable, white foreign body just beyond the vaginal introitus. The examination is otherwise unremarkable. Which of the following is the best next step in management of this patient?
Vaginal foreign bodies in children | |
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Vaginal foreign bodies are a common cause of vulvovaginitis in prepubertal girls. The most common vaginal foreign body is retained toilet paper (ie, friable, white object), although other objects (eg, small toys, hair bands) that a child may place in the vagina can be found. Chronic irritation from the foreign body on the vaginal tissue can result in malodorous/purulent vaginal discharge and intermittent vaginal bleeding (eg, spotting).
When a vaginal foreign body is suspected, an external pelvic examination is performed with the patient in a knee-chest or frog-leg position. Management depends on the ability to visualize the object, type of foreign body, and patient comfort.
In the case of a small, easily visualized foreign body (eg, toilet paper) in a cooperative child, an attempt at removal (after application of topical anesthetic in the vaginal introitus) can be made using vaginal irrigation with warm fluid or a swab.
In the case of a suspected foreign body that cannot be visualized or one that is large or associated with severe complications (eg, button battery causing burns), anesthesia is indicated for examination (eg, vaginoscopy [small-diameter endoscopy]) and foreign body removal. Patient anxiety, lack of cooperation, or very young age (generally age <5) may also prohibit adequate clinical evaluation, warranting examination under anesthesia.
(Choice B) Child protective services should be contacted when child abuse or neglect is suspected, and a vaginal foreign body can be the initial presentation of sexual abuse. However, the presence of what is likely toilet paper does not immediately raise concern for abuse, particularly in an otherwise asymptomatic patient (eg, no behavior changes, no signs of vulvar trauma) whose mother sought medical care on the first day of symptom onset.
(Choice C) CT scan of the abdomen and pelvis can be used to evaluate pelvic or ovarian masses; it is not indicated in evaluation of an easily visualized vaginal foreign body.
(Choice D) Speculum examination should not be performed in a prepubertal girl. It can result in significant discomfort and trauma due to the narrow vaginal introitus and sensitive hymenal tissue from a low estrogen level at this age. Even when under anesthesia, prepubertal girls should be evaluated with vaginoscopy, not speculum examination.
Educational objective:
Prepubertal girls with vaginal foreign bodies typically have malodorous vaginal discharge and vaginal spotting, commonly secondary to retained toilet paper. Management includes topical anesthetic application and removal with a swab or by vaginal irrigation with warmed fluid. Examination under anesthesia may be required.