Review Question - QID 104542

This 7-year-old girl who presents with bloody, foul-smelling vaginal discharge has a foreign body present in the vagina. The best initial management is warm fluid irrigation in an attempt to expel the foreign body; if this fails, an examination under general anesthesia should be pursued.

Vulvovaginitis is the most common gynecologic complaint among pre-pubertal females. Presenting symptoms include vaginal discharge, mucosal erythema, pruritis, and erythema. It often resolves with simple hygiene measures but may require antibiotics, estrogen therapy, or local corticosteroids depending on the etiology (infection, labial adhesions/urethral prolapse, or lichen sclerosus respectively). When symptoms persist despite treatment or the discharge is blood-stained, then the possibility of a foreign body should be explored. Often foreign bodies are inserted in the vagina by the child herself, but one should be vigilant for signs of abuse.

McGreal et al. review the causes of recurrent vaginal discharge in children, examining a cohort of 110 patients. The patients had a bimodal distribution centered around 4 and 8 years. The most common cause of the discharge was vulvovaginitis (82%), with sexual abuse (5%), foreign body (3%), labial adhesions (3%), and vaginal agenesis (2%) being less common. In this cohort, 35% of patients underwent exam under anesthesia with vaginoscopy; 29% of patients received simple hygiene advice and required no further intervention.

Stricker et al. review the clinical outcomes of 35 girls diagnosed with an intravaginal foreign body. The most common presenting complaints were blood-stained or foul-smelling discharge and vaginal bleeding (49%). The duration of symptoms ranged from 1 day to 2 years, and only 54% of patients recalled insertion of the foreign object. Symptoms uniformly resolved with removal of the foreign object followed by one-time vaginal flushing.

Figure A is a radiograph that reveals an intravaginal foreign body, a plastic cap of an eyebrow pencil. Illustration A shows classic physical exam findings associated with lichen sclerosus. Notice the "hourglass" shape, as the disease is usually relatively symmetric around the vaginal introitus.

Incorrect Answers:
Answer 2: Given the presence of blood-stained discharge and definitive radiograph, broadening antibiotic coverage would not be beneficial if the foreign body is not removed.

Answer 3: Examination under general anesthesia is an appropriate answer after attempts have been made to expel the foreign body using warm flushes.

Answer 4: Watchful waiting is inappropriate, as simple removal will provide definitive treatment.

Answer 5: Corticosteroids would be appropriate for treating lichen sclerosus, which can present with vaginal discharge and bleeding; itchiness and discomfort are usually prominent complaints. In contrast to this patient, the physical exam for lichen sclerosus usually shows thin, white, wrinkled skin, possibly with excoriations and mild bruising.