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The Urinary Tract

You are seeing a 4-year-old girl for a routine checkup with the physical examination finding shown in the photograph. She has no significant past history. Which of the following is the most appropriate next step in managing this child?


(Courtesy of Michael L. Ritchey, MD.)

a. Order surgical consultation for correction

b. Apply topical estrogen cream daily for a week

c. Apply topical hydrocortisone cream for a week

d. Refer to social services for possible sexual abuse

e. Order karyotype studies

The answer is b. (Kliegman et al, pp 1865-1869.) The patient pictured has female genitalia but labial adhesions (also called labial agglutination), a usually benign condition in which the labia minora are fused. Fusion ranges from a small area to the entire area between the clitoris and the fourchette. It is most common in young girls who are in the low estrogen state of preadolescence. Sometimes urine pooling can cause an increased risk of UTI. Treatment for asymptomatic girls can be merely observation, as the condition should resolve with the estrogenization that occurs with puberty. Nightly application of an estrogen cream for 4-6 weeks resolves this condition in the majority of patients. However, as recurrence is common, patients must be instructed to maintain good hygiene practice, and to apply daily petrolatum to the inner labia for several months after separation. Estrogen cream therapy should be discontinued if breast buds develop.

At the 2-week checkup of a term female neonate, the mother reports a grayish and sometimes bloody vaginal discharge since birth. The neonate's mother and grandmother are the only caretakers. Examination of the external genitalia reveals an intact hymen with a thin grayish mucous discharge. Which of the following is the most appropriate next step?

a. Parental reassurance

b. MRI of the brain

c. Ultrasound of the abdomen

d. Gonorrhea and chlamydial swabs

e. Referral to social services for possible sexual abuse

The answer is a. (Hay et al, p 15. Kliegman et al, pp 1865-1869. McMillan et al, p 197. Rudolph et al, p 179). This patient has a physiologic discharge related to estrogen withdrawal. Examination can exclude vaginal trauma, and the history makes sexual abuse unlikely. Imaging is not indicated at this point. Parents should be reassured that it will resolve in a few weeks.

A 25-year-old ...

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