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The Urinary Tract

You are seeing a 5-year-old girl for a routine checkup. The mother reports the child to be in good health overall, but does report that she has a 4-day history of foul-smelling, purulent vaginal discharge. She has no significant medical history. She lives with her parents and does not attend day care. On physical examination she has normal vital signs and no remarkable findings other than a foul-smelling, purulent vaginal discharge. Hymen is intact, and neither vaginal nor rectal trauma is noted. Which of the following is the most appropriate next step in managing this child?

a. Refer to pediatric surgery for examination under anesthesia.

b. Place patient in knee-chest position and examine vagina with nasal speculum.

c. Apply topical hydrocortisone cream for a week.

d. Refer to social services for possible sexual abuse.

e. Apply topical estrogen cream daily for 6 weeks.

The answer is b. (Kliegman et al, pp 2607-2613.) The patient very well may have a vaginal foreign body. The offending object may have been intentionally placed by the child, who did not tell her parents, or may be something such as a wad of toilet paper in a child who is undergoing toilet training. The first step in identification of the problem is a visual inspection. An attempt at placing the cooperative child in a knee-chest position and visualization with a nasal speculum may identify the offending object. If an object is identified and is unable to be removed, or if no object is identified and suspicion for foreign body remains high, an examination under anesthesia is the next most appropriate step. Child sexual abuse must always be on the differential; without vaginal or rectal findings referral to social services as the first step would be premature. Labial adhesion (also called labial agglutination) is a usually benign condition in which the labia minora are fused. Treatment for asymptomatic girls can be merely observation, as the condition often resolves with the estrogenization that occurs with puberty. Alternatively, nightly application of an estrogen cream with or without betamethasone for 6 weeks resolves this condition in the majority of patients.

At the 2-week checkup of a term female neonate, the mother reports a grayish and occasionally blood-tinged 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 with attention to the pituitary gland

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