(12) Acute Genital Bleeding in a 6-Month-Old

Background: Vaginal bleeding (VB) in an infant occurring outside the window of maternal estrogen exposure is considered pathologic in nature and requires thorough evaluation, including assessment for non-accidental trauma. The most important diagnostic element in assessing if sexual abuse has occurred is a history provided by the patient. When it is not possible to elicit this history, as is the case in infancy, it is of critical importance to conduct a comprehensive exam.

Case: LW is a 6-month-old female who presented to an outside facility with acute VB. On initial evaluation, she was hemodynamically (HD) stable, without active bleeding. Her Hgb was 8g/dL. A pelvic ultrasound showed a prepubertal uterus and hematocolpos. A vaginal lavage was performed and the patient was discharged home with a presumed diagnosis of urethral prolapse for which she was prescribed estradiol cream. She represented to the outside hospital two days later with another episode of VB. Her Hgb was 6.2g/dL at presentation, 5.5g/dL on repeat. Her physical exam was remarkable for extensive ecchymoses over her face and head. She was subsequently transferred to our facility for further management.

On arrival to our hospital, the patient was HD stable. Her genitourinary exam (Figure 1) was notable for a normal appearing urethra and crescentic hymen without apparent laceration. She continued to have low volume VB. Given concern for non-accidental trauma, she was taken to the operating room for exam under anesthesia (EUA) and vaginoscopy. On vaginoscopy, the cervix appeared normal. There was an approximately 1cm x 1cm colpotomy in the right posterior fornix (Figure 2). There was no active bleeding from this site; however, it was presumed this was the source of VB. Cystoscopy was also performed with no evidence of bladder injury. Given her clinical course, the decision was made to defer diagnostic laparoscopy and allow for the colpotomy to heal by secondary intention. The remainder of the patient’s hospital course was uncomplicated and she was discharged home on POD#3.

One month later, the patient was taken to the O.R. for EUA and vaginoscopy. On vaginoscopy the colpotomy had healed.

Comments: While most sexually abused children will not have signs of genital injury, patients presenting with genital trauma typically have external injuries. It is rare for a vaginal injury to occur in the absence of hymenal injury. This case illustrates the need for improved education regarding the differential diagnosis of VB in the infant and the importance of a thorough examination. Providers should have a low threshold to proceed with an exam under anesthesia and vaginoscopy in the setting of otherwise unexplained large volume VB.