Vaginal bleeding and intralabial masses - Pediatric Surgery

Vaginal bleeding and intralabial masses - Pediatric Surgery Vaginal Bleeding and Intralabial (Introital) Masses . Urethral Prolapse . click the images for more details   Incidence. A prolapse of the urethra is probably a relatively frequent cause of apparent vaginal bleeding during childhood and occurs in 50 percent in children, and thereafter, mainly beyond menopause. Toddlers, schoolchildren of up to 10 years of age, and girls of African ethnicity are particularly involved.  Clinical significance. 1. A urethral prolapse belongs to the relatively frequent causes of an abnormal vaginal bleeding in children. 2. A urethral prolapse is one of the causes of the leading symptom 'intralabial mass'. 3. Early diagnosis (made on the occasion of a routine examination) possibly makes surgery unnecessary.  Etiology.  Unknown. Increased intraabdominal pressure due to coughing, crying or squeezing are discussed as causes of prolapse, e. g. in constipation.  Pathology, anatomical types.  There is a prolapse of the mucous membrane of the distal urethra which is strangulated at the level of its introitus.  Pathophysiology  Following strangulation, a venous backflow occurs, followed by ischemia and infarction of the prolapsed mucosa.   Clinical presentation (history, findings, clinical skills).Illustrations History: The leading signs are blood-stained spots on the napkin or panties, or an observed vaginal bleeding and/or an intralabial mass. The former sign most frequently worries the parents. Dysuria and frequency of micturition are observed in one quarter of the children. Clinical findings and skills: The inspection of the vulva is performed by pulling the labia majora to the side and backwards. There is an annular mass 1 to 2 centimeters in diameter in front of the introitus with dark-red color in an advanced stage, painful and bleeding on touching. In case of gross swelling it may be impossible to see the central dimple corresponding to the meatus. The diagnosis may be confirmed by a catheterism of the bladder via the central dimple. show details Natural history   See pathophysiology.   Differential diagnosis.Illustrations In contrast to the supposed vaginal bleeding, an intralabial mass is often not recognized by the mother. In the differential diagnosis a hematuria or a lower intestinal bleeding must be excluded. In girls physiological and pathological vaginal bleedings can be observed: The former comprise neonatal bleeding due to stimulation of the endometrium by circulating maternal estrogen prior to birth, which is interrupted postnatally; it occurs in 3 % as visible and in 1/3 as microscopic bleeding in the vaginal discharge. In addition, vaginal bleeding as menarche between 8 and 16 years of age (mean age 12 years) and menstruations. The latter comprise malformations, precocious puberty ( included bleedings due to the application of estrogens), trauma, incidental injury, foreign bodies, infections and tumors, and finally, specific causes of bleedings beyond the menarche (dysfunctional uterine bleeding, pregnancy, birth control measures, and in hemorrhagic diathesis). The differential diagnosis of an intralabial (introital) mass must also be details Work-up examinations.  Depending on the history and local findings a rectal and a rectoabdominal palpation must be performed. The same applies to the additional examinations which include blood and urine analysis, vaginal specimen for cultures, abdominal ultrasound, pelvic x-ray, cystocolposcopy, and biopsy under general anesthesia.   Therapy.  Most children who are referred with a urethral prolapse need surgery. It includes a resection of the prolapsed mucous membrane and a suture of the edges, and is performed under general anesthesia. In early diagnosis non-operative management with baths and treatment of cough or constipation may be performed.   Prognosis.  Permanent cure in children.