Genital bleeding in premenarcheal girls H.A. Ugboma and *E.W. Ugboma

Genital bleeding in premenarcheal girls
H.A. Ugboma and *E.W. Ugboma
Department of Obstetrics and Gynaecology, College of Health Sciences, University of Port Harcourt and
*Department of Radiology, University of Port Harcourt Teaching Hospital
Correspondence to: Dr. H.A. Ugboma (E-mail: haugboma@yahoo.co.uk)
Abstract
Background: Premenarcheal vaginal bleeding is
not a common complaint.
This study was
undertaken to outline the major causes in our
environment.
Method: A retrospective study of 68 cases
managed in the University of Port Harcourt
Teaching Hospital(UPTH) over a 20-year period
was studied. Simple percentages were used to
analyse the results.
Results: Sixty-eight cases of premenarcheal
vaginal bleeding out of a total of 9,876
gynaecological admissions between January 1985
and December 2005 in UPTH were reviewed. The
major causes were urethral prolapse in 34 girls
(50%), straddle injuries in 11(16.2%), foreign bodies
10 in (14.7%), rape/sexual abuse 9 (13.2%), female
genital mutilation 3 (4.4%), unknown in 1 (1.5%).
In some cases, presentation in the clinic occurred
days to weeks after onset of symptoms.The ages
ranged between 0 and 8 years. Associated presenting
complaints were mass protruding from the vagina,
pelvic pain, dysuria, foul smelling discharge and
fever. Laboratory investigations, examination under
anaesthesia, abdominal and pelvic ultrasound scans
aided the management. Treatment options were
individualized to the causes. They were satisfactory
except in one case lost to follow-up.Two of the girls
had blood transfusion.There was no mortality in
this series.
Conclusion: Good care of young girls, early
presentation to hospital and competent treatment
of presenting cases give satisfactory outcome.
Key words: Premenarcheal vaginal bleeding,
Causes, Port Harcourt
Introduction
Patients and Method
Reports of premenarcheal vaginal bleeding are
scanty1. Genital bleeding is a great source of
parental anxiety2. The childs vulnerability and
inability to express herself compounds the parents
apprehension2. Fishman and Paldi, in their series,
indicated the variable aetiologies of vulvovaginitis
as the commonest causes of vaginal prepubertal
1
bleeding . Most of the cases are not serious.
Precocious puberty, and rare benign and malignant
tumours of the genital tract are all possible though
1
rare causes . The recurrent presentation of vaginal
bleeding in young girls in the University of Port
Harcourt Teaching Hospital(UPTH) has made it
necessary to accumulate data and focus on it
particularly. The aim of this study therefore is to
identify the causes of premenarcheal genital
bleeding as seen in UPTH.
A retrospective review of 68 consecutive cases of
genital bleeding in premenarcheial girls over a 20year period (1985-2005) admitted to the
gynaecological ward of the University of Port
Harcourt Teaching Hospital (UPTH) was
undertaken.
The case files of these patients were retrieved
from the records department of the hospital after a
careful search of the gynaecological ward and
theatre records. Information extracted from the
case notes included the patient`s age, presenting
complaints, clinical findings, investigations done,
diagnosis, aetiologic factors, treatment carried out,
outcome and length of hospital stay. Data were
analysed using simple percentages.
Port Harcourt Medical Journal 2007; 1: 186-189
186
Genital bleeding in premenarcheal girls
H.A. Ugboma and E.W. Ugboma
Results
There were 9,876 gynaecological admissions in
UPTH between January 1985 and December 2005.
Of these, 68(0.7%) cases were due to
premenarcheal genital bleeding in patients aged 0-8
years (Table 1).
The major causes were urethral prolapse in 34
(50%), straddle injuries in 11(16.2%), foreign bodies
in 10 (14.7%), rape/sexual abuse in 9 (13.2%),
genital mutilation in 3 (4.4%) and unknown
1(1.5%) (Table 2). Common presenting complaints
were mass protruding from the vagina 34(50%),
pelvic pain 17(25%), dysuria 9(13.2%), foul smelling
discharge 3(4.4%) and fever 3(4.4%) (Table 3) .
None of the girls had features of precocious sexual
development.
Investigations carried out were full blood count
in 68 (100%), urine culture and sensitivity 68
(100%), high vaginal swab
in 20 (29.4%),
abdominal and pelvic ultrasound in 6(8.8%),
hormone profile assay in 1 (1.5%), electrolyte, urea
and creatinine in 68 (100%) and examination under
anaesthesia in
50 (73.5%).The haemoglobin
concentration in one of the girls was 6.4 g/dl and
5.8 g/dl in another. Urinary tract infections
commonly seen were due to Escherichia coli,
Klebsiella species and Staphylococcus species.
Similar organisms were cultured in the high vaginal
swabs including Candida albicans in some of the
specimens. Ultrasonography revealed multiple
ovarian cysts in a 2-year old girl.
Treatment given were excision of prolapsed
urethral mucosa, repairs of pelvic injuries,
extraction of vaginal foreign bodies, analgesics and
antibiotic cover. Two of the girls with low
haemoglobin concentration which resulted from
haemorrhage required blood transfusion.
Table 1. Age distribution at presentation
Age (year)
0 -2
2-5
5-8
Total
Number
10
36
22
68
Percentage
1 4.7
52.9
32.4
100
Port Harcourt Medical Journal 2007; 1: 186-189
Table 2. Major causes of premenarcheal
genital bleeding
Causes
Urethral prolapse
Straddle injuries
Foreign Bodies
Rape/Sex abuse
Genital mutilation
Unknown
Number
34
11
10
9
3
1
Percentage
50
16.2
14.7
13.2
4.4
1.5
Table 3. Common presenting symptoms
Symptoms
Genital bleeding
Mass protruding
from vagina
Number
68
Percentage
100
34
50
Pelvic pain
Dysuria
Foul smelling
discharge
17
9
25
13.2
3
Fever
3
4.4
4.4
Discussion
Although genital bleeding is not common1, a report
has indicated otherwise2. This may result from
under- reporting due to out -patient treatment2, ,
3
stigmatization or as a result of others seeking care
4
from traditional healers . Its occurrence is a source
of concern to parents. These girls require detailed
evaluation.
The commonest occurrence of genital bleeding
occurred in the 2-5 years age group (52.9%). This is
the age of adventure and curiosity. The girls are in
school, are active and when left without minders are
prone to sexual abuse, genital infections and
5,11
insertion of vaginal foreign bodies .
Urethral prolapse was the commonest cause of
genital bleeding (50%) in our study. This is not in
line with reports from other centres, where
vulvovaginities was the commonest1,5. It is possible
that some of the urethral prolapse in our study were
late presentations of previous genital infections.
187
Genital bleeding in premenarcheal girls
These infections were detected early in some
centres1,2 and treated. The progression to urethral
prolapse is therefore reduced. The cause of
urethral prolapse is generally unknown6, and can
occur with no known precipitating factor7.
However, some have been attributed to genital
infections of the urethral mucosa8 and others to
congenital abnormalitiesof the urethra9. A bleeding
prolapsed mass in the external genitalia usually
causes enough anxiety to the parents who will
quickly seek specialist attention8,9.
Straddle injuries accounted for the second
commonest cause (16.2%) and resulted from fall
from height while climbing, riding bicycles and at
plays with peers10. One of these girls needed blood
transfusion having lost much blood from a
penetrating injury to the vagina.
Vaginal foreign bodies have in some cases been
associated with sexual abuse11. These girls were
evaluated for such and two of the girls with foreign
bodies in the vagina gave information of sexual
abuse by their male neighbours who used their
fingers to break the hymen in each patient, causing
bleeding sometimes. Tissue papers found in them
were used probably to stop vaginal bleeding as a
result of the sexual abuse. Other foreign bodies
found were stones and leaves. These may have been
inserted by the girls themselves. Vaginal foreign
bodies are usually associated with vaginal discharge,
11
infections, pelvic pain and fever .
Though rape accounted for 13.2% and was the
3
fourth in our series, it may be commoner than this .
The under- reporting may be as a result of the
stigma attached to it. Other factors may be due to
the lengthy court sessions with very embarrasing
questions which the victims may be required to
answer. The fear of contracting the human
immunodeficiency virus (HIV), itself a highly
3
stigmatized disease , may further keep the family
from seeking justice.These inhibiting factors may
have emboldened rapists to thrive in this criminal
act.
Genital bleeding caused by genital mutilation
accounted for 3(4.4%). It was so severe in one case
that blood transfusion was needed.This practice has
many other complications such as
genital
Port Harcourt Medical Journal 2007; 1: 186-189
H.A. Ugboma and E.W. Ugboma
infections, dyspareunia, haemorrhage, tetanus,
infertility, vesico-vaginal fistula and death4,12-14.
The cause of genital bleeding in a 2 - year old
girl was not diagnosed.
Examination under
anaesthesia did not reveal any significant finding.
Hormone studies were requested but the child was
lost to follow-up.
However, ultrasonography
revealed multiple ovarian cysts. Some series have
revealed that genital bleeding can be caused by
15,16
hypothyroidism and multiple ovarian cysts .
Treatments in our series were individualized.
All cases of urethral prolapse benefitted from
excision of protruding urethral mass. Repairs of
injuries to the pelvic region, extraction of foreign
bodies in the vagina, antibiotic cover and pain relief
were some of the treatments given.
The clinician should be sensitive to parental
anxiety and especially to the unspoken concern of
possible sexual molestation2. A careful medical
evaluation and investigation with attendant
sociologic and psychologic support are needed in
the management of these children. Parental
counselling and education in child care would
prevent or limit some of these avoidable causes like
12
female genital mutilation . Prompt recourse to
good health care will limit morbidity and blood
transfusion. Enabling legislation will enhance
efforts to protect the girl child from avoidable
conditions as have been advocated by others for
4,12
harmful traditional practices .
References
1 Fishman A, Paldi E. Vaginal bleeding in
premenarchal girls: a review. Obstet Gynecol
Surv 1991; 46: 457-460.
2 Hill NC, Oppenheimer LW, Morton KE. The
aetiology of vaginal bleeding in children. A 20year review. Br J Obstet Gynaecol 1989; 96: 467470.
3 Ekine S. Blood and oil. London: Center for
Democracy and Development, 2001: 57-65.
4 Ugboma HA, Akani CI, Babatunde S.
Prevalence and medicalization of female genital
mutilation. Niger J Med 2004; 13: 250-253.
188
Genital bleeding in premenarcheal girls
5 Baiulescu M, Hannon PR, Marcinak JF, Janda
W M , S ch r e cke n b e r g e r P C. C h r o n i c
vulvovaginitis caused by antibiotic resistant
Shigella flexneri in a prepubertal child. Pediatr
Infect Dis J 2002; 21: 170-172.
6 Eke N, Ugboma HA, Eke F. Urethral prolapse in
a woman in her reproductive age a very rare
occurrence. Niger J Med 2005; 14: 431-433.
7 Akani CI, Pepple DK, Ugboma HA. Urethral
prolapse: a retrospective analysis of
hospitalized cases in Port Harcourt. Niger J Med
2005; 14: 396-399.
8 Lowe FC, Hill GS, Jeffs RD, Brendler CB.
Urethral prolapse in children: insights into
etiology and management. J Urol 1986; 135: 100103.
9 Fernandes ET, Dekermacher S, Sabadin MA,
Vaz F. Urethral prolapse in children. Urology
1993; 41: 240- 242.
10 Greaney H, Ryan J. Straddle injuries-is current
practice safe? Eur J Emerg Med 1998; 5: 421424.
Port Harcourt Medical Journal 2007; 1: 186-189
H.A. Ugboma and E.W. Ugboma
11 Herman Giddens ME. Vaginal foreign bodies
and child sexual abuse. Arch Pediatr Adolesc Med
1994 ; 148: 195-200.
12 Eke N, Nkanginieme KE. Female genital
mutilation: A global bug that should not cross
the millennium bridge. World J Surg 1999;
23: 1082-1087.
13 Esiet N.O. Female genital mutilation is a
violation of girls rights. Growing up 1997; 10 : 23.
14 Njelesani E. Elimination of female genital
mutilation. WHO News letter 1997; 12: 8.
15 Takeuchi K, Deguchi M, Takeshima Y, Maruo T.
A case of multiple ovarian cysts in a prepubertal
girl with severe hypothyroidism due to auto
immune thyroiditis. Int J Gynecol Cancer
2004; 14: 543-545.
16 Gordon CM, Austin DJ, Radovick S, Laufer
MR. Primary hypothyroidism presenting as
severe vaginal bleeding in a prepubertal girl. J
Pediatr Adolesc Gynecol 1997; 10: 35- 38.
189