Approach to the Problem
The most common cause of genital irritation and bleeding in a prepubertal girl beyond the neonatal period is vulvovaginitis, and hygiene-related problems are often implicated. Other causes of postneonatal genital bleeding include genital warts, trauma, vaginal foreign body, hemangioma, tumors, and urethral prolapse. Dermatologic conditions—psoriasis; lichen sclerosis; impetigo; and seborrheic, contact, and atopic dermatitis—commonly cause rashes, pain, itching, bleeding, and fissures in the anogenital area. The distribution of the individual lesions is important for differentiating a generalized dermatitis from localized infections, trauma, and congenital lesions. The differential diagnosis of perineal sores and lesions includes child sexual abuse, which must be addressed by an experienced clinician.
Key Points in the History
• When approaching child sexual abuse, most of the medical history, review of systems, and context and content of the child’s disclosure can be obtained from adults who accompany the child without the child present. The child should be interviewed without the caretakers’ presence, if necessary for medical management. Questioning should be nonleading, open-ended, and carefully documented.
• The key to diagnosis of sexual abuse is the clear history of sexual contact provided by the child, whereas the diagnosis of straddle injury is supported by a clear history of blunt genital impact particularly during a fall onto an object.
• Midline fusion defects and hemangiomas should be recognized within the first few months of life if not detected at birth.
• The history of painful oral plus genital lesions suggests herpes simplex virus infection or Behçet syndrome.
• The history of dermatologic or allergic conditions involving other body sites should be considered because the anogenital rash, itching, pain, bleeding, or lesions may be the result of the same generalized condition.
• A history of maternal, congenital, or acquired syphilis with inadequate treatment precedes the condyloma lata of secondary syphilis.
• Genital itching typically accompanies candidal dermatitis and/or vaginitis, lichen sclerosis, and genital warts.
• Pain typically accompanies trauma (which may result from rubbing or itching), lesions from viral infections (caused by herpes, varicella, Epstein–Barr, coxsackie, or influenza), and Behçet syndrome.
Key Points in the Physical Examination
• The evaluation of a child who presents with a chief complaint of sexual abuse is often done best at a local or regional sexual abuse center. Clinicians should explain the examination in advance to the child who should be reassured that examination of the genital area by a physician is all right and that it will not be painful. A gentle, deliberate manner is appropriate, and physical force should not be used.
• The most common physical findings in cases of sexual abuse are normal or nonspecific anogenital examinations. When sexual abuse injuries are found, they are typically near the posterior midline within the vaginal vestibule and involve the hymen.
• Injuries from straddle trauma are typically unilateral or asymmetrical and anterior or anterolateral in location.
• Lesions associated with bleeding include acute straddle or sexual abuse injuries, hemangiomas, lichen sclerosis, and genital warts. Unlike most of the other lesions, hemangiomas and failure of midline fusion should be completely unchanged when reexamined 2 to 4 weeks later.
• Oral ulcerations with genital ulcerations suggest herpes simplex virus infection or Behçet syndrome.
• Lesions in nongenital areas may be found in some individuals with perineal hemangiomas, genital warts, or both.
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