HEMORRHAGE IN PREPUBERTY (Part three)

Differential Diagnosis

1 - Neonatal Hemorrhage

After the neonatal period, hemorrhage is classified as prepubertal. Neonatal hemorrhage is the bleeding in the first days of life. Bleeding in the first days of life is related to the transfer of maternal estrogens to the child.

2-Other Hemorrhages

Sometimes it is difficult to determine the source of hemorrhage which might be from the urinary tract or rectum (constipation, anal fissure, inflammatory bowel disease).

3 - Vulvar Lesions

They are associated with itching, excoriation, cutaneous maceration, and fissures that bleed.

-Urethral Prolapse

Occurs after an episode associated with increased abdominal pressure. The urethral mucosa protrudes through the meatus forming a round mass that often bleeds. It typically appears around the age of 5 years. Usually develops acutely, as a sensitive, symmetrical mass around the urethra and is associated with minor bleeding. In asymptomatic patients, it is treated with estrogen cream for a short time. It is also relieved by bathtub baths. In symptomatic patients with urinary retention or with a large, necrotic mass, exploration is performed and a urinary catheter is placed for 24 hours or more depending on the condition. In cases of infection, broad-spectrum antibiotic therapy is also administered.

-Condyloma

It is an infection caused by the human papillomavirus (HPV). It is transmitted by perineal contact, close physical contact, sexual abuse. We also have vertical transmission, due to the fetal aspiration of the upper respiratory tract of maternal infected secretions leading to laryngeal lesions. It appears as red and fragile warts. Lesions are found on the mucous membranes of the urethra, urinary bladder, mouth, eyes, vulva, vagina. Clinically, they present with vaginal bleeding, rectal bleeding, dysuria, vaginal discharge, painful defecation. Until the age of 2-3 years, the infection is perinatally acquired from the mother. After this age, sexual abuse is more suspected. Therapy is individualized. It is treated with a diluted solution of 5-25% podophyllin resin. Other treatment alternatives include local 5-fluorouracil cream, cryotherapy, electrosurgical necrotization, and carbon laser.

Lichen Sclerosus

It is a cutaneous pathology, which has a hereditary character and is associated with autoimmune diseases. This pathology leads to vulvovaginitis and vaginal hemorrhage. Lesions are small and located on the vulva or perineum. Often a secondary infection may superimpose. Treatment is with local steroids.

3 - Foreign Bodies

They are associated with purulent or bloody secretions. Foreign bodies are usually suspected when secretions continue despite treatment. During rectal examination, the foreign body can be palpated in the vagina. Evaluation and removal is performed under anesthesia through vaginoscopy.

4 - Precocious Puberty

This occurs when the onset of sexual maturation is 2 standard deviations from the norm. In this case, we have the appearance of secondary sexual characteristics (breast development, growth of pubic hair) before the age of 8 years or the arrival of menarche before the age of 10 years. Precocious puberty is associated with endometrial hemorrhage. In this case, an assessment of estradiol, gonadotropins, gonadotropin-releasing hormone stimulation test, pelvic echo, pelvic and abdominal CT, head CT to exclude any lesion in the CNS. The causes that can lead to precocious puberty are numerous such as medications with estrogens, functional ovarian cysts, ovarian neoplasia, McCune Albright syndrome, CNS lesions producing hormones, and idiopathic precocious puberty. Treatment is based on the cause with medications or surgery.

5 - Trauma

Traumas are assessed by careful history. They can be accidental or non-accidental (included in abuse). Accidental injury usually affects the anterior and lateral zones of the vagina whereas penetration affects the fork and hymenal ring.

6 - Abuse

Classified as:

• Without signs of abuse
• Possible abuse
• Conclusive evidence of abuse

7 - Others

• Tumors (rhabdomyosarcoma or botryoid sarcoma)
• Hormonally active ovarian tumors (lead to proliferation of the endometrium and endometrial hemorrhage)
• Exogenous estrogens
• Prolonged local and high-dose use of estrogens

Treatment

Treatment will be based on the cause that led to hemorrhage. The treatment is medical or surgical depending on the cause. For skin lesions, chronic irritations, and lichen sclerosis, treatment is with local steroids. For vaginal and ovarian tumors, consultation with an oncogynecologist is done.