Genital bleeding

Abstract

A 5-year-old girl of Ghanaian origin presented to the accident and emergency department with genital bleeding of sudden onset in the previous 12 h. A diagnosis of urethral prolapse was made. The congestion and bleeding settled with a daily sitz bath and topical oestrogen cream for 4 weeks, while the prolapse was referred to urologists.

Background

It is important to recognise urethral prolapse early in order to prevent unnecessary investigations and referrals to different specialities.

Case presentation

A 5-year-old girl of Ghanaian origin presented to the accident and emergency department with genital bleeding of sudden onset in the previous 12 h. There was no history of trauma. Systemic examination revealed a prepubertal girl and was otherwise unremarkable. Genital examination revealed a purplish red doughnut-shaped mucosal mass filling the vulva (figure 1). The tissue was congested and friable. Catheterisation of the bladder through the orifice of the mass drained clear urine which was culture negative. Full blood count, urea and electrolytes, and coagulation screen were normal. Ultrasound of the renal tract was normal. A diagnosis of urethral prolapse was made. The girl was treated with a daily sitz bath and topical oestrogen cream for 4 weeks. The congestion and bleeding settled promptly. The mucosal prolapse persisted and was referred to urologists.

Figure 1.

Genital prolapse with friable mucosa

Investigations

• ▶Full blood count, urea and electrolytes, and coagulation screen were normal
• ▶Urine culture showed no growth
• ▶Ultrasound scan of kidney, ureter and bladder was normal.

Differential diagnosis

• ▶Sexual abuse.

Treatment

• ▶Medical – topical oestrogen, sitz bath
• ▶Surgical – surgical repair.

Outcome and follow-up

The child's bleeding subsided after oestrogen treatment, but the prolapse persisted and the patient was referred to urologists for further management.

Discussion

Venugopal et al have published a case series of 27 cases, which showed that medical management was effective in only about a third of cases.¹ Owens et al published a case series in 1968 wherein most children required surgical correction.² Few cases have been published on this topic in the UK.

Learning points.

• ▶This case is a classical presentation of urethral prolapse.
• ▶Urethral prolapse is an important cause of genital bleeding in children and can be misdiagnosed as sexual abuse.
• ▶It is important to recognise urethral prolapse promptly so that unnecessary investigations and referrals can be avoided.