Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies.

STUDY
OBJECTIVE: Vaginal discharge in children is a common gynecologic complaint and may be resistant to symptomatic and/or antibiotic treatment. In recurrent or unresponsive patients, an evaluation to rule out a foreign body is traditionally recommended. The objective of this study is to review cases of vaginal discharge referred to our institution and assess outcome and diagnosis in those who required irrigation or vaginoscopy to rule out a foreign body.A retrospective chart review was performed on all premenarchal girls identified through the University of Michigan Pediatric and Adolescent Gynecology Clinic database who were seen for evaluation of vaginal discharge between June 1996 and December 2001. The records were reviewed for age, length of time of discharge, aspects of discharge, procedures done to rule out foreign bodies, and findings of such procedures.
SETTING: The study was performed in a tertiary care university hospital. PARTICIPANTS: Forty-one premenarchal girls were evaluated for vaginal discharge. The average age was 6.0 yr (range 3 months-11 yr).
RESULTS: The average duration of vaginal discharge prior to presentation was 13.7 months (range 1-42 months). Of the 41 girls, 18 girls underwent 1 procedure each, 2 girls underwent 2 procedures each, and 1 girl underwent 5 procedures. Ten vaginal irrigations in clinic were performed in 7 girls, 3 by the referring physician and 7 by us. These irrigations removed a foreign body (tissue paper) in 4 of 10 (40%) cases, 3 at our institution and 1 at an outside institution. In the three irrigation cases with foreign bodies performed at our institution, the foreign body was visible on genital examination prior to the irrigation. Seventeen vaginoscopies under anesthesia were performed in 16 girls, 5 by the referring physician and 12 by us. In the girls who underwent a vaginoscopy under anesthesia a foreign body was found in 3 of 17 (17.6%). The other findings of the vaginoscopies included: biopsy-proven severe dermatitis with no infection in 1 patient, lymphatic duct chylous drainage in 1 patient, nonspecific vulvovaginitis in 11 patients, and normal exam with eventual diagnosis of malingering in 1 patient. In all cases where a foreign body was identified, the patient presented with bloody or brown discharge.
CONCLUSIONS: Foreign bodies as a cause of persistent vaginal discharge in a tertiary care referral clinic were identified in 4 of 41 girls (9.8%) and 7 of 27 procedures (25.9%). One child had recurrent foreign bodies removed during 4 of 5 procedures for discharge. In children with persistent vaginal discharge, vaginal irrigation was feasible in older children (average age 7.7 yr). However, no foreign bodies were removed by irrigation that had not already been visually identified prior to the procedure. Exam under anesthesia and vaginoscopy allowed the identification of foreign bodies, and it facilitated the diagnosis of other unusual conditions.