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After studying Module 7: Lecture Materials & Resources, discuss the following:
A 6-year-old has a yellow vaginal discharge. The examination is otherwise normal.
What are key points in the history and physical examination?
How would you approach differ if the patient were a sexually active 16-year-old?
What are similarities and differences in the approach?
A 6-year-old presenting with a yellow vaginal discharge requires a systematic, age-appropriate approach that differs significantly from the evaluation of a sexually active adolescent, primarily due to the different spectrum of potential causes and the need to investigate possible abuse or foreign bodies in the younger child.
The primary goal of the history and physical examination (H&P) for a prepubertal child with vaginal discharge is to rule out trauma, foreign body insertion, or specific, often non-sexual, infections.
Foreign Body: This is the most common cause of persistent, foul-smelling discharge in this age group. Key questions include:
Has the child ever inserted anything into the vagina (e.g., small toy, tissue paper)?
Has there been a recent history of vulvar discomfort or pain?
Hygiene: Assess for poor hygiene habits, which can lead to non-specific vulvovaginitis (the most common diagnosis).
Does the child wipe from front-to-back?
Does she take frequent bubble baths or use scented soaps/detergents?
Does she wear tight-fitting clothing or synthetic underwear?
Infections: Inquire about signs of pinworms (Enterobius vermicularis), which can migrate from the anus and cause irritation and discharge.
Possible Abuse: Although many cases are innocent, sexual abuse must be considered. Inquire discreetly about any new bedwetting, fear of a specific person, or unexplained injuries.
General: Note the Tanner stage to confirm the prepubertal status (absence of estrogenized tissue).
External Genitalia (Inspection): Perform a careful inspection of the external genitalia (vulva and perineum) for:
Erythema (redness), excoriations (scratches), or signs of irritation.
Discharge characteristics (color, consistency, odor).
Signs of Pinworms: Inspecting the perianal area, especially at night.
Vaginal Examination (Limited): A speculum examination is not typically performed unless necessary to remove a foreign body or if abuse is strongly suspected, and often requires sedation or general anesthesia. The goal is a perineal inspection or, if necessary, a brief external visualization using a small cotton swab.
Other Sites: Check for signs of skin conditions that can cause irritation, like eczema or dermatitis.