Q1 :
A 7-year-old girl is brought to your clinic with complaints of vaginal bleeding for 2 days. The child is appropriately grown, with height and weight in the 50th percentile. She has had no chronic diseases, is taking no medications, has no skin conditions, and is using no topical creams. She denies any trauma or sexual abuse. She has felt well and has had no respiratory or gastrointestinal symptoms, although two family members recently had diarrhea. The mother’s menarche was at age 12 years. On physical examination, the well-appearing girl has no breast or pubic hair development or skin lesions. Perineal inspection reveals only a small amount of vaginal discharge that is blood-tinged, with otherwise normal findings for a prepubertal girl.
Of the following, the MOST appropriate diagnostic test is
A. computed tomography scan of the brain
B. follicle-stimulating hormone/luteinizing hormone measurement
C. karyotype
D. pelvic examination under anesthesia
E. vaginal culture for Shigella
Answer :
E
The assessment of abnormal vaginal bleeding in a child first requires determination of the patient’s Sexual Maturity Rating (SMR).
The girl described in the vignette has prepubertal secondary sexual characteristics (SMR 1), is normally grown for age, and has normal findings on physical examination, including perineal inspection, except for vaginal discharge. This suggests that an endocrine, central nervous system, or chromosomal cause is unlikely.
An examination under anesthesia is reserved for patients who have active bleeding, if there are concerns for vaginal trauma, or for patients who are unresponsive to conservative management.
Shigella culture is appropriate for this girl because Shigella vaginitis is one of the most common causes of prepubertal vaginal bleeding.
Prepubertal causes of vaginal bleeding can be categorized as :
- Traumatic.
- Foreign body-related.
- Anatomic
- Urethral prolapse
- Labial adhesions
- Anatomic
- Urethral prolapse
- Labial adhesions
- Infectious.
- Respiratory pathogens
- Enteric pathogens
- Respiratory pathogens
- Enteric pathogens
- Neoplastic.
- Dermatologic.
- Lichen sclerosus et atrophicus
- Friable warts
- Lichen sclerosus et atrophicus
- Friable warts
- (rarely) genetic : McCune-Albright syndrome (rare presentation)
The most common cause of benign bleeding is a foreign body, often toilet paper, in the vaginal vault. Symptoms are persistent vaginal discharge, intermittent bleeding, and foul-smelling odor. The foreign body may be seen by careful perineal inspection, particularly with the patient in the knee-chest position. The foreign body may be removed with a swab or forceps or by warm vaginal wash in a cooperative child or with the use of sedation; general anesthesia is reserved for particularly difficult cases.
Infectious vaginitis can be due to a number of respiratory and enteric pathogens.
Although group A Streptococcus is the most common cause of prepubertal bacterial vaginitis (usually without bleeding), Shigella vaginitis is a frequent cause of vaginal bleeding.
As in the case described in the vignette, either the patient or family members may have
diarrhea, but Shigella vaginitis has been found even without concomitant gastrointestinal symptoms.
-----------------------------------
Q 2 :
Answer :
E
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Q 2 :
An
otherwise healthy 7-year-old girl is brought to your office because her mother
noted a small amount of blood on the girl's panties on two separate occasions.
The girl denies abdominal pain or dysuria. There is no history of sexual abuse
or trauma. Physical findings include Sexual Maturity Rating (Tanner) stage 1
genitalia with a donut-shaped erythematous mass extruding from the urethra.
There is no vaginal discharge.
Of
the following, the MOST likely cause of vaginal bleeding in this prepubescent
girl is:
A. condyloma
acuminata
B. hemangioma
C. sarcoma
botryoides
D. ureterocele
E. urethral
prolapse
Answer :
E
There
are multiple causes of vaginal bleeding in prepubescent girls, some of which
are specific to this age group. Many causes, however, can be seen in both
preadolescent and adolescent girls and are associated with vulvovaginitis or a
vaginal discharge. In most cases, a comprehensive history and thorough external
genital examination without direct visualization of the cervix will lead to the
appropriate diagnosis.
Common
causes of vaginal bleeding in prepubescent girls include foreign bodies in the
vagina, such as small pieces of toilet paper, and some bacterial infections
(eg, group A Streptococcus and Shigella sp). Other, less common causes of
vaginal bleeding are vascular lesions such as a hemangioma, trauma from sexual
abuse, and estrogen withdrawal (eg, the child ingested the mother’s or sister’s
oral contraceptives). Straddle injuries may cause small perineal lacerations,
but rarely produce intervaginal bleeding. Urethral bleeding may be confused
with vaginal bleeding.
Findings
on the genital examination of the prepubescent girl described in the vignette
are consistent with a diagnosis of urethral prolapse .
The
donut-shaped erythematous mass is prolapsed urethral mucosa that bleeds from
local irritation.
It is seen more commonly in prepubescent African-American
girls and is self-limited. Rarely, surgical treatment is indicated, although
medical therapies often are tried initially, such as topical estrogen cream or
sitz baths.
Condyloma
acuminata (venereal warts) appear as flesh-colored, pedunculated
growths with multiple finger-like projections and are transmitted sexually.
They occur most frequently in moist areas, such as the vaginal introitus and
vagina, and bleed with minor trauma.
Hemangiomas can be seen in the vaginal
area, but they do not appear as donut-shaped erythematous masses extruding from
the urethra.
Although sarcoma botryoides can present with vaginal bleeding in a
prepubescent girl, the mass typically is described as grape-like clusters
originating from the vagina.
A ureterocele is a congenital anomaly that
includes cystic dilation of the terminal (intramural) part of the ureter and
can be seen as a mass in the urethral area. Approximately 90% are associated
with a duplex collecting system.
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Q3
-------------------------
Q3
During
the discharge examination from the newborn nursery, a term female infant is
noted to have bilateral swollen labia majora with slight hyperpigmentation and
rugae. No masses are palpated in the labioscrotal folds. The clitoris appears
normal-sized, and the vaginal opening and urethra are easily visualized.
Of
the following, the MOST likely cause for these physical findings is maternal
exposure to:
A. androgens
B. estrogens
C. marijuana
D. medroxyprogesterone
E. thyroid
hormone
Answer :
A
-----
Q 4
Answer
D
The child described in the vignette has physical findings most consistent with a nonspecific vaginitis that can be treated with sitz baths. Re-evaluation frequently is recommended both to reassure the parent and to confirm improvement. Administration of intramuscular ceftriaxone is not indicated because neither the history nor the physical examination findings are suspicious for a gonococcal infection. Oral fluconazole is not appropriate because the discharge does not appear to be from a yeast infection, and use of this drug for treatment of candidal vaginitis in this age group has not been studied. Because the discharge is not bloody or foul-smelling, it is doubtful that this patient has a vaginal foreign body.
Answer
A
Answer :
A
Prior
to 6 weeks of age, both the wolffian and müllerian duct systems are present in
the normal embryo, making male and female gonads indistinguishable. The
tendency of the fetus, however, is to develop as a female, unless a Y
chromosome is present. If present, a testes-determining factor induces
differentiation of the gonads into testes, and female genital development is
blocked. Leydig cells begin to produce testosterone, which acts on the wolffian
duct to form the male internal genitalia: vas deferens, epididymis, and seminal
vesicles. The testicles also produce an anti-müllerian hormone (AMH), also
known as müllerian-inhibiting substance, which causes regression of the
müllerian ducts. Formation of the phallus and scrotum (the external male
genitalia) requires the conversion of testosterone to dihydrotestosterone (DHT)
via 5-alpha-reductase and the presence of a specific androgen receptor. The
testes migrate into the scrotum later in gestation.
The
external genitalia of the female infant described in the vignette are
consistent with prenatal exposure to androgens or another virilizing drug.
Although the labia majora of most term female infants are swollen,
the accompanying hyperpigmentation and rugae, as described for the infant in
the vignette, are signs of masculinization. However, the normal-size clitoris
and the easily visible urethra and vaginal introitus exclude the diagnosis of
ambiguous genitalia.
Q 4
The
mother of an 8-year-old girl asks you to evaluate her daughter, who has had a
vaginal discharge for the past 2 weeks. The discharge is yellow, nonbloody, and
not foul-smelling. Both the girl and mother deny a history of sexual abuse.
Physical examination reveals Sexual Maturity Rating (Tanner) stage 1 genitalia;
normal crescentic hymen; and mild erythema of the labia majora, minora, and
perihymenal area. There is a small amount of opaque white discharge at the
introitus.
Of
the following, the most appropriate NEXT step in the evaluation of this
preadolescent girl is:
A. a
report to children’s services for sexual abuse
B. administration
of intramuscular ceftriaxone
C. administration
of oral fluconazole
D. sitz
baths and re-evaluation
E. vaginal
irrigation for a foreign body
Answer
D
The child described in the vignette has physical findings most consistent with a nonspecific vaginitis that can be treated with sitz baths. Re-evaluation frequently is recommended both to reassure the parent and to confirm improvement. Administration of intramuscular ceftriaxone is not indicated because neither the history nor the physical examination findings are suspicious for a gonococcal infection. Oral fluconazole is not appropriate because the discharge does not appear to be from a yeast infection, and use of this drug for treatment of candidal vaginitis in this age group has not been studied. Because the discharge is not bloody or foul-smelling, it is doubtful that this patient has a vaginal foreign body.
The
differential diagnosis of vaginal discharge in a prepubertal girl must include
vulvovaginitis. Vulvovaginitis signifies inflammation in the perineal area and
often is accompanied by a vaginal discharge.
In
the majority of cases, the most common etiology for vulvovaginitis in a
preadolescent girl is nonspecific inflammation caused by normal vaginal flora.
Poor hygiene and wiping back to front after urination or defecation may
contribute to the development of this nonspecific infection. Other, more
specific bacterial causes include both respiratory and enteric organisms, such
as group A beta-hemolytic Streptococcus, Haemophilus influenzae, and Shigella
sp. Chlamydia trachomatis and Neisseria gonorrhoeae also can cause vulvovaginitis
in a prepubescent girl, and a documented infection with either of these
organisms must be reported to child protective services. Yeast infections from
Candida albicans are not uncommon in this age group, especially after wearing
tight-fitting or moist clothing (eg, bathing suit) for a prolonged period. A
foreign body in the vagina or an infection with Enterobius vermicularis
(pinworms) also can lead to a vaginal discharge.
Depending
on the characteristics of the discharge, its evaluation in a prepubescent girl
may not warrant any laboratory studies. A complete history and physical
examination should be performed, particularly focusing on the possibility of
sexual abuse. If sexual abuse is not suspected, based on a negative history and
normal findings on the genital examination, cultures for N gonorrhoeae and C
trachomatis are not indicated. However, if the discharge is profuse and
yellow-green, cultures should be obtained for N gonorrhoeae and C trachomatis
regardless of the history and physical findings. A white-yellow discharge
usually indicates nonspecific inflammation, and a bloody or malodorous
discharge may indicate the presence of a vaginal foreign body. A thin, white,
or clear discharge is consistent with leukorrhea, a normal physiologic perimenstrual
discharge.
--------------------
Q 5
--------------------
Q 5
Of
the following, the BEST next step in the management of this girl would be to :
A.
conduct an external genital examination
B.
induce menses with a progesterone challenge
C.
order abdominal ultrasonography
D.
order follicle-stimulating hormone and luteinizing hormone levels
E. send
a urine sample for analysis and culture
Answer
A
Cyclic
lower abdominal pain in an adolescent who has never menstruated should prompt
one to consider a genital tract outlet obstruction, which is most often caused
by an imperforate hymen. This diagnosis can be made at birth, although it often
goes unrecognized because patients are usually asymptomatic before puberty.
After the onset of puberty, symptoms develop because of accumulation of
menstrual blood. Inspection of the external genitalia may reveal a bluish
bulging hymenal membrane. Blood may accumulate in the vagina
(hematocolpos), the uterus (hydrometrocolpos), and the fallopian tubes
(hematosalpinx). Symptoms include cyclic abdominal pain, nausea, vomiting, back
pain, pain with defecation, and difficulty urinating.
-----------------
Q 6:
The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months
ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication.
Which of the following is the most appropriatenext diagnostic step?
(A) an ultrasound of the pelvis
(B) a pelvic examination under general anesthesia
(C) computed tomography (CT) scan of her head
(D) a serum estradiol concentration
(E) a serum follicle-stimulating hormone (FSH) concentration
Answer :
(D)
Breast development in an infant or young child is the consequence of increased estrogen secretion, exposure to exogenous estrogens, or increased response of breast tissue to normal, prepubertal amounts of estrogen. After excluding exposure to exogenous estrogens (e.g., OCs, estrogen creams), increased response to estrogen is more common than increased estrogen secretion from the ovaries or adrenal glands
when breast development is the only sign of precocious puberty.
The uterus and adnexa can be palpated abdominally in prepubertal girls if they are pathologically enlarged. For this reason, an estrogen-secreting ovarian tumor (granulosa cell is the most common type) is usually palpable, and an ultrasound examination is unnecessary. For the same reason, a pelvic examination under anesthesia is not necessary, especially if the serum estradiol concentration is normal. CT scan of the head and
a serum FSH concentration are unnecessary if breast development is the only sign of precocious puberty, and the serum estradiol concentration is normal in the prepubertal range.
Q 7:
The tests you ordered are normal for a prepubertal girl. Which of the following is the most likely diagnosis?
(A) ingestion of the mother’s OC pills
(B) a granulosa cell tumor
(C) 21-hydroxylase deficiency
(D) polycystic ovary syndrome
(E) premature thelarche
Answer
(E)
Premature thelarche is a disorder that probably occurs as a consequence of increased sensitivity of breast tissue to the low levels of circulating estradiol in prepubertal girls. The disorder occurs most commonly before the age of 3 years.
The estradiol concentration may be normal in young girls ingesting estrogen if the serum estrogen concentration is not obtained at the time the estrogen is ingested. A negative medication history is helpful to
exclude this possibility. The absence of a palpable lower abdominal mass and a prepubertal
concentration of estradiol exclude a granulosa cell tumor.
Adrenal 21-hydroxylase deficiency and polycystic ovary syndrome are function disorders that require the stimulation of adrenocorticotropic hormone (ACTH) and pituitary gonadotropins (FSH and LH), respectively,to become clinically apparent. Neither disorder appears until after the onset of puberty. Moreover, both are associated with androgen excess and masculinization, not estrogen excess and precocious breast development.
Q 8.
Which of the following is the most appropriate management of this girl?
(A) pituitary suppression with a gonadotropin-releasing hormone (GnRH) agonist
(B) laparoscopy
(C) assurance that the condition is benign and self-limiting
(D) corticosteroid suppression of adrenal function
(E) breast biopsy
Answer
(C)
Premature thelarche is a benign, self-limited disorder that does not progress. Breast development may actually regress, though the regression may not be complete. The girl and her parents should be assured that the events of puberty will be normal at a normal age.
Examination of the girl should be repeated at 3- to 6-month intervals for about 1 year to be certain that additional pubertal events do not occur (such as growth of pubic hair, accelerated linear growth, and vaginal bleeding).
Because pituitary and adrenal functions are normal for a prepubertal girl, therapy with a GnRH agonist (Lupron, Synarel, and so forth) or a corticosteroid is ineffective and inappropriate.
Although breast cancer is a rare possibility in prepubertal girls, the presence of bilateral breast buds effectively excludes this diagnosis. A breast biopsy may destroy breast analge, and these girls will not have breast development at puberty.
-----------------
Q 6:
The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months
ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication.
Which of the following is the most appropriatenext diagnostic step?
(A) an ultrasound of the pelvis
(B) a pelvic examination under general anesthesia
(C) computed tomography (CT) scan of her head
(D) a serum estradiol concentration
(E) a serum follicle-stimulating hormone (FSH) concentration
Answer :
(D)
Breast development in an infant or young child is the consequence of increased estrogen secretion, exposure to exogenous estrogens, or increased response of breast tissue to normal, prepubertal amounts of estrogen. After excluding exposure to exogenous estrogens (e.g., OCs, estrogen creams), increased response to estrogen is more common than increased estrogen secretion from the ovaries or adrenal glands
when breast development is the only sign of precocious puberty.
The uterus and adnexa can be palpated abdominally in prepubertal girls if they are pathologically enlarged. For this reason, an estrogen-secreting ovarian tumor (granulosa cell is the most common type) is usually palpable, and an ultrasound examination is unnecessary. For the same reason, a pelvic examination under anesthesia is not necessary, especially if the serum estradiol concentration is normal. CT scan of the head and
a serum FSH concentration are unnecessary if breast development is the only sign of precocious puberty, and the serum estradiol concentration is normal in the prepubertal range.
Q 7:
The tests you ordered are normal for a prepubertal girl. Which of the following is the most likely diagnosis?
(A) ingestion of the mother’s OC pills
(B) a granulosa cell tumor
(C) 21-hydroxylase deficiency
(D) polycystic ovary syndrome
(E) premature thelarche
Answer
(E)
Premature thelarche is a disorder that probably occurs as a consequence of increased sensitivity of breast tissue to the low levels of circulating estradiol in prepubertal girls. The disorder occurs most commonly before the age of 3 years.
The estradiol concentration may be normal in young girls ingesting estrogen if the serum estrogen concentration is not obtained at the time the estrogen is ingested. A negative medication history is helpful to
exclude this possibility. The absence of a palpable lower abdominal mass and a prepubertal
concentration of estradiol exclude a granulosa cell tumor.
Adrenal 21-hydroxylase deficiency and polycystic ovary syndrome are function disorders that require the stimulation of adrenocorticotropic hormone (ACTH) and pituitary gonadotropins (FSH and LH), respectively,to become clinically apparent. Neither disorder appears until after the onset of puberty. Moreover, both are associated with androgen excess and masculinization, not estrogen excess and precocious breast development.
Q 8.
Which of the following is the most appropriate management of this girl?
(A) pituitary suppression with a gonadotropin-releasing hormone (GnRH) agonist
(B) laparoscopy
(C) assurance that the condition is benign and self-limiting
(D) corticosteroid suppression of adrenal function
(E) breast biopsy
Answer
(C)
Premature thelarche is a benign, self-limited disorder that does not progress. Breast development may actually regress, though the regression may not be complete. The girl and her parents should be assured that the events of puberty will be normal at a normal age.
Examination of the girl should be repeated at 3- to 6-month intervals for about 1 year to be certain that additional pubertal events do not occur (such as growth of pubic hair, accelerated linear growth, and vaginal bleeding).
Because pituitary and adrenal functions are normal for a prepubertal girl, therapy with a GnRH agonist (Lupron, Synarel, and so forth) or a corticosteroid is ineffective and inappropriate.
Although breast cancer is a rare possibility in prepubertal girls, the presence of bilateral breast buds effectively excludes this diagnosis. A breast biopsy may destroy breast analge, and these girls will not have breast development at puberty.
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