Blood Spot. Do you detect foul play?

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Blood Spot
For this 18-month-old girl, a trip to the playground led to a bloody diaper and a trip to the ED. Do you detect foul play?

The next case the resident presents is an 18-month-old African-American female who was taken to the park by some cousins. She played, had a great time and has been eating and drinking normally. Nothing seemed amiss until grandmother changed the diaper and saw bright red blood. She showed the parents, who are now in the ED, concerned that someone may have “messed” with their daughter.
The child has otherwise been healthy. She was born at 36 weeks to a diabetic mother, was somewhat large (10 pounds) and had a brief NICU stay for hypoglycemia. She hasn’t had any other significant past medical history. She takes no meds, has no allergies, gets regular check-ups and is growing and developing normally. She stays at home with her mother or grandmother during the day. It’s not clear who the parents feel might have sexually abused their child, they just want to make sure that’s not the cause of her bleeding. She’s had no trauma, no recent illness or medication exposures, no other unusual bleeding.
On exam, she is happy and playful. Her vital signs are unremarkable. Her exam is normal until you remove her diaper. There is a dark red spot on the front of the diaper. Her anus appears normal. Her labia separate easily. She has a small, pink mass in her perineal region. It appears separate from her vagina. There is no blood coming from her vagina. The mass has a small indentation in the center of it.
You consult OB-Gyn because of the patient’s young age and the parents’ concerns. They confirm the diagnosis: urethral prolapse.
Urethral prolapse is relatively rare. It occurs in a U-shaped distribution, with about half the cases in prepubertal girls and the other half in post-menopausal women. In children, most occur between 2 and 10 years of age, making 18 months a bit on the young side. In children, it is overwhelmingly seen in dark-skinned females, whereas there is no racial predilection in adults. The reasons for the predominance in dark-skinned individuals are unknown. Many cases occur spontaneously, as in this child, although it has been associated with coughing or straining.
The most frequent presentation of urethral prolapse is bleeding, which is often painless. On exam, most prolapses are nontender and measure 2 cm or less. Retracting the labia majora helps you see that the mass is separate from the vagina, although this can be hard if it is really large. A central depression indicates the lumen of the urethra. If you are unsure, use a catheter—it should go straight into the bladder. If you send urine, it may have some red cells.
Most girls will do fine with sitz baths and the application of topical estrogen cream. Make sure to warn the parents that the child may temporarily have breast buds associated with the application of the cream to the urethral area. Sometimes, if the prolapse is very angry and necrotic-looking or the child is having difficulty voiding, you will have to consult Urology.
Our patient went home with twice daily estrogen cream and sitz baths. At a follow-up exam about a week later, her exam was back to normal and her symptoms resolved, so the cream was discontinued.
There is a differential of urethral masses in little girls. This includes urethral polyps, sarcoma botryoides, prolapsed ureterocele, and carcinoma. All of these are extremely rare. Helpfully, none of these are shaped like donuts with a central depression—only a prolapsed urethra looks like that so you may feel comfortable diagnosing this clinically. Just make sure you have good lighting so you don’t miss the central dimple where the urethral opening is located.
Amy Levine, MD, is an assistant professor of pediatric EM at UNC Chapel Hill

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