Case #22

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Chief Complaint

A four year old girl named Molly is brought to your office on a Tuesday morning by her grandmother. The chief complaint on your schedule simply reads “cold symptoms”. When you greet Molly and her grandmother, you are told that she has had a runny nose for the past week. Her grandmother also thinks Molly has been tugging at her left ear during this time. Upon further questioning, you learn that Molly has not had any fever, sore throat, coughing, sneezing or eye complaints. She has been eating and sleeping well. When you ask if Molly has seemed more irritable, or “cranky”, her grandmother responds, “Well, she spent the weekend at her father’s and she did seem kind of tired when she came back yesterday morning. Also, there was something else I wanted to talk to you about…ever since yesterday I have noticed a lot of discharge coming from her vagina when I help her wipe.”

 
  1. What is the differential diagnosis of vaginal discharge?
  2. Which diagnoses are more likely in a pre-pubertal patient?
  3. Would an infectious etiology necessarily indicate sexual abuse?
When asked to describe the discharge, Molly’s grandmother states that it is dark green in color and has a bad odor. She did not see any blood in it. She did not notice any other abnormalities in her granddaughter’s anogenital region, although she admits she did not look carefully. “I just figured I better bring her to the doctor to get checked on.”
  1. What parts of the history are important in refining your differential diagnosis?

Physical Exam

Molly denies dysuria and her grandmother states that she has not noticed any urinary urgency or frequency. Molly has not taken any bubble baths and has not used any new cleaning products at home. Molly’s mother and grandmother do not use any powders or lotions on her vagina. As her primary caregiver, Grandma always helps Molly clean herself following a bowel movement. However, her grandmother cannot account for her time spent with her father over the weekend. Next, you would like to ask Molly specific questions about her vagina.d without nodularity.  No uterine or adnexal masses.  No nodularity of uterosacral ligaments.

  1. What is the best way to refer to genitalia in such a young patient?

Molly’s grandmother states that at home genitalia are referred to as “private parts” and the anal region is referred to as “backside”. Upon questioning for feelings of “hurt” or “itchiness” in her “private parts”, Molly shakes her head “no”. Her grandmother states that she has not noticed Molly scratching or touching her vagina. You then ask Molly if she ever put any toys or other objects in her “private parts”, at which she shakes her head “no” again.

 
  1. What are some ways to ask children about sexual abuse?
You begin by saying to Molly, “Many children come to see the doctor because somebody touched them in a way that made them feel uncomfortable. Has that ever happened to you?”

Molly looks over at her grandmother but does not offer you a response.

You then ask Molly, “Has anyone ever touched your private parts or your backside?”

Molly answers, “Grandma and Mommy help me wipe.”

“Anybody else?”

“Once Joey did.”

“What did Joey do?”

“Put his finger…” At this point Molly looks back at her grandmother.

Molly’s grandmother looks confused and asks, “Do you mean your cousin Joey?”

Molly nods her head.

You ask Grandma how old Joey is and she responds that he is almost five years old. You then try to ask Molly more questions but she is now sitting on Grandma’s lap and has buried her head into her arm. She does not want to answer any more questions.

Molly’s grandmother looks worried and urges Molly to speak up, but Molly simply shakes her head.

 
  1. Why is the history of Molly’s five year-old cousin touching her vagina important?
  2. What signs can you ask Grandma about that would make you more suspicious for sexual abuse?

Social History

Molly’s grandmother states that Molly has seemed more tired during last couple of days, which she had attributed to her cold. Other than this, she states she has not noticed any changes in behavior. She describes Molly as a generally shy little girl, but does not think she has been particularly withdrawn. She denies any unusual expressions of anger or aggression. She hasn’t noticed any inappropriate sexual play and is surprised at the mention of Joey having touched Molly’s vagina. Grandma describes Molly as a “picky eater” buttr has not noticed any changes in eating habits. Molly sleeps well and has not had any problems toileting.

You then ask Grandma if she has any doubts or fears regarding Molly’s father. You also ask if Molly has ever expressed any fear at going to see him on the weekends. She answers that she does not harbor any suspicions against Molly’s father and says that Molly “absolutely loves” the weekends when she visits her father because she spends most of the time playing with her cousins, who are all about her age.  
Molly’s past medical history is significant only for eczema. She is not on any medications and had not been prescribed any antibiotics in over two months.

Her social history is significant in that she lives with her 19 year-old mother and her grandmother, but is mostly raised by her grandmother since her mother works 2 jobs. She visits her father on the weekends. Her father lives in the same apartment building as his sister who has 2 children around Molly’s age. Molly does not go to day care, but will be starting pre-kindergarten in September. There is no prior history of sexual or physical abuse in either Molly or her mother. As far as Grandma knows, neither Molly’s mother or father abuses alcohol or drugs, although Molly’s mother does smoke cigarettes daily.
 
  1. What are the risk factors for child abuse?
  2. Can any be identified in Molly’s history?

Physical Examination

Physical Exam:
Vitals – T 36.3 P 88 RR 24 Wt 23.6 kg
General – Alert and active. Appears somewhat shy, but smiles and speaks appropriately.
 Neatly dressed.

HEENT
Ears-tympanic membranes clear bilaterally, without erythema or exudate
Nares-congested with yellow discharge
Oropharynx-mucosa pink and moist without lesions, palate without ecchymoses or laceration, pharynx without erythema or exudate
Neck – supple, without lymphadenopathy
Heart – RRR, normal s1 and s2 without murmurs, rubs or gallops
Lungs – coarse breath sounds secondary to upper airway congestion, but without crackles or wheezing
Abdomen – soft, non-distended, non-tender, + bowel sounds, - masses,
- hepatosplenomegaly
Skin – without lacerations, ecchymoses, or rash
Genitalia – profuse green, foul-smelling discharge soiling underwear. Vulva appears mildly erythematous, but without rash, lacerations, eccyhmoses or other lesions.
Anus without erythema, lacerations, ecchymoses, or fissures. Normal tone. Rectal exam unremarkable with heme negative – stool.

A large swab of the vaginal discharge is obtained to be sent for bacterial culture. A wet prep slide is also obtained and examined under the microscope. It is negative for clue cells and trichomonads.
Because Molly is so young and is so uncomfortable when you try to complete your genital examination, it is decided to send her for a pelvic examination under sedation.

This is scheduled with a gynecologist for later that day.
 
  1. What would be pertinent findings on physical examination when trying to looking for possible signs of sexual abuse in a child?
  2. What are considered normal vs. abnormal characteristics of the hymen?

Test Results

The pelvic exam performed under sedation reveals an intact crescenteric hymen without any lesions or clefts. There are no foreign bodies in the vaginal vault. Aside from the presence of the vaginal discharge and mild erythema of the vulva, Molly’s pelvic exam is unremarkable. Because of the copious, abnormally appearing and smelling discharge, cultures are sent for Chlamydia and Neisseria.
 
  1. What are the typical characteristics of vaginal discharge due to the major etiologies (including bacterial vaginosis, trichomonas vaginitis, candidiasis, mucopurulent cervicitis, and nonspecific vulvovaginitis)?
At this point, a detailed history and a complete physical exam have been performed and it is time to decide if a report needs to be made to Children and Youth. In reviewing Molly’s history, you make note of Molly’s mention of sexual play with her five year-old cousin. However, there was no indication of inappropriate touching by an adult. Neither Molly nor her grandmother provided a history of sexual abuse. Also, Molly’s grandmother clearly denied any changes in Molly’s behavior. Her physical exam revealed an abnormal vaginal discharge and mild vulvar erythema. However, a pelvic exam was performed under sedation and revealed no other abnormalities. When you put all this information together, you decide that you do not have a history of abuse or behavioral changes and only non-specific findings on physical exam.

 
  1. Are there general guidelines that can be used to determine if Children and Youth should be notified?
In this case, it was decided not to call Children and Youth, but to follow up closely. You make an appointment to meet with Molly and her grandmother again in two days (when the lab results will be ready). But before meeting with them again later this week, you would like to offer advice regarding Molly’s symptoms.

 
  1. How would you counsel a patient with non-specific vulvovaginitis?

 

 You counsel Molly’s grandmother on the use of sitz bath multiple times a day to help minimize vulvar irritation. You advise her not to dry Molly’s vulva by wiping with a towel but rather to let it air-dry. You re-iterate the importance of avoiding the use of lotions, powders and cleansers on the vulvar region and counsel her to only let Molly wear loose-fitting underwear and clothing. You also remind Molly’s grandmother on the importance of wiping fecal matter away from the vulva following a bowel movement and advise her to educate Molly’s father for when she visits him on the weekends.

Finally, and most importantly, you talk to Molly about her “private parts” and educate her that only her parents, grandmother and doctor are allowed to touch them. You tell her grandmother that she should review this with her at home and tell her to talk to both Molly’s father and Joey’s parents about the episode of genital touching, so that it can be prevented in the future. 

The following day, the lab results are back and show the following: Swab cultures grew out mixed flora with a predominance of Streptococcus. The tests for Gonorrhea and Chlamydia were both negative.
 
  1. What is the prevalence, pathophysiology, clinical presentation and treatment of streptococcal vaginitis in the premenarchal girl?

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This page was last updated on April 24, 2006
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