2yr with dysuria and foul vaginal discharge...expln plz - USMLE Forums
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Old 06-10-2012
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Kids 2yr with dysuria and foul vaginal discharge...expln plz

The mother of a 2-year-old girl reports that her daughter complains
of burning when she urinates and that she has foul-smelling discharge from
her vagina. She has some slight staining on the front of her underwear, but
denies fever, nausea, vomiting, or other constitutional signs. The child does
not attend day care, and she has demonstrated no change in behavior. The
physical examination is normal with an intact hymen, but the child’s vulva
is reddened and with a malodorous scent noted. Her urinalysis and culture
are normal. Management of this condition includes which of the following?
a. Complete genitourinary (GU) examination under general anesthesia
b. Progesterone cream to the affected area for a week
c. Advice to stop taking prolonged bubble baths
d. Mebendazole to eradicate pinworm infestation
e. Referral to social services for possible sexual abuse
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Old 06-10-2012
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E...........?????
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Old 06-11-2012
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Quote:
Originally Posted by K06100 View Post
E...........?????
I thought of sexual abuse at first too.. But you dont refer to social services.. You call the Child Protective Services (not the same).

This question is weird..
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Old 06-11-2012
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Quote:
Originally Posted by patelMD View Post
I thought of sexual abuse at first too.. But you dont refer to social services.. You call the Child Protective Services (not the same).

This question is weird..
hmmmm.......!!!!
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Old 06-11-2012
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Quote:
Originally Posted by tyagee View Post
The mother of a 2-year-old girl reports that her daughter complains
of burning when she urinates and that she has foul-smelling discharge from
her vagina. She has some slight staining on the front of her underwear, but
denies fever, nausea, vomiting, or other constitutional signs. The child does
not attend day care, and she has demonstrated no change in behavior. The
physical examination is normal with an intact hymen, but the child’s vulva
is reddened
and with a malodorous scent noted. Her urinalysis and culture
are normal. Management of this condition includes which of the following?
a. Complete genitourinary (GU) examination under general anesthesia
b. Progesterone cream to the affected area for a week
c. Advice to stop taking prolonged bubble baths
d. Mebendazole to eradicate pinworm infestation
e. Referral to social services for possible sexual abuse
e. Referral to social services for possible sexual abuse

Although prolonged bubble baths can lead to reddened vulva, I am concerned about malodorous scent with normal urinalysis and culture.
Chlamydia can cause malodorous vaginal discharge.

d. Mebendazole to eradicate pinworm infestation is a very good possibility since they can act as a FB in the vagina leading to secondary infection but there is no history of intense itching.

Last edited by Novobiocin; 06-11-2012 at 05:51 PM.
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Old 06-12-2012
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C, best answer choice
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Old 06-12-2012
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The answer is c.
(Hay et al, pp 142-143. Kliegman et al, pp 2274-2278.)

The symptoms listed are those of vulvovaginitis, with nonspecific (or chemical) vulvovaginitis accounting for 70% of all pediatric vulvovaginitis cases.
The discharge in nonspecific vulvovaginitis is usually brown or green and with a fetid odor. The burning with urination occurs because of contact
between raw skin and urine. Further history in this case might reveal use of tight-fitting clothing (including swimsuits or dance outfits), nylon
undergarments, prolonged bubble baths with contamination of the vagina with soap products, use of perfumed lotions in the vaginal area, or improper toilet
habits (wiping of fecal material toward rather than away from vagina). Attention to these causative conditions usually results in resolution of the symptoms.
The finding of a normal hymen, the history of a single caretaker, and the absence of behavioral changes all point away from, but do not completely
exclude, sexual abuse. A vaginal examination under general anesthesia is usually required when a vaginal foreign body is suspected. Pinworms can
infest the vagina, but symptoms usually include significant itching of the rectum and vagina. Estrogen cream, as well as antibiotic creams, are sometimes
helpful in reducing the discomfort of vaginitis. In a sexually active adolescent (or in a sexually abused younger child), a variety of infectious agents,
such as candida, Chlamydia trachomatis, Trichomonas vaginalis, Gardnerella vaginalis, and Neisseria gonorrhoeae, would be higher on the differential.
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