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Chapter 32 • Urinary Problems in Females and Children 391
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urine, but cloudy urine can also result from other
causes.
Sediment
Sediment from casts, blood cells, and bacteria can be
detected by microscopic examination. Casts indicate
hemorrhage or various conditions of the nephron.
RBCs indicate acute inammatory or vascular disor
ders of the glomerulus. More than 1 or 2 RBCs per
highpower eld (HPF) is abnormal and can indicate
renal or systemic disease or trauma to the kidney.
Sediment is labeled as active when an abnormal num
ber of cells, tubular casts, crystals, or infectious organ
isms are found.
A healthy person’s urinalysis usually contains no
cells, although an occasional cell per HPF is seen.
More than 1 tubular epithelial and transitional epithe
lial cell per HPF suggests damage to the tubules or
bladder wall. More than 1 RBC or WBC per HPF is
considered abnormal. The more cells per HPF, the
more active may be the renal disease.
Microscopic examination of the urine resulting in
20 or more organisms per HPF indicates UTI. Fewer
than 20 organisms per HPF merits further study such
as culture and sensitivity (C & S).
Red Blood Cells
Hematuria is the presence of more than 3 RBCs/HPF.
Distorted, irregularly shaped cells suggest a glomeru
lar problem. The major causes of hematuria include
acute and chronic prostatitis or urethritis, hemorrhagic
cystitis, renal stones, or tumors of the kidney, renal
pelvis, ureter, bladder, and urethra. Hematuria with
proteinuria usually suggests a renal origin. Isolated
hematuria is usually produced by sites outside the
kidneys.
White Blood Cells
Pyuria (.5 WBCs/HPF) is highly sensitive for the
presence of a UTI. However, it may occur with dehy
dration, renal stones, appendicitis, or other extrinsic
ureteral irritation in the absence of demonstrable
microbial infection.
abnormal cells, protein, hemoglobin, myoglobin, or
other debris with a cast helps identify the type of renal
disease.
Urine Culture and Sensitivity
Culture is indicated in children if you are uncertain
of a diagnosis of uncomplicated lower tract UTI
based on clinical ndings and urinalysis, or if the
patient has signs and symptoms of an upper UTI or
complicated UTI.
Potassium Hydroxide and Wet Mount/
Preparation
Perform these procedures if you suspect vulvovagini
tis as a cause of the urinary tract symptoms. See
Chapter 34 for an explanation and a discussion of
these procedures.
Vaginal Culture/DNA Testing
for Infectious Organisms
Use these testing procedures to diagnose or conrm
vaginal infection (see Chapter 34).
Ultrasonography
Ultrasonography is a noninvasive technique that can
provide information about the kidneys, ureters, blad
der, and vascular structures. Renal ultrasound is a good
rst test to determine kidney size, contour, and the
presence of calculi. Urinary bladder sonogram is used
to identify tumors of the bladder, thickening of the
bladder wall, posterior masses behind the bladder, or
obstruction of the lower urinary tract showing residual
urine.
Radiography
A at plate of the abdomen can be used to identify
structures of the kidney, ureters, and bladder. Urinary
calculi are usually visible on radiographs.
Computed Tomography
Noncontrast helical (spiral) CT is the gold standard for
evaluating kidney stones. It has 95% sensitivity and
98% specicity.
Casts
Tubular casts are formed in the distal portion of the
nephron. A hyaline cast is a wispy, translucent, cylin
drical replica of the tubular lumen. Red cell casts are
characteristic of glomerular origin. The presence of
DIFFERENTIAL DIAGNOSIS
Uncomplicated Urinary Tract Infection
Uncomplicated lower UTIs (or bacterial cystitis) are
common in women. Uncomplicated UTIs occur in
individuals with normal urinary tract anatomy and
392 Chapter 32 • Urinary Problems in Females and Children
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function. Patients present with dysuria and may
have urinary frequency, hematuria, back pain, mild
nausea, nocturia, urgency, and voiding of small
amounts. Fever is notably absent in adults but
may be present in pediatric patients. Neonates may
present with prolonged jaundice and failure to
thrive.
The adult patient appears well on physical examina
tion and may or may not have costovertebral angle
(CVA) tenderness. Clinical diagnosis is supported by
urine dipstick ndings, which may include the pres
ence of blood, leukocyte esterase, and nitrites. How
ever, a negative dipstick result does not rule out UTI.
Microscopic analysis may show the presence of RBCs
and WBCs. No casts will be present. Urine culture
and sensitivity will conrm the diagnosis. See the
EvidenceBased Practice boxes for evidence support
ing the diagnosis of UTI in adults or children.
EVIDENCE-BASED PRACTICE
In a systematic review, Bent et al (2002) report four symp
toms (dysuria, frequency, hematuria, and back pain) and one
sign (costovertebral angle tenderness) that significantly increase the probability of uncomplicated UTI. In women who
present with one or more of these symptoms, the probability
of infection is about 50%. Specific combinations of symptoms, such as dysuria and frequency without vaginal discharge and irritation, raise the probability of UTI to more than
90%. If the dipstick result is positive, the probability of UTI is
high, but if the dipstick result is negative, the probability of
Diagnosing Uncomplicated UTI in Adults
Urethritis
Dysuria suggests urethritis, especially if accompanied by
vaginal discharge. The history often includes a new sex
partner, frequent sex, a partner with urethritis, or multiple
sex partners. As with uncomplicated UTI, the patient ap
pears well and on physical examination has no CVA ten
derness or fever. On urinalysis using a dipstick, ndings
may include the presence of blood, leukocyte esterase,
and nitrites, although the patient may have urethritis in the
absence of these ndings. Urine culture or DNA testing
conrms the presence of the offending pathogens, usually
Chlamydia, N. gonorrhoeae, Trichomonas, and herpes.
Vulvovaginitis
Vulvovaginitis is a common cause of dysuria. The
patient often describes the dysuria as “external”—a
burning sensation as the urine passes inamed labia.
UTI is still high and a urine culture should be considered to
rule out infection. The absence of dysuria, the absence of
back pain, a history of vaginal discharge and irritation, and the
presence of vaginal discharge on examination significantly
decrease the probability of UTI.
Conclusion: History alone may effectively rule in the
diagnosis of uncomplicated UTI. However, the history and
physical examination and dipstick urinalysis cannot reliably
rule out UTI in women who present with urinary tract
symptoms.
Data from Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S: Does this woman have an acute uncomplicated urinary tract infection? JAMA
287:2701, 2002.
EVIDENCE-BASED PRACTICE
A meta-analysis performed by Shaihk et al (2007) offers insight
into the diagnosis of UTI in infants and children based on
clinical examination and urine dipstick. Although certain signs
and symptoms (high fever, fever for 24 hours, history of a previous UTI, abdominal pain, nonblack race, lack of circumcision, back pain, dysuria, frequency, new-onset urinary incontinence, suprapubic tenderness, and absence of another source
of fever on examination) increase the probability of UTI, no
single sign or symptom has a sufficiently high likelihood ratio
Data from Shaikh N, Morone NE, Lopez J, Chianese J, Sangvai S, D’Amico F et al: Does this child have a urinary tract infection? JAMA 298:2895,
2007.
Diagnosing UTI in Infants and Children
to definitively diagnose UTI or sufficiently small likelihood ratio
to rule out UTI. A urine dip positive for both nitrites and leukocyte esterase substantially increases the likelihood of UTI.
Accordingly, a positive dipstick test should always be followed
up with a confirmatory urine culture.
The bottom line: Although no sign or symptom by itself
is diagnostic of UTI in children, the absence of several key
signs and symptoms in combination can be used to identify
infants at low risk for UTI.
Chapter 32 • Urinary Problems in Females and Children 393
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The patient usually has a history of vaginal discharge,
odor, and/or itching. On physical examination, dis
charge is usually present in the vagina or from the
cervix. Wet mount, KOH, and vaginal culture or
molecular testing for infectious organisms can conrm
the diagnosis (see Chapter 34).
In older women, atrophic vaginitis may produce
urinary tract symptoms. These women may be peri
menopausal or postmenopausal. Women with atrophic
vaginitis may report vaginal dryness or discomfort
during sexual intercourse. On physical examination,
the vaginal mucosa is thin, pale, and dry, with less
rugation. Diagnosis is made on the basis of clinical
ndings.
Interstitial Cystitis
Interstitial cystitis produces diminished bladder capac
ity along with symptoms of frequent, painful urination.
Hematuria may be present. The cause is unknown but
may be related to collagen disease, may be an autoim
mune disorder or an allergic manifestation, or may
occur secondary to an unidentied infectious agent.
The bladder wall becomes inamed, with mucosal ul
ceration and scarring that produce contraction of the
smooth muscle and cause the symptoms. Middleage
women are most often affected. Typically, the patient
appears well and has no physical ndings. Suprapubic
tenderness may be present. Urinalysis is usually nega
tive. This is a diagnosis of exclusion, and the patient is
often frustrated because no cause has been previously
found for her longstanding and persistent symptoms.
The patient has no evidence of urological disease
on radiographic and cystometric studies. Cystoscopic
evidence of interstitial disease includes focal ulcer
ation, edema, and perivascular inltrates.
Pyelonephritis
The patient presents with fever and chills, appears toxic,
and reports back pain. Nausea and vomiting may be pres
ent. Some patients also report lower urinary tract symp
toms, including frequency and dysuria. The patient feels
and looks ill. On physical examination, CVA tenderness
is usually present. The abdomen may also be tender. On
microscopic examination, WBCs are usually present.
White cell casts suggest pyelonephritis. Bacterial casts,
although rare, are pathognomonic of pyelonephritis.
A urine culture and sensitivity test conrms the diagnosis
and identies the pathogen—usually E. coli, Klebsiella,
Proteus mirabilis, or Enterobacter.
Urolithiasis
Urinary stones can occur anywhere in the urinary tract
and may produce symptoms of acute pain, hematuria,
and secondary infection. Many calculi are “silent” and
may cause only hematuria, either microscopic or gross.
Renal calculi may occur when a stone obstructs the
urinary tract. Typical symptoms of renal colic include
severe ank pain that radiates along the pathway of
the ureter to the inner thigh. Chills, fever, and urinary
frequency are common. The patient may have nausea,
vomiting, and abdominal distention.
The clinical diagnosis is supported by urinalysis and
imaging ndings. The urine may be normal; however,
gross or microscopic hematuria is common. Pyuria
(WBCs) with or without bacteria may be present. Crys
talline structures may be present. Noncontrast helical
(spiral) CT is the gold standard for evaluating kidney
stones.
Poststreptococcal Glomerulonephritis
This condition is an immunemediated nephritis. It
occurs most commonly in elementary school children.
There is a history of recent streptococcal skin or
pharyngeal infection within the past 1 to 3 weeks. An
orexia, vomiting, fever, abdominal pain, headache, and
lethargy are reported. On physical examination, peri
orbital edema is usually present, as is hypertension.
Orthopnea, dyspnea, cough, and rales may be present.
Hematuria and proteinuria are present. A positive serum
ASO titer conrms recent infection. A depressed serum
concentration of C3 is found in the rst few days of the
disease.
Chemical Irritation
There is a history of the use of bubble baths, body
lotions, soaps, and sprays. The patient experiences
frequency, burning, and urgency with small volumes
of voided urine. Children will frequently suppress
voiding because of pain. Physical examination may
reveal erythema of the labia and urethral outlet. Labo
ratory examination may reveal pyuria and bacteriuria
as a result of local infection and denudation.
394 Chapter 32 • Urinary Problems in Females and Children
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Urinary Problems in
Females and Children
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Uncomplicated UTI Dysuria, frequency,
mild nausea, nocturia,
urgency, voiding small
amounts; neonates and
young infants present
with anorexia and
irritability
Urethritis Dysuria; vaginal discharge;
history of new sex
partner, frequent sex,
partner with urethritis,
multiple sex partners
Vulvovaginitis History of vaginal itching,
discharge, burning,
dryness; postmenopausal
Interstitial cystitis Frequent painful urination;
hematuria; most often
middle-age women; often
frustrated because no
cause has been
previously found for
long-standing and
persistent symptoms
Pyelonephritis Fever, chills, back pain,
nausea and vomiting,
toxic appearance; some
patients also have frequency and dysuria
Urolithiasis Pain, hematuria; may have
symptoms of
secondary infection; renal
colic: pain that radiates
to inner thigh; nausea,
vomiting
Poststreptococcal
glomerulonephritis
Chemical irritation History of bubble baths,
C & S, culture and sensitivity; CT, computed tomography; CVA, costovertebral angle; RBC, red blood cell; U/A, urinalysis; UTI, urinary tract
infection; WBC, white blood cell.
History of skin or throat
infection 1-3 weeks prior;
lethargy, anorexia,
vomiting, abdominal pain
soaps, lotions, sprays;
urgency, dysuria
No fever in adults;
appears well; no CVA
tenderness; may have
suprapubic tenderness;
neonates and young
infants may present
with failure to thrive,
bacteremia and fever
Appears well; has no CVA
tenderness or fever
Inflamed or atrophic
labia; vaginal or cervical
discharge
Appears well and has no
physical findings; suprapubic tenderness may
be present
Feels and looks ill; fever;
CVA tenderness;
abdomen may be tender
May have CVA
tenderness; looks ill
during periods of acute
pain; may have
abdominal distention
Hypertension, periorbital
edema, CVA tenderness;
may have dyspnea,
cough, pallor
No fever; erythematous
labia, urethral opening
Urine dipstick: 1 blood, 1
leukocyte esterase, 1
nitrites; microscopic
analysis: RBCs, WBCs, no
casts; urine C & S; in
children, voiding
cystourethrogram and renal
ultrasound are
recommended
Urine dipstick: may have 1
blood, 1 leukocyte esterase,
1 nitrites; urine culture; DNA
testing vaginal specimen
Microscopic exam, vaginal
cultures, molecular testing
Urinalysis usually negative;
x-ray and cystometric
studies to rule out other
urological disease;
cystoscopy
Urine dipstick: 1 blood,
1 leukocyte esterase,
1 nitrites; microscopic
examination: WBCs may
have white cell casts or
bacterial casts; urine C & S:
E. coli, Klebsiella, Proteus
mirabilis, Enterobacter;
blood cultures
Urinalysis: gross or
microscopic hematuria;
WBCs with or without
bacteria; crystalline
structures may be present;
noncontrast helical CT
U/A: 1 proteinuria, 1 hema-
turia, 1 ASO titer; serum C3
low early in disease
Hematuria common, gross
hematuria unusual and casts
never seen
Chapter 32 • Urinary Problems in Females and Children 395
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REFERENCES AND READINGS
Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S: Does this
woman have an acute uncomplicated urinary tract infection?
JAMA 287:2701, 2002.
Bent S, Saint S: The optimal use of diagnostic testing in women with
acute uncomplicated cystitis, Am J Med 113:20, 2002.
Bremnor JD, Sadovsky R: Evaluation of dysuria in adults, Am Fam
Phys 65:1589, 2002.
Colgan R, Lindsay E, Nicolle LE, Mcglone A, Hooton TM: Asymp
tomatic bacteriuria in adults, Am Fam Phys 74:985, 2006.
Ebell MH: Treating adult women with suspected UTI, Am Fam Phys
73:293, 2006.
Grabe M, Bishop MC, BjerklundJohansen TE, Botto H, Çek M,
Lobel B et al: Uncomplicated urinary tract infections in adults.
In: Guidelines on urological infections. Arnhem, The Netherlands:
European Association of Urology (EAU): 1138, 2009. Available
at www.guidelines.gov. Accessed May 28, 2010.
Graham K, Levy J: Enuresis, Pediatr Rev 30:165, 2009.
Grossfeld GD, Wolf JS Jr, Litwan MS, Hricak H, Shuler CL, Agerter
DC et al: Asymptomatic microscopic hematuria in adults: summary
of the AUA best practice policy recommendations, Am Fam
Physician 63:1145, 2001.
Heffner V, Gorelick M: Pediatric urinary tract infection, Clin Ped
Emerg Med 9:233, 2008.
Lindbloom EJ: What is the best test to diagnose urinary tract stones?
J Fam Pract 50:657, 2001.
Meyers K: Evaluation of hematuria in children, Urol Clin North Am
31:559, 2004.
Portis AJ, Sundaram CP: Diagnosis and initial management of
kidney stones, Am Fam Physician 63:1329, 2001.
Roberts KB: The AAP practice parameter on urinary tract infections
in febrile infants and young children. American Academy of
Pediatrics, Am Fam Physician 62:1815, 2000.
C H A P T E R
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33
Vaginal Bleeding
he average menstrual cycle is 28 days. It is
considered abnormal if the cycle occurs more
T
often than every 21 days (polymenorrhea) or
less often than every 35 days (oligomenorrhea).
Bleeding at irregular intervals is known as metrorrhagia. Intermenstrual bleeding is bleeding between
cycles. The average duration of menses is 4 days; a
duration of longer than 7 days or blood loss heavier
than 80 mL is considered excessive and is classied
as menorrhagia. Hypomenorrhea occurs when the
frequency of periods remains normal but the menstrual ow decreases in amount. Systemic disorders
that cause an imbalance in the hypothalamicpituitary-ovarian (HPO) axis may lead to menses that
are too heavy (menorrhagia/hypermenorrhea), too
often (polymenorrhea), or too heavy and irregular
(menometrorrhagia).
Other systemic reasons for vaginal bleeding include
blood dyscrasias, liver and kidney diseases, and medications (e.g., hormones, anticoagulants, and nonsteroidal anti-inammatory drugs [NSAIDs]). Organic
causes for aberrant menstrual cycles are multiple and
include problems such as vaginitis, ectopic pregnancy,
broids, and polyps. Vaginal bleeding in perimenopausal and postmenopausal women may indicate gynecological cancer. When organic and systemic reasons
for abnormal vaginal bleeding are not found, the diagnosis of dysfunctional uterine bleeding (DUB) is
warranted.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is this an acute condition that requires
immediate intervention?
Key Questions
n How heavy is the bleeding?
n Do you have a bleeding disorder?
n Are you taking anticoagulants?
396
Patients who have profuse bleeding, have had substantial blood loss, or are hemodynamically unstable require immediate intervention.
Amount of Bleeding
More than three soaked pads or six full regularabsorbency tampons a day for 3 or more days likely
equates to greater than 80 mL of blood loss (Brown,
2005). A history of ooding, clots, or leaking, especially overnight, may be associated with a clotting
disorder.
Bleeding Disorder/Anticoagulants
Severe acute uterine bleeding in a nonpregnant patient
usually occurs as the result of a coagulopathy or from
taking anticoagulants. Women with submucous broids
can also present with profuse bleeding.
Could this be related to pregnancy?
Key Questions
n Do you have any symptoms of pregnancy (e.g.,
missed period, breast tenderness, nausea, vomiting)?
n When was your last normal menstrual period?
n What are you using for birth control?
n Have you recently delivered a baby?
Pregnancy
A small amount of bleeding can occur at the time of
implantation. The blastocyst burrows into the endometrium and invades the maternal blood supply; the formation and implantation of the placenta follow. If
bleeding occurs from implantation, it happens about
1 week before the expected menstrual cycle. Regard
women of childbearing age as pregnant until pregnancy is ruled out. It is estimated that up to 50% of all
fertilized eggs die and are aborted spontaneously, usually before the woman knows she is pregnant. About
20% of pregnant women have some vaginal bleeding
during the rst trimester.
Chapter 33 • Vaginal Bleeding 397
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Recent Delivery
If the patient has recently delivered a baby, the abnor-
mal vaginal bleeding is likely from retained placenta,
infection of the uterus (endometritis), or a laceration.
If the patient is pregnant, is this a
complication?
Key Questions
n How old are you?
n How many weeks pregnant are you?
n Do you have any chronic health problems?
n Are you experiencing any pain or cramping?
n Have you passed any tissue?
n Are you having any other symptoms?
n Have you ever had a sexually transmitted infection?
n Have you ever had an infection of your tubes
(pelvic inammatory disease [PID])?
n Have you ever been pregnant before this? What
were the number of times and outcomes of your
pregnancies?
Age
The risk for spontaneous abortion is higher in women
older than age 35 years. Most ectopic pregnancies occur
in women ages 25 to 34 years. However, women older
than age 35 have a higher rate of death from ectopic
pregnancy.
Weeks of Gestation
Among known pregnancies, the rate of spontaneous
abortion is approximately 10% and usually occurs
between the seventh and twelfth weeks of pregnancy.
An estimated 10% to 15% of clinically recognized
pregnancies result in rst trimester loss. The patient
experiencing an ectopic pregnancy typically presents
at about 6 to 8 weeks of gestation.
In ectopic pregnancy, the pain may lateralize to one
side. Severe, sharp, and sudden pain in the lower
abdominal area may indicate rupture of the ectopic
pregnancy. Ruptured ectopic pregnancy is a surgi-
cal emergency.
Passing Tissue
The passage of tissue from the vagina suggests spontaneous abortion. Ectopic pregnancies can be accompanied
by sloughing material.
Other Symptoms
Pain referred to the shoulder is suggestive of ectopic
pregnancy rupture with peritoneal free uid and signicant hemorrhage. Other symptoms of rupture include
feeling dizzy or faint, or actually fainting.
Sexually Transmitted Infection
Sexually transmitted infections (STIs) that have been
unnoticed, untreated, or inadequately treated can cause
scarring of the fallopian tubes, which is associated with
greater risk for ectopic pregnancy. Ectopic pregnancy
occurs in about 1 of every 200 pregnancies (Box 33-1).
However, if the woman has had PID, the rate is as high
as 1 of every 40 pregnancies.
Box 33-1
Risk Factors for Ectopic
Pregnancy
History of PID
Previous ectopic pregnancy
History of tubal surgery
Infertility
In utero diethylstilbestrol exposure
Present use of IUD
Smoking
Chronic Health Conditions
The risk for spontaneous abortion is higher in women
with systemic diseases, such as diabetes or thyroid
problems.
Pain
Low back pain or abdominal pain that is dull, sharp, or
cramping may indicate spontaneous abortion or ecto-
pic pregnancy. If there is pain associated with ectopic
pregnancy, it will usually be described as “crampy,”
pelvic pressure, or “soreness” in the lower abdomen.
Previous Pregnancies
The risk for spontaneous abortion is higher in women
older than age 35 and in women with a history of three
or more prior spontaneous abortions.
Is this related to age? Where is the woman
in her reproductive life cycle?
Key Questions
n How old are you?
n Are you postmenopausal?
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Age
Knowing a woman’s age can help focus the differential diagnosis. The majority of adolescents with abnormal bleeding experience anovulatory cycles
caused when estrogen stimulates the uterine lining
with no opposing progesterone. This condition leads
to a thicker, more vascular, and less stable endometrium, predisposing the adolescent to dyssynchronous
bleeding. A young woman’s bleeding is most frequently caused by pregnancy, contraceptive methods,
or infection. Women over age 40 are more likely to
have problems related to polyps, broids, or ovarian
dysfunction.
Postmenopause
If a woman is postmenopausal, the origin of bleeding
irregularities is often hormone therapy (HT), endometrial hyperplasia, or endometrial cancer (see section on
postmenopausal bleeding).
tell me?
Key Questions
n When did the bleeding begin?
n How long have you been bleeding?
n What is the ow like?
n How many pads do you use?
n Are there any accompanying problems?
Symptom Analysis
Determine the amount of ow and its duration to establish if there is menorrhagia, metrorrhagia, or menometrorrhagia. Menorrhagia is considered to be 80 mL of
menses, which is estimated as saturating a sanitary pad
hourly, over several hours. Metrorrhagia is dened as
bleeding at irregular intervals or intermenstrual bleeding. When the menstruation has an unpredictable
schedule and lasts for a prolonged time, it is termed
menometrorrhagia.
Associated Complaints
Patients may experience postcoital bleeding with
cervical infections, cervical polyps, or cervical cancer. Accompanying dyspareunia may indicate endometriosis. Dysmenorrhea can be caused by an intrauterine device (IUD) or adenomyosis. Pelvic pressure
or pain is suspicious for persistent corpus luteum
cyst. Uterine prolapse causes pelvic pressure, which
is subjectively described as “something falling out of
the vagina.” Fever is associated with a pelvic infection. Menorrhagia, accompanied by fatigue, weight
gain, hair loss, cold intolerance, decreased libido,
and constipation, is a symptom of hypothyroidism.
Bleeding disorders may become apparent for the
rst time in the teenager, with severe menorrhagia
accompanied by bruising, petechiae, and gingival
bleeding.
Is this problem acute or chronic? How does
it compare with usual menses?
Key Questions
n Has this kind of vaginal bleeding occurred before?
n Were your periods regular before this episode?
n How long did they last?
n What was the amount and pattern of bleeding?
Irregular Menses
In anovulatory cycles, the endometrium proliferates
under the inuence of high estrogen levels until it can
no longer be supported—then bleeding occurs. This
results in a menstrual pattern that is longer than
28 days with a very heavy ow that lasts 7 to 14 days.
If the patient’s estrogen levels are uctuating, she may
have two periods a month. Both of these patterns are
consistent with DUB. However, organic problems
with any component of the reproductive tract must be
ruled out.
Acute Bleeding
One episode of acute bleeding in a woman with
normally regular menstrual cycles suggests uterine
broids or a complication of pregnancy, such as threatened abortion. In a postmenopausal woman with an
intact uterus, an episode of vaginal bleeding is indicative of endometrial hyperplasia and is suspicious for
endometrial cancer.
Chronic Bleeding
Chronic, irregular menstrual cycles coupled with
obesity are likely to be caused by polycystic ovary
syndrome (PCOS), also known as Stein-Leventhal
syndrome. Chronic midcycle spotting can occur
secondary to the normal midcycle drop in estrogen
levels and usually is not bothersome to the patient
because the amount of vaginal bleeding is very scant
and the duration is short.
Could this be caused by the patient’s birth
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control method?
Key Questions
n Do you use birth control?
n Which kind(s) of birth control do you use?
n How do you use it?
Birth Control
Menorrhagia from IUD contraception is accompanied
by increased cramping and pain. If spotting or cramp-
ing is not of a usual pattern, ectopic pregnancy or in-
fection must be considered. Displacement or perfora-
tion of the uterus by the IUD can be veried by pelvic
ultrasound. Women who have recently discontinued
the use of oral contraceptive (OC) pills after several
years of use may experience heavier menstrual bleed-
ing than when they were on OC pills. Breakthrough
bleeding caused by OC pills may occur in the rst
2 weeks of the cycle because of low estrogen level or
in the last 2 weeks because of low progesterone level.
Long-acting progestin contraceptives (Norplant) may
cause irregular heavy menses because there is a lack
of estrogen to stabilize the endometrium. Changes in
bleeding patterns for progestin users necessitate ruling
out pregnancy.
Is this prepubertal bleeding?
Key Questions
n How old is the child?
n Is there a family history of early sexual development?
n Is there a family history of bleeding problems or
blood dyscrasias?
n Did the child ingest any birth control pills or
estrogens?
n Are there any accompanying symptoms?
Pediatric Vaginal Bleeding
In the United States, the average age of menarche is
12 years old. Vaginal bleeding before age 9 is abnor-
mal and may indicate foreign body or injury. The pres-
ence of secondary sexual characteristics indicates
sexual precocity. Newborn girls may experience breast
bud enlargement, galactorrhea, and a small amount of
vaginal bleeding from maternal exogenous hormones.
These symptoms resolve without intervention within a
few weeks.
Chapter 33 • Vaginal Bleeding 399
Although uncommon, malignant genital tract
tumors in girls can cause vaginal bleeding. Vaginal
adenosis and adenocarcinoma are the most common
tumor types.
Bleeding Problems
A family history of bleeding problems or a positive
review of systems and physical examination indicating
the presence of petechiae or bruises suggests a bleeding tendency. Platelet counts or clotting studies are
indicated.
Accompanying Symptoms
Vulvovaginitis is the most common pediatric gynecological problem. Vaginal discharge, vaginal itching,
vulvar erythema, and lesions often accompany vulvovaginal bleeding. A foul-smelling discharge is noted
with bacterial vaginosis, trichomoniasis, and a foreign
body. Wet mounts and cultures should be taken for all
vaginal discharges of a child, including cultures for
gonorrhea and Chlamydia. If a sexually transmitted
infection (STI) or sexual abuse is suspected, syphilis
and human immunodeciency virus (HIV) testing
should be done. Throat and rectal cultures for gonorrhea and Chlamydia should also be obtained.
Trauma to the perineum is more common in children
because there is less subcutaneous fat of the vulva.
Large lacerations and hematomas warrant referral for
examination and repair under anesthesia.
Prolapse of the urethra may cause bleeding. It is
accompanied by pain at the meatus and pain with
urination.
Is the patient experiencing anovulatory
cycles?
Key Questions
n Have you experienced irregular menstrual cycles?
n Are you having symptoms of menopause (e.g.,
vaginal dryness, hot ashes, night sweats)?
n At what age did your mother or grandmother go
through menopause?
Irregular Menstrual Cycles
Anovulatory cycles are the most common cause of
irregular bleeding patterns among females beginning
(adolescent) or ending (perimenopausal) their menstrual cycles. It is estimated that 80% of young adolescents will be anovulatory during the rst year of
400 Chapter 33 • Vaginal Bleeding
https://t.me/med1917
menstruation. Regular ovulatory cycles are usually
established by the second year of menses but may take
up to 5 years.
Menopause Symptoms
The hot ash is the most commonly experienced
symptom of menopause. It is a sensation of increased
upper body warmth that begins in the chest area and
progresses upward to the neck and face. Sweating,
which can be so profuse as to leave clothing wet, follows the hot ash. Hot ashes often lead to disturbed
sleep patterns, insomnia, and fatigue. Vaginal atrophy
is experienced by the patient as vaginal dryness, dyspareunia, and atrophic vaginitis (see Chapter 34).
Atrophic changes can affect the urinary system, causing urinary frequency, urgency, and exacerbation of
stress incontinence.
Menopausal Syndrome
The frequency of monthly ovulation becomes irregular
at about 40 years of age, and this leads to intermittent
symptoms of menopause. The time frame from onset
of symptoms to complete cessation of menstruation is
termed the perimenopause or climacteric phase. The
perimenopause phase can last up to 10 years. If menopause is completed before age 40, it is considered
premature ovarian failure. The age of menopause is
genetically determined and will be similar to those of
the woman’s mother and grandmother. Menopause is
unrelated to age of menarche, pregnancies, or contraceptive methods used.
Is the patient experiencing postmenopausal
bleeding?
Key Questions
n How old were you when you stopped menstruating?
n Do you still have a uterus?
n Did you have a hysterectomy? Why did you have
surgery? Were your ovaries removed?
n Are you using hormones?
Age at Menopause
The average age for a woman in the United States to go
through menopause is 51 years. Menopause is dened as
1 year without menstrual cycles. However, a diagnosis
can be accurately made earlier by measuring the rising
follicle-stimulating hormone (FSH) and the falling
estradiol levels. Postmenopausal bleeding is any bleeding that occurs after the establishment of menopause.
Vaginal bleeding after menopause warrants investigation to rule out endometrial cancer. Box 33-2 lists risk
factors for endometrial cancer.
Intact Uterus
In postmenopausal women with an intact uterus, unexplained vaginal bleeding suggests endometrial hyperplasia with a suspicion for endometrial cancer.
Hysterectomy
Any vaginal bleeding after a hysterectomy justies
suspicion of cancer, but the bleeding will most likely
be a symptom of atrophic vaginitis. If the ovaries were
left in place at the time of the hysterectomy, the woman
may not experience menopausal syndrome until about
8 to 10 years after the surgery. The ovaries become
atrophic and nonfunctional over time, probably secondary to altered blood ow resulting from the surgery.
The bleeding of atrophic vaginitis occurs from the
slightest trauma; even wiping the perineum with tissue
after urination can cause spotting.
Hormone Therapy
Hormone therapy for menopausal symptoms may cause
vaginal bleeding in women with an intact uterus. Regimens for women with an intact uterus include the cycling
of estrogen and progestin and continuous daily doses of
both hormones. The cycled hormones produce a regular
scheduled bleeding. However, the continuous daily combination therapy will often cause amenorrhea after 3 to
6 months of use. After a pattern of amenorrhea has been
established, new bleeding should be investigated.
Unopposed estrogen therapy in a woman with an
intact uterus predisposes her to endometrial cancer
Box 33-2
Risk Factors for Endometrial
Cancer
Postmenopausal with intact uterus and abnormal vaginal
bleeding
Family history of endometrial cancer
Hypertension, diabetes mellitus, liver disease
Obesity
Chronic anovulatory cycles
Unopposed estrogen therapy with intact uterus
Tamoxifen therapy
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