Review Question - QID 215023

This patient most likely has a vaginal foreign body, which is the most common cause of foul-smelling vaginal discharge with spotting or bleeding in children. In this case, the foreign body is likely toilet paper given the white clumps seen on exam, which is a common cause of vaginal foreign body in children. When the foreign body is relatively small and visible on exam or the cause is toilet paper, the best first step in management is irrigation with warm fluid. If the object is larger, then anesthesia and pelvic exam are needed to remove it.

Incorrect Answers:
Answer 1: Although urinary tract infections can occur in young girls, typical symptoms include burning or pain with urination, foul-smelling urine, or increased urinary frequency or urgency. The patient may have lower abdominal pain and may have fever if pyelonephritis develops. In this patient, the foul-smelling discharge with white clumps on exam and the patient’s history of spotting are not consistent with a urinary tract infection.

Answer 3: Symptomatic bacterial vaginosis is uncommon in pre-pubertal girls, but it can occur during a girl’s period or after sex. Symptoms include a fishy smell with thin white or grey discharge, vaginal itching, and burning during urination. Clue cells will be visible on saline smear. Bacterial vaginosis is typically treated with metronidazole.

Answer 4: Vulvovaginal candidiasis, or a yeast infection, is common in young girls. Symptoms include itching and irritation, burning during urination, and redness and irritation of the vulva. On exam, patients often have thick, white vaginal discharge with a cottage cheese appearance; however, it is usually odorless in contrast to the foul-smelling discharge found in a vaginal foreign body.

Answer 5: It is always important to be aware of potential signs and symptoms of sexual abuse in children. Vaginal bleeding and spotting could be a sign of sexual abuse in a young girl. However, the foul-smelling white clumps seen on physical exam in this patient is consistent with a vaginal foreign body.

Bullet Summary:
Vaginal foreign body is the most common cause of foul-smelling discharge with spotting or bleeding in children and can be treated with warm water irrigation if the foreign body is small and visible on exam or if the cause is toilet paper.