[size=20px]A 4-year-old presents with a history of recurrent brown vaginal discharge, associated with odour. It has recurred despite multiple courses of oral antibiotic therapy with amoxicillin.

What is the next most appropriate step?

 

a- Consult child protective services.

 

b- Perform a vulvar biopsy.

 

c- Flush or irrigate the vagina.

 

d- Prescribe an antifungal cream.

 

e- Prescribe a course of trimethoprim and sulfamethoxazole.[/size]

(Untitled)

 

a

think again my dear

C

A - would be an initial step

but I would also do EUA of the perineum and vagina as it might be Foreign body in vagina

C

correct

 

Foreign bodies often are diagnosed after a prolonged period (up to a year or more) of persistent or recurrent vaginal discharge. The discharge is typically either brown or bloody. Eighty per cent of vaginal foreign bodies are small pieces of toilet paper. Toilet paper can be flushed from the vagina successfully in cooperative patients. older children (mean age of 7 years) tend to be more compliant with office vaginal irrigation performed with a paediatric catheter or feeding tube and a syringe. Foreign bodies should be suspected: if discharge is refractory to implementation of appropriate hygiene measures and antibiotic therapy, if discharge is bloody or if there is a history of previous foreign body placement. A foreign body will be recovered in up to 10% of girls taken for vaginoscopy under anaesthesia with symptoms suspicious for one. The differential diagnosis of a patient with vaginal discharge includes non-specific vulvitis, infectious vaginitis, lichen sclerosis, atopic dermatitis and other dermatoses. Recurrent discharge that is specifically bloody suggests a foreign body. Prepubertal girls with unoestrogenised genitalia rarely have yeast vaginitis, unless they have a predisposing factor such as immunocompromisation, diabetes or are still wearing nappies. Non-specific vulvitis generally responds well to improved vulvar hygiene measures. In regard to specific vaginal infections, shigella can cause an acute vaginitis associated with bloody vaginal discharge. Shigella is more common in communities where infection is endemic. Transmitted by the faecal–oral route it may also produce severe diarrhoea and fever associated with either a mesenteric adenitis or acute terminal ileitis. Shigella is treated with sulfa antibiotics. The most common causes of infectious vaginitis are the upper respiratory tract pathogens: streptococccus group A and Haemophilus influenzae; both usually present with an acute course, with profuse vaginal discharge and associated severe vulvar and vaginal erythema. Chlamydia and gonorrhoea do produce vaginitis in prepubertal girls, and may present with vaginal discharge. The prevalence of sexually transmitted infections in sexually abused children is low; chlamydia rectovaginal infection rates range from 4% to 17% of abused children. If a sexually transmitted infection is suspected, culture remains the preferred method of documentation of infection to limit the risk of false positive tests in a low prevalence population. Cultures should be obtained from any suspected site of penetration (oral, genital, rectal). If a nucleic acid amplification test (NAAT) is performed, a positive result should be confirmed by a second different NAAT test.