Vaginal Foreign Bodies and Child Sexual Abuse: An Important Consideration
A 4-year-old girl presented to the PED at the University of Maryland Children’s Hospital (UMMC) with a chief complaint of vaginal itching for 2 weeks and a vaginal discharge for 2 days. When directly questioned by her mother and the emergency physician (EP), the girl denied being touched in the genitourinary area. Her mother reported that the discharge was initially white, but over the next two days it became malodorous and green.\nHer physical examination in the PED was noteworthy for erythema of the labia majora and a copious greenish-white vaginal discharge. A foreign body was suspected, and vaginal irrigation revealed a small piece of foreign material, believed to be toilet tissue, which was removed. Chlamydia and gonorrhea cultures of the vaginal discharge were obtained, and the child was discharged from the PED with instructions to follow up with her pediatrician if the discharge persisted.\nSix days later the PED was notified that the culture of the vaginal discharge was positive for N. gonorrhea. The family was contacted and the child was referred to the Sexual Abuse & Rape Assessment (SARA) Center at the UMMC for further evaluation and treatment. Further history revealed persistence of the vaginal discharge, which had now taken on a more prominent greenish color. Her exam was otherwise unchanged from the initial presentation, and the child was treated with a single dose of IM Ceftriaxone. The case was then referred to the local child advocacy center (CAC) for further evaluation of sexual abuse.