Newborn vaginal bleeding
Caused by hormones from mother into baby's body.
Normal
Usually disappear over several weeks spontaneously.

Hymenal skin tags
A small piece of skin protrude from the vagina
Normal
Usually shrinks down their own when child grows up
Don’t need treatment
Don’t rub or clean the skin tags excessively which can cause irritation and bleeding

Labial adhesions
The labia minora (outer lips of the vulva) from each side fuse together in the middle, which can cover over all or part of the vaginal opening.
Occur most often in infants and girls aged 3 months to 6 years old
2% of prepubertal girls, higher in infants

Causes
Local inflammation and irritation, recurrent vulvovaginitis
Low estrogen levels in infants and prepubertal girls
Stools not wiped out and irritate the area
Urine pooling in the vagina
Soaps or bubble bath
Local tissue trauma

Treatment
Pull-down and tract open maneuver: apply Aquaphor, Petroleum Jelly, or A & D ointment by Q-tip to adhesion area, gently tract labia to side several times when changing diapers, at least two times a day.
Topical Estrogen cream: applied by Q-tip only to the labia adhesion area each evening or twice daily for several weeks. Estrace is better than Premarin because it doesn't contain an alcohol base and better tolerated. The success rate of topical estrogen is 40 to 90%.
Maintenance and prevention: once the labia are separated, apply an emollient such as Aquaphor, Petroleum Jelly, or A & D ointment daily for several months to keep the labia open and decrease irritation of the vulva area.
Periodic observation: If not response to estrogen cream, the adhesions usually resolve in their own when child grows up with increasing estrogen level.
Referral to Gynecologist or pediatric urologist if has extensive scarring or in cases resistant to medical management.

Ambiguous Genitalia
Newborns’ genitalia are abnormal which can vary from the more obviously apparent to the almost invisible. Features in genetic females (babies with two X chromosomes)
Clitoris: enlarged that appears to be a small penis
Labia may be fused which looks like a scrotum
Vagina is not visualized
Urethral opening appears along, above, or below the surface of the clitoris.

Developmental disorders of the female reproductive tract

Urethral Prolapse
Usually occurs around age 5-8.
Painless bleeding, bright red, and protruding vaginal mass
Unknown etiology.
More common in African American and Hispanic girls.
Confirm diagnosis: probing the middle of the mass with pediatric feeding tube identifying the opening and obtaining urine.
Treatment: topical estrogen or sitz baths. Surgery is rarely necessary.

Vulvovaginitis
Vulvitis: itching and red vulva (genital skin), or painful urination (dysuria)
Vaginitis: vaginal discharge, foul-smelling

Cause
Most-nonspecific: poor genital hygiene, fecal contamination, soap irritation, vaginal foreign body
Specific infections: ardneralla vaginalis, Candida (yeast ), Enterococci, Anaerobic, Protozoa, Helmints-Pinworms, Viruses, STDs, systemic illnesses, polyps or tumors (rare)

Treatment
Initial management-Good genital hygiene usually result in resolution of 95% of the cases
Dress child in white 100% cotton underpants, loose-fitting.
Encouraged to urination with her legs spread widely apart.
Wiping the genital area from the front to the back after each urination or bowel movement.
Wash genital area twice a day with warm water or take shower, or soak in warm clear water twice per day (sitz baths).
Avoid harsh soaps, bubble baths, and shampoo from the bath water
Use shampoos and soap in the shower, avoid the affected area.
Apply soothing cream such as A&D, Johnson -Johnson or Balmex twice per day.
Mild hydrocortisone with an antipruritic such Benedryl at bedtime can help itching

Recurrent or with other symptoms
Vaginal culture
Urine analysis or/and urine culture as needed
Oral antibiotics as indicated
Topical estrogen cream or antibiotic ointment is often helpful
Recurrent despite antibiotic treatment
Exam under anesthesia to rule out foreign bodies and other causes
Specific Treatment
Gardneralla vaginalis- antibiotics
Candida (yeast )- Nystatin, Clotrimazole (Lotrimin) or Ketoconazole (Nizoral)
Enterobiasis (Pinworms)- Mebendazole
Giadiasis - Metronidazole
Pediculosis pubis - 1%Lindane lotion (Kwell) or 5% Permethrin cream (Elimite)
Scabies- 1%Lindane lotion (Kwell) or 5% Permethrin cream (Elimite)

Foreign Body in Vaginal
Foul smelling, brown or bloody discharge, and redness over external genital area
Common foreign bodies: toilet paper, crayons, paper clips, pen caps, and rolled up balls
Best visualized in the distal vagina with the child in the knee-chest position
Can be irrigated out of the vagina with about 20cc of lukewarm tap water (not saline) delivered via a pediatric feeding tube