This 6-year-old girl was referred to the endocrine service for evaluation of an ‘enlarged clitoris’. The workup for a metabolic disorder was unremarkable. When a physician attempted to examine her genitalia, the child became hysterical and ran from the examination room. The endocrine team was alarmed by her behaviour and was concerned that she might have been sexually abused. Their concern was based on the child’s obvious distress at the prospect of a genital examination. When questioned about her child’s behaviour, the mother reported that the child has had this reaction to genital exams ever since she was examined by another physician who ‘made her bleed there’. When she was examined, these findings were seen (Images 49a and 49b).

How can a genital examination be facilitated in a frightened child?

What additional historical information is needed?

What diagnosis can be made from these findings?

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The child was able to cooperate for the genital examination after an extensive preparation by a child development specialist. The images were obtained during that exam after preparation. Image 49a demonstrates what appears to be an enlarged/prominent clitoris. Image 49b was obtained with mild downward traction and clearly demonstrates an adhesion of the superior/anterior aspect of the labia minora.

On further questioning of the mother, she reported that the child had complained of burning on urination and was seen by a primary care provider. While the physician was examining the child, the mother observed that he ‘pulled on her down there’. The child began to cry and subsequently the mother noted blood in the child’s underwear.

These findings are consistent with labial adhesions that were partially separated during the previous examination. The non-estrogenized genital tissue of a prepubertal girl can be traumatized with vigorous traction during an examination. 1