• Injury to the vulva--The term "straddle injury" typically is used to describe any injury that occurs from straddling an object or falling on an object while in a straddle position. Unfortunately, this type of injury is pretty common, caused by a slip that lands a girl on the bar of a bike, while she's sliding down a banister, or if she falls down while dangling one foot in a swimming pool.
  
  If bleeding is involved but does not include any internal injuries, it can often be managed simply by putting pressure on the area with ice in a plastic bag, wrapped in a towel or washcloth. This numbs the area as well as diminishes swelling and bleeding.
  
  If the bleeding doesn't stop easily or is coming from inside the vagina, if there is a lot of swelling or bruising, if the girl has difficulty urinating, or if the story of how the injury occurred simply is unclear or suspicious, the child must see a doctor. Sometimes stitches are required.



• Vaginitis--Some vaginal infections can lead to bleeding. A medical professional can take a culture of the discharge to determine which bacteria are responsible for the infection. These types of infections respond to oral antibiotic treatment and local care, and in due time, the bleeding will stop. Good hand washing on the part of the child can help prevent the spread of these sorts on infections from the mouth or rectum into the vagina.
  
  While less common in young girls, sexually transmitted infections, such as gonorrhea, unfortunately can be found to cause this type of bleeding.



• Foreign object in the vagina--One of the most common causes of vaginal bleeding in a child is the presence of a foreign body in the vagina. Most often, the culprit is a small bit of toilet paper. However, all sorts of foreign bodies reportedly have been found in the vaginas of little girls, from bobby pins to Barbie shoes. It isn't clear how the foreign body gets into the girl's vagina, since most of the time young girls either don't remember putting it there or don't admit to doing so.
  
  If the material is soft, a medical professional often can flush it out with a squirt of saline solution into the vagina, but sometimes a trip to the operating room with anesthesia is needed for removal.



• Urethral prolapse--A less common cause of vulvovaginal bleeding is urethral prolapse, in which the end of the tube that allows the bladder to empty (the urethra) turns inside out. When this happens, there appears to be a ring of dark pink irregular tissue at the opening of the vagina, which may be associated with pain or discomfort during urination.
  
  This usually resolves without surgery simply by having the child soak the area in warm water and using topical emollients. Some experts recommend topical estrogen cream or antibiotics, but this should always be discussed with a healthcare professional.



• Other vulvovaginal problems--Other vulvar or vaginal problems can lead to bleeding. For example, rare cancers can cause bleeding in little girls. Although it's important to keep in mind that these more serious causes are extremely uncommon, all girls with vaginal bleeding should be seen by a practitioner who has experience with the gynecological care of children.



• Uterine bleeding--The age of menstruation in the United States is getting younger and occurs earlier in African-Americans than in Caucasians. These days, vaginal bleeding can be normal after age eight in whites and age seven in blacks, provided other signs of puberty--such as breast development, body odor, growth spurt, or pubic hair--are already present and other causes have been ruled out.
  
  If there are no other signs of puberty, then the bleeding is probably not coming from the uterus. True precocious puberty, where uterine bleeding and/or other signs of puberty are seen in girls as young as two or three, requires evaluation by a pediatric endocrinologist and can be delayed if treated early. This not only helps to temporarily stop the menstrual bleeding, but also can be important in determining the girl's ultimate height, since early onset of puberty is associated with shorter adult height (under 5 feet).

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