If early in menarche should prompt an investigation for inherited bleeding disorders.

Bernard-Soulier syndrome causes mucocutaneous bleeding, thrombocytopenia, and giant
B HCG could be detected  in urine or blood, as early as 10–12 days after conception, and
levels will increase exponentially early in pregnancy before leveling off approximately in
week 10–12.

A single β-hCG level, however, is not able to indicate whether the gestational sac is
implanted in the correct location.

Presents in any postmenarcheal patient with abdominal pain, syncope, or vaginal bleeding.

Transvaginal sonogram can detect intrauterine gestational sac in a patient with a β-hCG
level of 1,000–2,000 mIU/mL or who is at approximately 4–6 weeks’ gestation, whereas a
transabdominal sonogram requires a level of at least 6,500 mIU/mL.

If the ultrasound demonstrates an empty uterus with either a mass in another pelvic
structure or abnormal amounts of free fluid in the pelvis, the patient should be treated as
having a likely ectopic pregnancy and obstetrics/gynecology should be consulted.

β-hCG level in a patient with a viable intrauterine pregnancy should double in 48 hours; If
the increase is less, it is indicative of an ectopic pregnancy. If the level decreases, than it is
likely either a nonviable pregnancy, which will undergo a spontaneous abortion, or an
ectopic pregnancy that should resolve spontaneously.
Ectopic Pregnancy
Vaginal Foreign Body
Foul-smelling vaginal discharge (with or without bleeding) should raise suspicion for a
vaginal foreign body, particularly if it is recurrent or recalcitrant despite treatment.

Remember to consider sexual abuse as a contributing factor in the diagnosis of a vaginal
foreign body.

Vaginal irrigation can be used in a cooperative patient to flush out a vaginal foreign body.

Examination under anesthesia should be used in an uncooperative patient if there is
suspicion of a vaginal foreign body.
Balanoposthitis – inflammation of glans and foreskin
Treatment – Kelfex or augmentin

Phimosis - Unable to retract foreskin - Normal finding until 4-5 years of age
Treatment if persistant or found later – steroids

Paraphimosis - Tight Foreskin is retracted proximal to the glans - “Stuck retracted”
Treatment - Manual reduction or dorsal slit

Labial adhesions – NOT congenital – due to inflammation
Treatment – none resolve on own IF excessive or associated with UTI – Estrogen cream

Urethral prolapse - Red – soft – annual dough-nut shaped mass-spotty blood in the underwear
Treatment – Estrogen cream plus sitz baths
Male and Female Tit Bits