Make the Diagnosis: Summer 2017

D.M. is a 5-year-old female with no past medical or surgical history who presented to an outside hospital with persistent urinary leakage. She had been wet through potty training, but had achieved perfect continence of stools. She had no fevers, respiratory symptoms, or diarrhea. Her urinalysis was normal. On ultrasound she had normal kidneys and a normal appearing bladder that held 15 cc. She was able to completely empty her bladder. D.M. had been seen by her primary physician, who had placed her on a timed voiding schedule, but she seemed to be nearly continuously incontinent of urine.

On physical exam the abdomen was soft and nontender. The anus was in a normal position. The kidneys were not palpable. The bladder was empty on percussion. The outward appearance of the mons pubis was normal with the exception of an apparent subtle defect, which suggested that there was a pubic diastasis of about 1 cm. There did appear to be a soft dimple in between the pubic bones at the level of the pubic rami. On inspection of the perineum, there appeared to be redness and apparent irritation in the area of the urethra and vagina. Close inspection appeared to suggest a bifid clitoris.

Edward Hart, MD, of Cambridge, Massachusetts, submitted the first correct answer to last issue's challenge, autism spectrum disorder, the subject of this issue’s cover article.