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Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty

Different positions for performing a gynecologic examination on a child. A, Frog leg position. B, Knee-chest position. C, Prone position. D, Sitting on mom’s lap.
( A, from John J. McCann, M.D., F.A.A.P., David L. Kerns, M.D., F.A.A.P. Examination technique, frog leg position. Union, MO: Evidentia Learning; 2016. Available at www.childabuseatlas.com ; B and C and D, from Finkel MA, Giardino AP, eds. Medical Examination of Child Sexual Abuse: A Practical Guide. 2nd ed. Thousand Oaks, CA: Sage, 2002:46-64.)
Examination of the vulva, hymen, and anterior vagina by gentle lateral retraction ( A ) and gentle gripping of the labia and pulling anteriorly ( B ).
(From Emans SJ. Office evaluation of the child and adolescent. In: Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 4th ed. Philadelphia: Lippincott-Raven; 1998.)
Types of hymens. A, Crescentic. B, Annular. C, Redundant. D, Microperforate. E, Septated. F, Imperforate. G, Hymeneal tags.
( A through F, from Perlman SE, Nakajima ST, Hertweck SP. Clinical Protocols in Pediatric and Adolescent Gynecology. London: Parthenon Publishing Group; 2004; G, from John J. McCann, M.D., F.A.A.P., David L. Kerns, M.D., F.A.A.P. Hymenal tag, a congenital variation. Union, MO: Evidentia Learning; 2016. Available at www.childabuseatlas.com .)
Common Indications for Pelvic Examination in the Adolescent
Clinical Features of Children Presenting With Vulvovaginitis
From Pierce AM, Hart CA. Vulvovaginitis: causes and management. Arch Dis Child . 1992;67(4):509-512.
From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. Indiana Med. 1993;86(3):236-239.
Etiologic Factors of Premenarcheal Vulvovaginitis
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Aug 8, 2021 | Posted by drzezo in GYNECOLOGY | Comments Off on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty
It is important to give the child a sense that she will be in control of the examination process. Emphasize that the most important part of the examination is just “looking” and that there will be conversation during the entire process.
Many gynecologic conditions in children can be diagnosed by inspection alone.
The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years.
The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman.
The vagina of a child is 4 to 5 cm long and has a neutral pH.
During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. The normal prepubertal uterus and ovaries are nonpalpable. The relative size ratio of cervix to uterus is 2:1 in a child.
Many adolescent girls do not want other observers, such as mothers, in the examining room.
It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation and discharge.
Positive identification of gonorrhea or chlamydia in a child with premenarcheal vulvovaginitis is considered diagnostic of sexual abuse. However, many infants are infected with Chlamydia trachomatis during birth and remain infected for up to 2 to 3 years in the absence of specific antibiotic therapy.
The major factor in childhood vulvovaginitis is poor perineal hygiene.
A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body.
In the period surrounding the time of puberty, children often develop a physiologic discharge secondary to the increase in circulating estrogen levels.
The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene.
The majority of cases of persistent or recurrent nonspecific vulvovaginitis respond to improved hygiene and treatment of irritation resulting from trauma or irritating substances.
The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole.
The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue.
Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. However, it is important to do a thorough workup because of the serious sequelae of some of the causes of vaginal bleeding.
Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment.
The usual cause of genital trauma during childhood is an accidental fall. Most such traumas involve straddle injuries.
Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. Because of compassion and empathy, the gynecologist may underestimate the extent of the anatomic injuries.
Small follicular cysts in preadolescent girls are usually self-limiting.
Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents.
Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. In preadolescent girls, both benign and malignant ovarian tumors are usually unilateral. Routine biopsy of the normal-appearing contralateral ovary should be avoided.
Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common.
The most common malignancy in preadolescent girls is a germ cell tumor.
Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass.
The surgical therapy of an ovarian neoplasm in a child should have two goals: the appropriate surgical removal of the neoplasm and the preservation of future fertility.
Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance.
Presence or absence of Doppler flow in the ovary on ultrasound is not diagnostic of ovarian torsion, and the decision to pursue surgical intervention should be based on the level of clinical suspicion.
Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. This chapter considers gynecologic diseases of children from infancy through adolescence. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters.
The evaluation of children’s gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . The evaluation of young girls is age dependent. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. Thus the office visit and the gynecologic physical examination are performed differently in a prepubertal child compared with an adolescent girl or a mature reproductive-age woman.
Considerable effort should be devoted to gaining the child’s confidence and establishing rapport. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ).
The pediatric gynecologic visit may be unique to both the child and the parent. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . This may create considerable and understandable anxiety in the child and parent. The majority of children’s gynecologic problems are treated by medical , rather than surgical, means .
The most common gynecologic condition of children is vulvovaginitis . Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia.
A successful gynecologic examination of a child demands that the physician employ an exam pace that conveys both gentleness and patience with the time spent, without seeming to be hurried or rushed. One excellent technique is for the physician to sit, not stand, during the initial encounter. This conveys an unhurried approach. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as children’s posters are present. Interruptions should be avoided. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit.
The components of a complete pediatric examination include a history, inspection with visualization of the external genitalia and noninvasive visualization of the vagina and cervix, and, if necessary, a rectal examination ( ).
Obtaining a history from a child is not an easy process. Children are not skilled historians and will often ramble, introducing many unrelated facts. Much of the history must be obtained from the parents . However, young children can help define their exact symptoms on direct questioning.
In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. One way to describe genital area and breasts is to call them “ private areas ” and define this as meaning areas that are covered by a bathing suit. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse.
After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . It is important to give the child a sense that she will be in control of the examination process. A helpful technique is to place the child’s hand on top of the physician’s hand as the abdominal examination is being performed and to give her some choices, such as having a doll, an electronic tablet, or a toy with her. This will give the child a sense of control and divert the child’s attention if she is ticklish or is squirming. Emphasize that the most important part of the examination is just “looking” and there will be conversation during the entire process. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant.
A child’s reaction will depend on her age, emotional maturity, and previous experience with health care providers. She should be allowed to visualize and handle any instruments that will be used. Many young children’s primary contact with providers involves immunizations; children should be assured that this visit does not involve any “shots.” It is also helpful to assure the adult accompanying the child that speculums are not part of the examination.
Occasionally it is best to defer the genital examination until a second visit . This is a difficult decision and is based on the extent of the child’s anxiety in relation to the severity of the clinical symptoms. Physicians may elect to treat the primary symptoms of vulvovaginitis for 2 to 3 weeks, realizing that on rare occasions they could be missing something more serious. It is recommended that the examination start with the nongenital areas , such as listening to the heart and lungs; an abdominal examination and inspection of the skin should be performed. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. A child should never be restrained for a gynecologic examination . Often reassurance and sometimes delay until another day are the best approaches. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. The most important technique to ensure cooperation is to involve the child as a partner. Ideally children should feel they are part of the examination rather than having an exam “done to them.”
Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. A handheld mirror may help in some instances when discussing specifics of genital anatomy. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. Children often cannot hold still for long intervals while instruments are being located.
The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. 12.1 ). An infant may be examined on her mother’s lap. Pads should be placed in the mother’s lap because examination often is associated with urination. Young children may be examined in the frog leg position, and children as young as 2 to 3 years of age may be examined in the lithotomy position with use of stirrups, although this is generally used for girls aged 4 to 5 years and older.
Once the child is positioned, the vulvar area and introitus should be inspected. Many gynecologic conditions in children may be diagnosed by inspection . The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. 12.2 ). Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Visualization of the introitus is better achieved using the previously described traction and the Valsalva maneuver than separation because it gives a deeper view of the structures and partial visualization of the vagina.
The second phase of the examination involves evaluation of the vagina . This can be accomplished without the insertion of any instruments. One method is to use the knee-chest position (see Fig. 12.1 , B ). The child lies prone and places her buttocks in the air with legs wide apart. The vagina will then fill with air, aiding the evaluation. The child is told to have her abdomen sag into the table. An assistant pulls upward and outward on the labia majora on one side while the examiner does the same with the nondominant hand on the contralateral labia. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina.
While the light from the otoscope or ophthalmoscope is shone into the vagina, the examiner can evaluate the vaginal walls and visualize the cervix as a transverse ridge, or flat button, that is redder than the vagina. This technique is generally successful in cooperative children unless there is a very high crescent-shaped hymen, in which case it is too difficult to shine the
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