Prepubertal Vagina

Prepubertal Vagina

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1 Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston.

A B Berenson .

Curr Opin Obstet Gynecol .

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1 Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston.

Hornor G.
Hornor G.
J Pediatr Health Care. 2010 May-Jun;24(3):145-51. doi: 10.1016/j.pedhc.2008.10.007. Epub 2008 Dec 18.
J Pediatr Health Care. 2010.

PMID: 20417886

Pillai M.
Pillai M.
J Pediatr Adolesc Gynecol. 2008 Aug;21(4):177-85. doi: 10.1016/j.jpag.2007.08.005.
J Pediatr Adolesc Gynecol. 2008.

PMID: 18656071

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Berkowitz CD.
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J Child Sex Abus. 2011 Sep;20(5):537-47. doi: 10.1080/10538712.2011.607752.
J Child Sex Abus. 2011.

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Price J.
Price J.
Best Pract Res Clin Obstet Gynaecol. 2013 Feb;27(1):131-9. doi: 10.1016/j.bpobgyn.2012.08.008. Epub 2012 Nov 10.
Best Pract Res Clin Obstet Gynaecol. 2013.

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McCann J, Miyamoto S, Boyle C, Rogers K.
McCann J, et al.
Pediatrics. 2007 Nov;120(5):1000-11. doi: 10.1542/peds.2006-0230.
Pediatrics. 2007.

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For many reasons including the recent increase in the reporting of sexual abuse, more physicians are being asked to perform genital examinations on prepubertal girls. Recent studies have clarified the appearance of structures in this area in nonabused children and demonstrated both acute and chronic changes that may result from trauma.

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Overview of vulvovaginal conditions in the prepubertal child
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Overview of vulvovaginal conditions in the prepubertal child
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Literature review current through: Sep 2022. | This topic last updated: Nov 23, 2021.
This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.
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● Clinical manifestations – Medical history of foreign body placement is usually lacking. Chronic vaginal discharge, intermittent bleeding or spotting, and/or a foul-smelling odor are the usual clinical manifestations. If the patient has pain and a gray, watery discharge, an intravaginal battery should be suspected [ 2-4 ].
● Diagnosis – Visualization of the foreign body during examination (child in the knee-chest position ( picture 1 )) confirms the diagnosis. A vaginoscopy can be performed in the office if tolerated; otherwise, an examination under anesthesia may be necessary. On plain radiographs, vaginal button batteries appear as a radio-opaque, circular object located in the pelvis [ 5 ].

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Pediatrics for the Clinician |
April 01 1980

Division of Adolescent Medicine and Gynecology, The Children's Hospital Medical Center, Boston, and the Departments of Pediatrics and Obstetrics and Gynecology, Harvard Medical School, Boston

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Division of Adolescent Medicine and Gynecology, The Children's Hospital Medical Center, Boston, and the Departments of Pediatrics and Obstetrics and Gynecology, Harvard Medical School, Boston

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https://doi.org/10.1542/peds.65.4.758

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S. Jean Emans, D. P. Goldstein; The Gynecologic Examination of the Prepubertal Child with Vulvovaginitis: Use of the Knee-Chest Position. Pediatrics April 1980; 65 (4): 758–760. 10.1542/peds.65.4.758
Vulvovaginitis is a common complaint in the prepubertal child. The proximity of the vagina to the anus and the thin uncornified vaginal epithelium make the young child especially susceptible to vulvovaginal infection. Not only is hygiene often suboptimal in this age group, but pinworm infestations, bubblebaths, harsh soaps, and tight-fitting nylon tights can all contribute to the vulvar irritation. Because children are frequently sent to gynecologists, traumatized by a rectal examination as the first part of the evaluation, or sent for an x-ray of the vagina with the hope of excluding a radiopaque foreign body, we believed it would be useful to present our approach to the gynecologic evaluation of the prepubertal child in which the kneechest position is used for visualizing the vagina.
The evaluation of a prepubertal child with vulvovaginitis in the Gynecology Clinic of Children's Hospital is done in the following order: (1) history; (2) inspection of the perineum with the child supine; (3) visualization of the vagina and cervix in kneechest position; (4) cultures; and (5) a rectal examination in girls with vaginal bleeding or abdominal pain.
The knee-chest position (Figure) provides a particularly good view of the vagina and cervix without instrumentation. The little girl is asked "to lie on her tummy with her bottom in the air." She is reassured that the examiner plans "to take a look" but "will not put anything inside her." The child rests her head to one side on folded arms and supports her remaining weight on bended knees (6 to 8 in apart).

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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.)
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