Toddler Pussy Exam

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© 2021 MJH Life Sciences And Contemporary Pediatrics. All Rights Reserved.
© 2021 MJH Life Sciences™ and Contemporary Pediatrics. All rights reserved.
Gynecologic examination of the prepubertal girl
A gentle, patient approach is important when examining a prepubertal girl. Pay special attention to anatomic and pathophysiologic differences in the child. Emphasize setting the stage to make the examination a positive experience for your young patient.
Choose article section...Principles of gynecologic assessmentTaking the historyBeginning the examinationExamining the external genitaliaExamining the vaginaConcluding the examinationSIDEBAR: Common gynecologic findings in the prepubertal girlVulvovaginitisVaginal bleedingLabial adhesions
By Jessica Annette Kahn, MD, and S. Jean Emans, MD
A gentle, patient approach is important when examininga prepubertal girl. Pay special attention to anatomic and pathophysiologicdifferences in the child. Emphasize setting the stage to make the examinationa positive experience for your young patient.
Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. Routine gynecologic examinationof infants and children can help prevent future health problems such asvulvovaginitis by giving the clinician the opportunity to educate parentsabout perineal hygiene.1 During the annual genital inspection,the pediatrician also may discover such significant abnormalities as clitoromegaly,signs of early puberty, vulvar dermatoses, or rarely hymenal or vaginaltrauma. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. Making the examination a positive experience, ifpossible, therefore is critical.2
Pediatricians are uniquely qualified to perform an appropriate clinicalassessment because of their expertise in examining young children and knowledgeof many anatomic and pathophysiologic conditions specific to children. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. Thisarticle focuses on setting the stage so that the examination is a positiveexperience for the patient and her family, describes specific techniquesand strategies for performing an appropriate and non-traumatic examination,and reviews diagnosis of disorders commonly found in prepubertal children.
One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. This canbe accomplished by establishing rapport with the child, keeping the paceunhurried, proceeding from less to more intrusive examinations and askingfor consent before proceeding, and allowing the child to be an active participantin the process as much as possible.2
Another important consideration when performing a gynecologic assessmentis providing anticipatory guidance to the patient and her parents. You canmodel for parents appropriate ways to discuss gynecologic issues with theirchild, and help parents and children understand the importance of discussingissues related to reproductive healthand sexuality during the prepubertalyears.1
Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. Most young children will prefer to have aparent--usually their mother--in the room at all times. In some cases, however,it is helpful to spend time alone with the child during the interview, andto ask whether she prefers to be alone for the examination. When alone withan examiner, a child may disclose abuse or other concerns, and allowingher to be interviewed or examined alone may give her a greater sense ofcontrol and responsibility for her own health.
The history is critical in terms of making a diagnosis, but it also providestime for you to establish rapport with the patient and elicit her understandingof her symptoms and expectationsof the visit. Whenever possible, addressquestions directly to the child.
You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. Opening questions can include inquiriesabout the family structure and recent changes, school, friends (such aswhether she has a best friend), and the types of activities she enjoys.It is important to assess who cares for the child and to uncover--both fromthe parent and from the child--information about any history of sexual abuseor current concerns in that regard. Asking the child whether anyone hasever touched her in a way that made her feel uncomfortable often is helpfulin drawing out this information.
The medical history should be guided by the presenting complaint anddifferential diagnosis. If the issue is vaginal discomfort, pruritus, ordischarge, the differential diagnosis includes nonspecific or infectiousvulvovaginitis, vulvar skin disease, lichen sclerosis, and presence of aforeign body. Your questions should address the onset of symptoms; the type,frequency and timing of discharge; associated bleeding, pain, or pruritus;foreign body insertion; perineal hygiene; recent infections in the patientor her family (such as streptococcal pharyngitis or pinworms); recent antibiotictherapy; masturbation; and a history of sexual abuse.
If the issue is "vaginal" bleeding, the differential diagnosisincludes condyloma acuminatum, urethral prolapse, vascular lesions, precociouspuberty, hormonal medications, and (rarely) sarcoma botryoides, in additionto vulvovaginitis, foreign body, and lichen sclerosus. The history shouldassess the child's growth and development; signs of puberty such as breastdevelopment, axillary hair, pubic hair, growth spurt, and leukorrhea; genitaltrauma; vaginal discharge; and a history of foreign body insertion. A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal abuse. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. Urethritis can be caused by an infectiousagent, irritation, or trauma.
Past medical history should include information about congenital anomalies,systemic disorders with dermatologic manifestations, and growth and development.Congenital anomalies, and particularly renal anomalies, may be associatedwith gynecologic anatomic abnormalities. Many dermatologic disorders, suchas atopic dermatitis, seborrhea, and psoriasis, can manifest as vulvitisor vulvovaginitis. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders.
After you have established a rapport with the child and taken her history,you should explain the gynecologic examination to both the child and herparent. This is an important step toward reinforcing the child's sense ofcontrol over the examination.
Explain to the child that the most important part of the examinationis "looking," and that it is important for her to communicatewith you during the examination. Tell the child that the examination willnot hurt, and if you are going to use instruments, that these tools areall specially designed for little girls.1Let the child look atand touch the instruments to be used, such as an otoscope or a hand lens.When talking with parents, it is important to carefully explain that thechild's hymen will not be altered in any way by the examination, becausemany parents do not fully understand the anatomy of the vagina and hymen.Basic diagrams of the anatomy may be helpful.
A parent or caretaker is usually present during the examination of ayoung child, and most children are comfortable with the parent sitting closeby or holding their hand. An older child should be asked whom she prefersto have in the room during the examination. Using a hand mirror can be usefulto promote education, distract a child, and allow her to participate moreactivelyin the examination. Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. If thechild is anxious, you may need to leave the room and return when she feelsready to be examined; in some cases, the procedure may have to be postponedfor several days. However, if the reason for the visit is urgent, such assignificant vaginal bleeding, and a child is uncooperative, you may haveto perform the exam under anesthesia.
Begin the procedure with relevant elements of the general pediatric exam,including height and weight and examination of the thyroid, neck, breasts,lungs, heart, and abdomen. Inspect the child's breasts and palpate themfor signs of puberty. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. Tailor your gynecologic examination to the presentingissue. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation.
Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). For a small childwho is fearful of the exam, it may be best to have the mother sit on thetable in a semireclined position (feet in or out of stirrups) with the child'slegs straddling her thighs (Figure 3).
If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. Have the child resther head to one side on her folded arms and support her weight on bent knees,which are six to eight inches apart. The child's buttocks will now be heldup in the air and her back and abdomen will fall downward (Figure 4). Usingthis position and an otoscope head for magnification and light, you willbe able to visualize the lower vagina, and usually the upper vagina andcervix, in 80% to 90% of prepubertal girls.3
With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). The child can assist you by holding herlabia apart. Inspect her for pubic hair and note the condition of the urethra,size of the clitoris, any signs of estrogenization, configuration of thehymen, and perineal hygiene. Newborns will exhibit maternal estrogen effects:the labia majora, labia minora, and clitoris will be relatively large, theepithelium a dull pink color, and the hymen often thick and redundant. Afterthe newborn period, the average size of a normal clitoral glans in a premenarchalchild is 3 mm in length and 3 mm in transverse diameter.4 Inprepubertal girls, the vaginal mucosa and perihymenal tissue will be moreatrophic and appear thin and red.
Visualizing the hymen. If you cannot fully visualize the hymen, ask thechild to cough or take a deep breath, or pull the labia gently forward anddown or laterally yourself so that you can see the hymen and the anteriorvagina. A hand lens or otoscope often is helpful. Classifications of hymenalconfiguration include posterior rim (crescent), annular, or redundant (Figures6 and 7).5 Congenital anomalies, including imperforate, microperforate,and septate hymen, also can occur.
In a microperforate hymen, it may be difficult to identify an opening.To establish its presence, try squirting a small amount of warm water orsaline with a syringe or angiocath, placing the girl in the knee-chest position,or probing with a small urethral catheter, feeding tube, or nasopharyngealCalgiswab moistened with saline or vaginal lubricant (Figure 8). If vaginalcultures are not needed, lidocaine jelly can be used to decrease the child'sdiscomfort. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. An imperforate hymen appearsas a thin membrane, and will bulge if hydromucocolpos is present. Vaginalagenesis is characterized by thick vestibular tissue, and often there isa dimple surrounded by a vulvar depression where the hymen should be.6
Acquired hymenal abnormalities usually are caused by sexual abuse andrarely by accidental trauma. Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. The significance of the diameter of the hymenalorifice is controversial; a large orifice may be consistent with a historyof sexual abuse, but it is not an absolute criterion.7,8
The vulva and anus. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. If extensive labial adhesions are present, you maynot be able to adequately examine the hymen and vagina and will need toreexamine the child after she has successfully completed treatment withlocal hygiene measures and topical estrogen (see Sidebar, "Common gynecologicfindings in the prepubertal girl").
Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits.
Chronic vaginal discharge, which can occur with a vaginal foreign bodyor vaginitis, also can lead to vulvitis, which is characterized by an erythematous,hyperpigmented, or hyperkeratotic line along the dependent portion of thelabia majora.9 Clitoral erythema and pruritus often is a symptomof a prior or current vulvitis, and may be caused by adhesions between theclitoral hood and the glans clitoris. Treatment is the same as for labialadhesions. Lichen sclerosis also can present as vulvar discomfort or pruritus.It is characterized by atrophy of the vulvar skin, which may distort theanatomy of the labia and clitoris, producing ecchymoses and "bloodblisters."
A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Viscous lidocaine and warmsaline for irrigation through an IV set-up may be helpful when examininga child who has an acute straddle injury and bleeding.
After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.6 In premenarchal girls, the vagina is 4 to 5 cm long withthin, red epithelium. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. Leukorrhea may be present.
The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen. For girls olderthan 2 years, the knee-chest position also permits excellent visualizationof the vagina and cervix without instrumentation.3 If necessary,an experienced examiner or pediatric gynecologist may use a small vaginoscope,cystoscope, hysteroscope, or flexible fiberoptic scope with water insufflationof the vagina to improve visualization.
These procedures are usually performed under anesthesia. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11
Dealing with a foreign body. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass.
Obtaining cultures. When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. Remember that this procedure can be painful to achild if you use a dry cotton swab or do not perform the examination gently.A better way of obtaining specimens from the prepubertal child is to usea nasopharyngeal Calgiswab moistened with nonbacteriostatic saline. Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin.If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort. You can also ask the child to cough in order todistract her and cause her hymen to open.
A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.12 Another method ofobtaining samples, used by Pokorny and Stormer, consists of a catheter-in-a-cathetertechnique.13 The proximal end of an IV butterfly catheter isinserted into the distal end of a size 12 bladder catheter, and a 1-mL tuberculinsyringe with 0.5 to 1.0 mL of sterile saline is attached to the hub of thebutterfly tubing. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.).
Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques. Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating. The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse.
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