Leukorrhea may be present. 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. Before puberty, the girls reproductive organs are in a resting, dormant state. 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. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. These data can be used to inform the design of teaching interventions to improve skill in this area. They schedule and bill separately for their services, and are not employees of the Hospital. Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Office evaluation of the child and adolescent. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Having a relationship with a pediatric gynecologist can help girls take . Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. This includes feeling a girl's uterus and ovaries to be sure everything's normal. 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. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. If the bleeding is unexplainedor you suspect a foreign body or tumor and the vagina cannot be fully visualized,an exam under anesthesia by a gynecologist is necessary. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. A discharge that is both bloody and purulent is likely not from vulvovaginitis but from a foreign body (see Vaginoscopy for Prepubertal Bleeding without Signs of Puberty later in this chapter), although patients infected with some pathogens, particularly Shigella boydii, often present with a bloody or blood-tinged discharge . Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . This includes feeling a girl's uterus and ovaries to be sure everything's normal. 4:40. Pay special attention to anatomic and pathophysiologicdifferences in the child. . The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. Urethral prolapse also can present with bleeding. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. The Pelvic Exam. The last step in the pelvic examination may be a rectal examination. 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. 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. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as childrens posters are present. 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. There often are predisposing factors that lead to vulvar irritations, such as the use of perfumed soaps or the pressure from tight seams of jeans or tights, which create denudation, allowing the rectal flora to easily infect the irritated epithelium. Stanford ENT Free Oral Screening November 2nd. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation and discharge. After your examination is complete, congratulate the child for her cooperationand bravery. This can be accomplished without the insertion of any instruments. Usually, it is related to menstrual cramps, though many other conditions can cause it, including endometriosis, a painful disease in which uterine tissue grows outside the uterus. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. When indicated, both vaginoscopy and hysteroscopy procedures can be performed by a pediatric and adolescent gynecologist at Childrens Hospital Colorado. Loose-fitting cotton undergarments should be worn. Lichen sclerosus may present as vulvar discomfort or pruritus.It is characterized by atrophy of the vulvar skin, which causes the labiaand clitoral hood to appear thin, white, and parchment-like. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later). Caring pediatric nurses are available 24/7 to help answer your questions. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. Visualizing the hymen. This period of transition involves important physical and emotional changes. 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. Can you diagnose the cause of the patients lymphedema? Pelvic Exam The pelvic exam is a vital part of every woman's preventative care and is also important towards making a number of diagnoses when presenting with abdominal or pelvic complaints. The most common gynecologic condition of children is vulvovaginitis . The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. Philadelphia, PA, WB Saunders, 1981, 5. Recurrent vulvovaginitis, persistent bleeding, suspicion of a foreign body or neoplasm, and congenital anomalies may be indications to perform a vaginoscopy and examine the inside of the vagina. Affecting approximately one in every 4,500 newborn girls, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome can be challenging to treat both medically and psychologically, due to the potential loss of fertility. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. One excellent technique is for the physician to sit, not stand, during the initial encounter. The child can assist you by holding herlabia apart. Inspect the child's breasts and palpate themfor signs of puberty. There is no significant geographic barrier between the vagina and anus. Vulvovaginitis in children may also be caused by a variety specific pathogens such as group A or group B b-hemolytic streptococci, Haemophilus influenzae, and Shigella boydii ; Neisseria gonorrhoeae, Trichomonas vaginalis, and Chlamydia trachomatis may also be responsible in cases associated with abuse but are significantly less common. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Physiologic leukorrheacan be confused with vulvovaginitis. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. In this video, Stephen Scott, MD, MPH, emphasizes the fact that pain originates from nerve signaling and uses this understanding to help him identify the source of pain and its cause. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. 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. Mycotic vaginal infections may be seen in immunosuppressed prepubertal girls such as those with human immunodeficiency syndrome (HIV) or diabetes or on chronic steroid therapy. Addressing the Youth Mental Health Crisis, Department of Pediatric and Adolescent Gynecology, Fertility Preservation and Reproductive Late Effects Program, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome, Insurance, billing and payment information. 12.1 ). Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. Non-sexually acquired genital ulcers (NSGUs) in adolescent females are uncommon, painful skin lesions on the mucous membranes of the vulva and vaginal structures, unrelated to sexual activity. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers. 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. Different positions for performing a gynecologic examination on a child. 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). 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. Children usually are asymptomatic,but they may present with secondary infection. They may be discovered by means of a flashlight or by dabbing of the vulvar skin with clear cellophane adhesive tape, ideally before the child has arisen in the morning. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . 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. The film opens with a woman sitting in an office of a physician. Pads should be placed in the mothers lap because examination often is associated with urination. 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. Pediatrics 1990;86:428, 9. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. 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 ( ). Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. These are the organs related to your monthly menstrual cycles, to sexual activity, and to pregnancy and childbirth. Many dermatologic disorders, suchas atopic dermatitis, seborrhea, and psoriasis, can manifest as vulvitisor vulvovaginitis. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. The pelvic exam doesn't change whether you are a virgin. Because the pubertal changes are often a cause of concern for adolescent girls and their parents, the gynecologist must offer the adolescent patient an empathetic, kind, knowledgeable, and gentle approach. A carefulhistory is important; a history of hormonal medications or signs of precociouspuberty may suggest the cause of the bleeding. You may need a pelvic exam sooner if you are experiencing problems with your period or have other symptoms, including: Pain in your lower abdomen or pelvic area. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. A complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). 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 child should be instructed to void with her knees spread wide apart (even while facing the toilet to improve urine draining) and taught to wipe from front to back after defecation. In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. Join Childrens Hospital Colorado pediatric experts for a virtual Were passionate about providing answers, treatment and care for the full range of female reproductive health concerns, from infancy through adolescence and into adulthood. Girls should have their first gynecological exam between the ages of 13 and 15. So this is the scariest picture weve got! Because the child lacks the labial fat pads and pubic hair of the adult, when a child squats, the lower one-third of the vagina is unprotected and open. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. Watch the gynecology medical education videos below for protocols and research from our experts to help improve the care of your patients. Despite widespread belief, mycotic (yeast) vaginal infections are not common in prepubertal children because the alkaline pH of the vagina does not support fungal growth. Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. However, young children can help define their exact symptoms on direct questioning. Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. There will also be an extra sheet you can use to cover yourself. The American Academy of Pediatrics (AAP) promotes the inclusion of the pelvic examination in the primary care setting within the medical home. DR. KAHN is Assistant in Medicine, Children's Hospital, Boston, and Instructor in Pediatrics, Harvard Medical School, Boston, MA.DR. 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. Pokorny SF. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits. HPV is also verticallytransmitted and lesions may appear in the first few years of life. In life-threatening emergencies, find the emergency room location nearest you. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Nonspecific vulvovaginitis. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. 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. Support teaching, research, and patient care. 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. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. During a pelvic exam, a doctor evaluates your reproductive organs. Interruptions should be avoided. The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen. The most important technique to ensure cooperation is to involve the child as a partner. Urethritis can be caused by an infectiousagent, irritation, or trauma. Sometimes doctors do pelvic exams if they think there's a problem. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. (From Emans SJ. Menstrual bleeding in adolescents can be chaotic. The vulva and anus. The pediatric gynecologic visit may be unique to both the child and the parent. Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. 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. The child lies prone and places her buttocks in the air with legs wide apart. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation. Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing. The introduction of any instrument into the vagina of a young child takes skillful patience. Obtaining a history from a child is not an easy process. In noncooperative children, treatment should not be withheld if a specimen cannot be collected and empiric treatment may be started., many techniques have been described for attempting to collect a specimen, including the use of a very slim urethral Dacron swab moistened with nonbacteriostatic saline (used for collection of male urethral cultures). 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 light into the small aperture of the vaginal introitus. Bacterial vaginosis during pregnancy may lead to increased risks for preterm birth, preterm delivery, and spontaneous abortion, according to new research in the Archives of Gynecology and Obstetrics. 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. In this video, Chief of Pediatric and Adolescent Gynecology, Tricia Huguelet, MD, discusses the epidemiology, clinical features and management of ovarian cysts that may occur during the fetal and neonatal periods, and on through adolescence. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. In addition, periods may exacerbate other medical issues or they may prefer to have no periods due to hygiene or other concerns. Bates' Visual Guide features head-to-toe and systems physical exam videos completely reshot with an emphasis on clinical accuracy and patient care. When this intervention fails, there should be greater suspicion of bacterial colonization; in this case a reasonable approach is the use of broad-spectrum oral antibiotics such as amoxicillin or trimethoprim/sulfamethoxazole given for 10 to 14 days. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. Many young childrens 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.
