The presence of sexually transmitted organisms in a child is usually a strong indication that sexual abuse may have taken place, and appropriate referral and follow-up is necessary (see Chapter 9 ). To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. The film opens with a woman sitting in an office of a physician. 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. There are many narrow-diameter endoscopes that will suffice, including the Kelly air cystoscope, contact hysteroscopes, pediatric cystoscopes, small-diameter laparoscopes, plastic vaginoscopes, handheld disposable hysteroscopes (e.g., Endosee Handheld Hysteroscopy System, CooperSurgical Inc., Trumbull, CT), and special smaller, narrower speculums designed by Huffman and Pederson. New onset of Trichomonas vaginitis in theprepubertal child is associated with sexual abuse. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. The color ranges from white or gray to yellow or green. Philadelphia, PA, WB Saunders, 1981, 5. A hand lens or otoscope often is helpful. Management is dictatedby the diagnosis: antibiotics and hygiene measures for infectious vulvovaginitis,surgical repair of trauma if necessary, biopsy of polyps or suspected tumors,removal of foreign bodies, further investigation for sexual abuse if itis suspected by exam or history or if condylomata are found, sitz bathsand estrogen cream for urethral prolapse, and further investigationinto the etiology of precocious puberty. Am J Obstet Gynecol1987;157:950, 6. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. The differential diagnosis of persistent or recurrent vulvovaginitis not responsive to treatment should include considerations of a foreign body, primary vulvar skin disease (allergic or contact dermatitis), ectopic ureter, and child abuse. 0:38. After observing an increase in the rate of syphilis cases, the Cleveland Clinic Ob/Gyn & Womens Health Institute has partnered with the Center for Pediatric Infectious Diseases to evaluate the effectiveness of current testing strategies. In this age of reliable access to ultrasonography, the internal genital examination to evaluate the uterus and ovaries can be performed with the assistance of sonography , often sparing the child from a rectal or pelvic examination. Emphasize setting the stage to make the examination a positive experience for your young patient. Children are not skilled historians and will often ramble, introducing many unrelated facts. 12.3 ). 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. This may create considerable and understandable anxiety in the child and parent. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. Much of the history must be obtained from the parents . Obtaining a history from a child is not an easy process. Topics for the pediatric nurse practitioner to be aware of. If vaginalcultures are not needed, lidocaine jelly can be used to decrease the child'sdiscomfort. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. The most common gynecologic condition of children is vulvovaginitis . If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. The classic symptom of pinworms is nocturnal vulvar and perianal itching. 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. 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. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Hysteroscopy is performed in the operating room under general anesthesia. The Pelvic Exam. Before the exam, you will need to undress and put on a gown. 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. Managing vulvovaginitis. 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. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. 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 ( ). In addition, she reviews the potential for ovarian torsion, including signs and symptoms, evaluation and management. Sometimes doctors do pelvic exams if they think there's a problem. Although rare, it isimportant to recognize sarcoma botryoides, or embryonal rhabdomyosarcoma.Such a tumor can present as a lower abdominal mass or as vaginal bleedingor passage of part of the tumor. 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. 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. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses. An ectopic ureter emptying into the vagina may only intermittently release a small amount of urine; thus this rare congenital anomaly should be considered in the differential diagnosis in young children. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. A nurse retrieves the patient from the office and takes her to an exam room. Ideally children should feel they are part of the examination rather than having an exam done to them.. Childrens Hospital Colorado providers are faculty members of the University of Colorado School of Medicine. After viewing, providers will be better able to counsel patients and their families on treatment methods as well as provide them with updated resources on this topic. 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. (From Emans SJ. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. In determining the diagnosis, it may be helpfulto inquire about persistently wet underwear, recurrent fevers, unexplainedUTI, and abdominal or lower back pain. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. An older child should be asked whom she prefersto have in the room during the examination. What is it? The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. We see more, treat more and heal more children than any hospital in our seven-state region. Pediatrics 1990;86:428, 9. Genital bleeding should always be assessed thoroughly. Endocrinologic issues, such asneonatal bleeding due to maternal estrogen withdrawal, precocious puberty,exogenous hormone preparations, and hypothyroidism should be ruled out.Dermatoses such as lichen sclerosus can cause bleeding. 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. Learn how doctors should perform a bedside swallow evaluation! 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. This easily assembled adaptation uses a No. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases. This is a difficult decision and is based on the extent of the childs anxiety in relation to the severity of the clinical symptoms. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. Pinworms are another cause of vulvovaginitis in prepubertal children. This is an important step toward reinforcing the child's sense ofcontrol over the examination. During the exam, your doctor will check your vagina, uterus, and ovaries. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. 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. Watch the gynecology medical education videos below for protocols and research from our experts to help improve the care of your patients. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. Capraro VJ: Gynecologic examination in children and adolescents.Pediatr Clin North Am 1972;19:511, 12. In severe cases, clobetasol (Temovate)may be useful, applied twice daily for two weeks and then gradually taperedover the next several weeks, but this requires expertise and careful supervisionwith frequent follow-up. The extent of labial adhesions and associated symptoms are variable (seefigure "B"). Gynecologic Examination with Pap Smear. 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. If you put your stethoscope over this, what will you hear? Experts in Children's Hospital Colorado's Department of Pediatric and Adolescent Gynecology are dedicated to advancing the field to improve the care and lives of all young females with gynecologic conditions. Adolescents often come for examinations with the preconceived idea that it will be very painful. Children usually are asymptomatic,but they may present with secondary infection. 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. Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics(Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies). At the 44th National Association of Pediatric Nurse Practitioners Conference, data was presented on how to diagnose and treat polycystic ovarian syndrome in adolescent patients. Those in middle or late adolescence (aged 15 to 19 years) may be more accepting of the idea of an examination and more likely to cooperate with the proper counseling and in the appropriate setting. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . 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. 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. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. Loose-fitting cotton undergarments should be worn. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Abraham-Vergheses-TED-Talk:-Over-one-million-views! Noninfectious causes of vulvovaginitis also are common. Heavy menstrual bleeding is common in adolescents, with about 15% to 40% of teens experiencing heavy bleeding, but many teens dont recognize that their bleeding is abnormal. Gynecological examination of the prepubertal girl can be challenging. 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. Without continuation of the hygiene measures, however, broad-spectrum antibiotics will only offer temporary relief and the problem is likely to recur ( ). 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 ( ). If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. The importance of patient/family preference along with individualization based on medical history and treatment goals is reviewed. Approach to evaluation of premenarcheal child with a gynecologicproblem. A girl who has nonspecific vaginitis shouldbe counseled to do the following: (1) practice good perineal hygiene; (2)urinate with her knees spread apart; (3) wear white cotton underpants andloose clothing; (4) take sitz baths once or twice a day; (5) avoid irritantssuch as bubble bath and use hypoallergenic soaps; and (6) apply a barrierointment such as A and D, Vaseline, or Desitin to the perineum. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. When is it best to reassure, and when is it necessary to evaluate? After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. 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). Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. A child should never be restrained for a gynecologic examination . She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. The ideal pediatric endoscope is a cystoscope or hysteroscope because the accessory channel facilitates the retrieval of foreign bodies while at the same time allowing a vaginal lavage to be performed. 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. In life-threatening emergencies, find the emergency room location nearest you. 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. EMANS is Chief, Adolescent Division, Children's Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston. Your patient gets this rash, whats the diagnosis? 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. Pelvic pain is common in adolescent girls. The most common malignancy in preadolescent girls is a germ cell tumor. A vaginal self-examination is a way to look at your vulva and vagina to better understand your body and to spot problems that may need medical attention. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. The vagina will then fill with air, aiding the evaluation. An ectopic ureter can present as persistent wetnessor purulent discharge. Learn Peds Genitourinary 04 Genital Exam Intro from UBC Learn Pediatrics on Vimeo. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. Your doctor checks your vulva, vagina, cervix . In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as childrens posters are present. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies.