Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. Office evaluation of the child and adolescent. It is important to give the child a sense that she will be in control of the examination process. 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. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. A visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help. Small follicular cysts in preadolescent girls are usually self-limiting. 12.2 ). 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. The Pelvic Exam. Philadelphia, PA, WB Saunders, 1981, 5. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. A gentle, patient approach is important when examininga prepubertal girl. It is not diagnostic since few vaginal diseases can be diagnosed visually. In 2019, there were over 1.7 million new cases of cancer, with 10,270 cases occurring among children ages 0 to 14 years of age and 70,000 occurring in adolescents and young adults. Observation alone is appropriate for small adhesions. Sometimes doctors do pelvic exams if they think there's a problem. It is important to give the child a sense that she will be in control of the examination process. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. Vulvovaginitis also may be associated with aspecific infectious agent. Am J Obstet Gynecol 1987;156:581. Treatment for extensivelabial adhesions is topical estrogen cream applied along the adhesion withgentle pressure twice a day for three weeks, then at bedtime for three weeks.Once the adhesion has resolved, a barrier ointment should be used to preventrecurrence. These minor accidents result in injury because the genital tissues in children, without estrogen, are very thin and easily traumatized. A mounding of hymeneal tissue is often called a bump. Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. The pathophysiology of the majority of instances of vulvovaginitis in children involves a primary irritation of the vulva, which may be accompanied by secondary involvement of the lower one-third of the vagina. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. 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. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. Forpersistent cases, prescribe a one- to three-month course of a low-potencytopical steroid preparation, such as hydrocortisone 1% or 2.5%, followedby careful hygiene and use of emollients. The classic symptom of pinworms is nocturnal vulvar and perianal itching. The most common malignancy in preadolescent girls is a germ cell tumor. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Children's Hospital Colorado partners with NRC Health to gather star ratings and reviews from patients, residents and family survey data. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. 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Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Prep for OSCEs! Dealing with a foreign body. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). In addition, she reviews the potential for ovarian torsion, including signs and symptoms, evaluation and management. Making the examination a positive experience, ifpossible, therefore is critical.2. Pay special attention to anatomic and pathophysiologicdifferences in the child. For example, if a girl complains of . Abraham-Vergheses-TED-Talk:-Over-one-million-views! Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. 1. Specific vulvovaginitis. What questions should PNPs consider related to womens health? A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. 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. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. There are no reported cases of congenital absence of the hymen. 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. If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. The pelvic exam doesn't change whether you are a virgin. 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. In this video, Tricia Huguelet, MD, provides an overview of normal menstrual flow, screening for heavy menstrual flow in teens, and identifying red flags for an underlying bleeding disorder. 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. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. 12.3 ). Your patient gets this rash, whats the diagnosis? A gentle, patient approach is important when examining a prepubertal girl. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle. 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"). Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . Considerable effort should be devoted to gaining the childs confidence and establishing rapport. Show Transcript. Caring pediatric nurses are available 24/7 to help answer your questions. A helpful technique is to place the childs hand on top of the physicians 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. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . This is a difficult decision and is based on the extent of the childs anxiety in relation to the severity of the clinical symptoms. Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. . Diagnose this skin lesion with newest Stanford 25 video and topic. Many adolescent girls do not want their mother, guardian, or other observers in the examining room, and in many adolescent gynecology visits, a full pelvic examination is unnecessary ( ). Inspect the child's breasts and palpate themfor signs of puberty. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). 0:38. Urethral lesions alsoshould be considered. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. So this is the scariest picture weve got! 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 child can assist you by holding herlabia apart. W Webcam. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. Vaginoscopy is a diagnostic procedure that can be used to evaluate the inside of the vagina and is recommended for girls who are too young for a speculum exam or cannot tolerate one. Thefinding of genital herpes type 2 is a strong indication of sexual abuse.Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.14Trichomonaswill rarely cause symptoms in the newborn period and spontaneously resolveswith waning of estrogen levels. This is an important step toward reinforcing the child's sense ofcontrol over the examination. Teens don't usually get pelvic exams. Female Pelvic Exam. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. Capraro VJ: Gynecologic examination in children and adolescents.Pediatr Clin North Am 1972;19:511, 12. Slang terminology for speculums among teens includes the threatening label the clamp. Teens should be assured that although the examination may include mild discomfort, it should not be painful . Asking the child whether anyone hasever touched her in a way that made her feel uncomfortable often is helpfulin drawing out this information. 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. Loose-fitting cotton undergarments should be worn. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). The second phase of the examination involves evaluation of the vagina . The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. 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. 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. Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. In: Emans SJ, Laufer MR, Goldstein DP, eds. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. 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. Cultures from the vagina indicate normal rectal flora or Escherichia coli. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. In preadolescent girls, both benign and malignant ovarian tumors are usually unilateral. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. 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The last step in the pelvic examination may be a rectal examination. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. Clinical manifestations includepruritus, vaginal discharge and odor, vaginal bleeding, dysuria, and vulvarredness and irritation. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. 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. EMANS is Chief, Adolescent Division, Children's Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal 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 vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. 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. 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. This includes the process for diagnosis and considerations for work-up, evaluation and treatment, such as support and counseling. Inspect the child's breasts and palpate themfor signs of puberty. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. Vulvovaginitis is the most common gynecologic problem in prepubertal girls. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. 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 ( ). Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits.