Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits. Dealing with a foreign body. The genital examination of the infant through adolescence.Curr Opin Obstet Gynecol 1993;5:753, 11. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. 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. 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. Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. 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. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. 25:50. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body. Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. In: Emans SJ, Laufer MR, Goldstein DP, eds. The prepubertal vagina is neutral or slightly alkaline. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. Newborns and pubescent girls sometimeshave significant vaginal secretions because of estrogen effect. The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole. 0:31. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. Gynecological examination of the prepubertal girl can be challenging. They schedule and bill separately for their services, and are not employees of the Hospital. There is no significant geographic barrier between the vagina and anus. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. Although anovulatory cycles are common in the years after menarche, there are established norms and, alternatively, abnormal findings that require further investigation. The color ranges from white or gray to yellow or green. A child should never be restrained for a gynecologic examination . She also discusses the preferred diagnostic modality and when to consider surgery. 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. A gentle, patient approach is important when examining a prepubertal girl. 11 mins, 28 secs. 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. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. Children are not skilled historians and will often ramble, introducing many unrelated facts. Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. This is to help girls understand that there is a doctor dedicated to their reproductive health. Am J Obstet Gynecol 1987;156:581. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). Employee communication. The source maybe the vulva, vagina, endometrium, and occasionally the urethra. Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement. 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. Adult pinworms maybe visible at night. In this video, adolescent gynecologist Eliza Buyers, MD, reviews the pathophysiology and diagnosis of PCOS in adolescent patients. She provides an overview of the physiology and evaluation of AUB, including recommendations on when to consider referring patients to our Spots and Dots Clinic. 1 A vaginal self-exam is not the same as a vulvar examination. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. Physicians may elect to treat the primary symptoms of vulvovaginitis for 2 to 3 weeks, realizing that on rare occasions they could be missing something more serious. Some healthcare professionals listed on our website have medical privileges to practice at Childrens Hospital Colorado, but they are community providers. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Thus, a positivevaginal culture should be considered evidence of sexual abuse in the child.Likewise, C trachomatis rarely persists beyond age 2 to 3 years, and mostinfants and toddlers have been treated since birth with an antibiotic thatwould treat Chlamydia. 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. You can use this section to discover where and how this . The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. Below is a collection of all our Stanford 25-generated videos also found throughout the website. Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. Asking the child to pretend to blow out candles on a birthday cake may facilitate the 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. A tape testmay be useful for suspected pinworm. Before puberty, the girls reproductive organs are in a resting, dormant state. This video demonstrates how to perform a comprehensive pelvic examination, including an examination of the external genitalia, a Papanicolaou test to screen for cervical dysplasia, a bimanual exami. 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 allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). . Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Routine biopsy of the normal-appearing contralateral ovary should be avoided. In this video, the Director of the Fertility Preservation and Reproductive Late Effects Program, Leslie Appiah, MD, discusses the prevalence of reproductive late effects and female risk stratification based on age and therapy doses. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. 12.4 ). Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . Obstet Gynecol Clin NorthAm 1992;19:39, 10. 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. Different positions for performing a gynecologic examination on a child. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. The introduction of any instrument into the vagina of a young child takes skillful patience. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. Treatment is the same as for labialadhesions. Leukorrhea may be present. Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes. Diagnose this skin lesion with newest Stanford 25 video and topic. Children often cannot hold still for long intervals while instruments are being located. 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. 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. Adolescents often come for examinations with the preconceived idea that it will be very painful. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors. N gonorrhoeaerarely persists beyond the newborn period without symptoms. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. 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. Includes speculum and bimanual exams. This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. For example, if a girl complains of . Most such traumas involve straddle injuries. 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. A pelvic exam usually lasts only a few minutes. The most common gynecologic condition of children is vulvovaginitis . In addition, periods may exacerbate other medical issues or they may prefer to have no periods due to hygiene or other concerns. Pads should be placed in the mothers lap because examination often is associated with urination. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. That's why we conduct research to advance care techniques that can be used for our patients and kids anywhere. From AccessMedicine. Physiologic leukorrheacan be confused with vulvovaginitis. Visualization of the introitus is better achieved using the previously described traction and the Valsalva maneuver than separation because it gives a deeper view of the structures and partial visualization of the vagina. 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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. W Webcam. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. Medical Forensic Exam Videos Adult/Adolescent Sexual Assault Medical Forensic Exam This 58 minute video includes: History Taking Discussion of HIV Prophylaxis Full anogenital exam with evidence collection Demonstration of Foley catheter technique Demonstration of toluidine blue dye application Photography Pediatric History Taking This 63 minute video uses unscripted interactions with children . The major factor in childhood vulvovaginitis is poor perineal hygiene. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases. 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. After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. 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. A patient presents with foot pain and these chronic findings? 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. Symptoms of vulvovaginitis can occur if an adhesionis extensive enough to cause pooling of urine above the agglutinated tissue.If that is the case, a child may have symptoms of urethritis or a historyof urinary tract infections. The majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). An Initiative of the Program for Bedside Medicine, Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. This short 1958 educational film from the American Cancer Society shows how to perform a routine pelvic examination and cytologic test for the detection of cancer of the uterus. Cystic ovarian masses commonly occur in infants, children and adolescents. A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal abuse. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. 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. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. In this video, Veronica Alaniz, MD, provides guidelines for examining and understanding genital lacerations and hematomas resulting from vulvovaginal trauma, including blunt trauma or straddle injury and penetrating. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. Pokorny SF. Much of the history must be obtained from the parents . A gentle, patient approach is important when examininga prepubertal girl. Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. Pediatrics 1980;65:758, 4. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. Abraham-Vergheses-TED-Talk:-Over-one-million-views! The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). What is it? Rectoabdominal exam. 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. Stanford Medicine 25 Launches New Website, Medical Errors and Adverse Events from a Missed or Inadequate Physical Exam, Announcing the Stanford 25 Skills Symposium, Thyroid Nodule Overview - The Thyroid Exam. 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. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . Specific vulvovaginitis. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. 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 ). A genital examination might be indicated in relation to suspected or alleged: Sexually transmissible infection Pregnancy Pelvic pain or other genital symptoms or concerns Sexual assault Foreign body Cervical cytology screening is not 5currently recommended until the age of 25 years. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases. An older child should be asked whom she prefersto have in the room during the examination. Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.Referral should be made to a gynecologist with experience in pediatric gynecology. 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. Approach to evaluation of premenarcheal child with a gynecologicproblem. This includes the process for diagnosis and considerations for work-up, evaluation and treatment, such as support and counseling. Your doctor checks your vulva, vagina, cervix . With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). Many gynecologic conditions in children may be diagnosed by inspection . Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. Interruptions should be avoided. Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. Topics for the pediatric nurse practitioner to be aware of. Pediatrics 1990;86:428, 9. Gidwani GP. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam.

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