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. Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. 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. Loose-fitting cotton undergarments should be worn. Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. A gentle, patient approach is important when examininga prepubertal girl. 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. 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. 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. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. Historically, these masses were surgically removed, often involving removal of the entire ovary. 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. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Pads should be placed in the mothers lap because examination often is associated with urination. W Webcam. 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. These minor accidents result in injury because the genital tissues in children, without estrogen, are very thin and easily traumatized. Childrens Hospital Colorado providers are faculty members of the University of Colorado School of Medicine. Condylomata acuminataalso can cause bleeding but may be difficult to recognize, because in prepubertalchildren, they often do not have the typical cauliflower-like appearance.Rather, genital warts typically present as exophytic lesions or papuleswith small red punctations over the surface. With puberty , the prepubertal vagina becomes acidic under the influence of bacilli dependent on a glycogenated estrogen-dependent vagina. 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. These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. Patient has this new skin finding, what should you worry about? Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Host virtual events and webinars to increase engagement and generate leads. A tape testmay be useful for suspected pinworm. Your pediatrician will describe each step of the exam. 0:31. 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). The vagina will then fill with air, aiding the evaluation. This chapter considers gynecologic diseases of children from infancy through adolescence. Gynecologic Examination with Pap Smear. Female Pelvic Exam. Making the examination a positive experience, ifpossible, therefore is critical.2. 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. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation (discomfort/pruritus) or discharge ( Table 12.1 ) ( ). The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Power your marketing strategy with perfectly branded videos to drive better ROI. 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. This is referred to as nonspecific vulvovaginitis. 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. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Adult pinworms maybe visible at night. Teens don't usually get pelvic exams. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. The evaluation of young girls is age dependent. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. There are no reported cases of congenital absence of the hymen. Examination of the Female Genitourinary System. 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. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. All-New Assessment Videos! The introduction of any instrument into the vagina of a young child takes skillful patience. Pokorny has described another method for collecting fluid from a childs vagina using a catheter within a catheter ( ). Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. It is important to give the child a sense that she will be in control of the examination process. However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. 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. These exams may be done as part of a yearly check-up for teenagers or young adults, however, you may need them sooner or . Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. Pokorny SF. You can use this section to discover where and how this . Children often cannot hold still for long intervals while instruments are being located. In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube 0:00 / 15:07 Dr. Ahmed Darwish - Pediatrics: General Examination Dr. Ahmad Darwish 13.1K subscribers Subscribe 1.5K 114K views 5. If a child's symptoms are severe,a one- to four-week course of a moderate-potency ointment can be recommended,followed by a lower-potency preparation. 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. 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. Using a hand mirror can be usefulto promote education, distract a child, and allow her to participate moreactivelyin the examination. 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. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. . Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. If patients are going to be treated with antibiotics, one should attempt to collect a sample of the vulvovaginal discharge for culture before initiation of the antibiotics . First gynecological exam is about establishing care and a relationship not a pelvic exam. 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. 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. When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. 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. If vaginalcultures are not needed, lidocaine jelly can be used to decrease the child'sdiscomfort. Cultures from the vagina indicate normal rectal flora or Escherichia coli. 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. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. Buyers also reviews treatment options, including menstrual suppression, with a focus on key counseling points to help patients and families decide which method is best for them. For example, if a girl complains of . At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. 12.1 ). What Stands in the Way of Bedside Teaching? 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. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. Emans SJ, Lanfer MR, Goldstein DP: Pediatric and Adolescent Gynecology,4th ed. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies. From AccessMedicine. ObstetGynecol 1971;37:462, 13. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Affiliated with the University of Colorado School of Medicine. Show Transcript. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. So this is the scariest picture weve got! 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. 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. 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. 1. Philadelphia, PA, WB Saunders, 1981, 5. Cystic ovarian masses commonly occur in infants, children and adolescents. Using Google Glass to Examine the Hand with Dr. Verghese. A gentle, patient approach is important when examining a prepubertal girl. The quantity of discharge can vary greatly, from minimal to copious. Leukorrhea may be present. Hymens are often crescent shaped but may be annular or ringlike. Physiologic leukorrheacan be confused with vulvovaginitis. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. Vaginal burning, itching or foul-smelling discharge. Dealing with a foreign body. 12.4 ). All children should have a chance for a healthy future. Teens don't usually get pelvic exams. It's also not true that the pelvic exam is a "test" to see if you are a virgin. This period of transition involves important physical and emotional changes. 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. 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. This is an important step toward reinforcing the child's sense ofcontrol over the examination. Prepubertal vulvovaginopathies. 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. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. 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. Most young children will prefer to have aparent--usually their mother--in the room at all times. The outer catheter serves as an insulator, and the inner catheter is used to instill a small amount of saline and aspirate into the vaginal fluid. 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. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. Managing vulvovaginitis. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. 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. The atrophymay distort the anatomy of the labia and clitoris. Group A streptococciand Shigella are the most common causes. One excellent technique is for the physician to sit, not stand, during the initial encounter. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. 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. How To do a Pediatric Physical Exam Zachys 1.48K subscribers Subscribe 2.8K Share 1.1M views 7 years ago Today Nurse Lindsey demonstrates how to give a proper pediatric physical exam. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . 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. With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. 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.". Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. View a sample video. During the exam, your doctor will check your vagina, uterus, and ovaries. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. 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. 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. Not every variant of hymen is normal, and transections between 3 and 9 oclock should raise a suspicion for abuse because these are likely acquired rather than congenital (discussed further in Chapter 9 ). The Pelvic Exam. Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds. The majority of cases of persistent or recurrent nonspecific vulvovaginitis respond to improved hygiene and treatment of irritation resulting from trauma or irritating substances. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. 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. An ectopic ureter can present as persistent wetnessor purulent discharge. Vaginoscopy in a prepubertal child most often requires sedation with a brief inhalation or intravenous anesthetic, but in select circumstances it can also be performed in the office with older, cooperative children. 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. 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. Pay special attention to anatomic and pathophysiologic differences in the child. Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. The medical history should be guided by the presenting complaint anddifferential diagnosis. If you put your stethoscope over this, what will you hear? In addition, she reviews the potential for ovarian torsion, including signs and symptoms, evaluation and management. 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. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. 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. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. Chronic pelvic and abdominal pain can be debilitating for a young girl. 25:50. Philadelphia, PA, Raven-Lippincott, 1998, 2. Obtaining a history from a child is not an easy process. 12.3 ). Dr. Appiah also reviews the expert consensus position statements that provide guidance on how providers should care for this population, including informing patients about options for fertility preservation and future reproduction prior to treatment. Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. Specific vulvovaginitis. This results from the anatomic proximity of the rectum and vagina coupled with the fact that, after toilet training, most youngsters are unsupervised when they defecate. The pediatric gynecologic visit may be unique to both the child and the parent. Am J Obstet Gynecol1987;157:950, 6. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. These interactions between the physician and the adolescent girl allow the physician an opportunity to gain the patients trust and educate the pubertal teenager about pelvic anatomy and reproduction. Intestinal parasitic invasion with pruritus. 4:40. Stanford 25 Skills Symposium 2016 Announced! 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. These procedures are usually performed under anesthesia. 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. 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. PCOS occurs due to a complex interaction of genetic and environmental factors can affect the menstrual cycle, hair growth, skin, weight and the ability to have children. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. Gynecological examination of the prepubertal girl can be challenging. The normal prepubertal uterus and ovaries are nonpalpable. 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. 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. 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. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. 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. An interesting illustration of the physical exam. A pelvic exam is where a doctor or nurse practitioner looks at a girl's reproductive organs (both outside and internally). Pediatrics 1990;86:428, 9. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . Your patient gets this rash, whats the diagnosis? Many adolescent girls do not want other observers, such as mothers, in the examining room. Girls should have their first gynecological exam between the ages of 13 and 15. Tailor your gynecologic examination to the presentingissue.
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