Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. This technique is generally successful in cooperative children unless there is a very high crescent-shaped hymen, in which case it is too difficult to shine the light into the small aperture of the vaginal introitus. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). 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. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. The exam can be done even if you have never had sexual intercourse, because the opening to your vagina is large enough to allow for the exam. The child's buttocks will now be heldup in the air and her back and abdomen will fall downward (Figure 4). . The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). 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. 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. Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. 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 ) ( ). In girls with persistent, purulent, or recurrent vaginal discharge, orthose with a suspicion of sexual abuse, obtain a wet preparation and culturesfor bacterial pathogens, C trachomatis, and N gonorrhoeae. Group A streptococciand Shigella are the most common causes. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. Vulvovaginitis: causes and management. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. A discharge that is both bloody and purulent is likely not from vulvovaginitis but from a foreign body (see Vaginoscopy for Prepubertal Bleeding without Signs of Puberty later in this chapter), although patients infected with some pathogens, particularly Shigella boydii, often present with a bloody or blood-tinged discharge . She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors. Bacterial vaginosis during pregnancy may lead to increased risks for preterm birth, preterm delivery, and spontaneous abortion, according to new research in the Archives of Gynecology and Obstetrics. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Not sure if you need urgent or emergency care? The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. 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. 14 mins, 33 secs. Ideally children should feel they are part of the examination rather than having an exam done to them.. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The tape is subsequently examined under the microscope. A gentle, patient approach is important when examining a prepubertal girl. This is an important step toward reinforcing the child's sense ofcontrol over the examination. The child is told to have her abdomen sag into the table. 5 Minute Pelvic Exam Video. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. Host virtual events and webinars to increase engagement and generate leads. Adult pinworms maybe visible at night. A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. 12.2 ). View a sample video. The vulva and anus. This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. Inspect the child's breasts and palpate themfor signs of puberty. Patient has this new skin finding, what should you worry about? This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. Children often cannot hold still for long intervals while instruments are being located. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. Change gloves, lubricate the rectum, and then gently . Sources of accidental trauma areusually straddle injuries. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. Having a relationship with a pediatric gynecologist can help girls take . Intestinal parasitic invasion with pruritus. 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. 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. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. 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. Emans SJ, Lanfer MR, Goldstein DP: Pediatric and Adolescent Gynecology,4th ed. It can also present as a chronic colonization (diaper rash) in patients using diapers. Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. 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. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. What is it? Interruptions should be avoided. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. The usual cause of genital trauma during childhood is an accidental fall. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. You might have a pelvic exam as part of your regular checkup. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. You canmodel for parents appropriate ways to discuss gynecologic issues with theirchild, and help parents and children understand the importance of discussingissues related to reproductive healthand sexuality during the prepubertalyears.1. Your doctor checks your vulva, vagina, cervix . Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. One method is to use the knee-chest position (see Fig. Your pediatrician will describe each step of the exam. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. Without continuation of the hygiene measures, however, broad-spectrum antibiotics will only offer temporary relief and the problem is likely to recur ( ). 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. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. 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. Although anovulatory cycles are common in the years after menarche, there are established norms and, alternatively, abnormal findings that require further investigation. Includes speculum and bimanual exams. 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. In this video, adolescent gynecologist Eliza Buyers, MD, reviews options for menstrual suppression, how they work, and various considerations for teens with complex medical issues. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. The typical location is the anterior vaginalwall near the cervix. This period of transition involves important physical and emotional changes. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. 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. Obstet Gynecol Clin NorthAm 1992;19:39, 10. The majority of cases of persistent or recurrent nonspecific vulvovaginitis respond to improved hygiene and treatment of irritation resulting from trauma or irritating substances. Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. 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. 3 simple steps. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. 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. These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. Chronic pelvic and abdominal pain can be debilitating for a young girl. Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . 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. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. Genital bleeding should always be assessed thoroughly. 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. For a small childwho is fearful of the exam, it may be best to have the mother sit on thetable in a semireclined position (feet in or out of stirrups) with the child'slegs straddling her thighs (Figure 3). So this is the scariest picture weve got! One excellent technique is for the physician to sit, not stand, during the initial encounter. Before puberty, the girls reproductive organs are in a resting, dormant state. She reviews the services that the Program provides, such as inpatient and outpatient consults, fertility preservation services and reproductive healthcare, and how to request consultation. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. Pay special attention to anatomic and pathophysiologic differences in the child. These are the organs related to your monthly menstrual cycles, to sexual activity, and to pregnancy and childbirth. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. 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. Pediatrics 1980;65:758, 4. 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. In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. That's why we conduct research to advance care techniques that can be used for our patients and kids anywhere. Often reassurance and sometimes delay until another day are the best approaches. A tape testmay be useful for suspected pinworm. Loose-fitting cotton undergarments should be worn. 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. Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. Urethritis can be caused by an infectiousagent, irritation, or trauma. 12.1 ). 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. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. Learn how doctors should perform a bedside swallow evaluation! It is important to give the child a sense that she will be in control of the examination process. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). In life-threatening emergencies, find the emergency room location nearest you. Pinworms are another cause of vulvovaginitis in prepubertal children. 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. A mounding of hymeneal tissue is often called a bump. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle. A gentle, patient approach is important when examininga prepubertal girl. Philadelphia, PA, WB Saunders, 1981, 5. The most common gynecologic condition of children is vulvovaginitis . 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. Children are not skilled historians and will often ramble, introducing many unrelated facts. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. A complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children. We see more, treat more and heal more children than any hospital in our seven-state region. What will bedside manner look like for new data-driven physicians? 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. In this. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Visualizing the hymen. N gonorrhoeaerarely persists beyond the newborn period without symptoms. In the period surrounding the time of puberty, children often develop a physiologic discharge secondary to the increase in circulating estrogen levels. . Once the child is positioned, the vulvar area and introitus should be inspected. 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. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). They may be discovered by means of a flashlight or by dabbing of the vulvar skin with clear cellophane adhesive tape, ideally before the child has arisen in the morning. This is referred to as nonspecific vulvovaginitis. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. Menstrual bleeding in adolescents can be chaotic. Childrens clothing is often tight fitting and nonabsorbent, which keeps the vulvar skin irritated, warm, moist, and at risk for vulvovaginitis. Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. If you cannot fully visualize the hymen, ask thechild to cough or take a deep breath, or pull the labia gently forward anddown or laterally yourself so that you can see the hymen and the anteriorvagina. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. 0:38. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Philadelphia, PA, Raven-Lippincott, 1998, 2. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. Pelvic pain is common in adolescent girls. Gidwani GP. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. They may ask for their mothers to be there, be fearful of the examination concept, and need more than one visit to achieve the goals of the visit. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. She should be allowed to visualize and handle any instruments that will be used. The last step in the pelvic examination may be a rectal examination. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later). The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. Managing vulvovaginitis. Am J Obstet Gynecol 1987;156:581. Obtaining cultures. This chapter considers gynecologic diseases of children from infancy through adolescence. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. With puberty , the prepubertal vagina becomes acidic under the influence of bacilli dependent on a glycogenated estrogen-dependent vagina. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. A pelvic exam usually lasts only a few minutes. Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. 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. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. Children usually are asymptomatic,but they may present with secondary infection. Many gynecologic conditions in children can be diagnosed by inspection alone. A child should never be restrained for a gynecologic examination . An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse. 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. 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. 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. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescents hormonal milieu. 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. 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. 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. This may create considerable and understandable anxiety in the child and parent. Rectoabdominal exam. 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. View a sample video Learn about our mission and more, or search for opportunities to join our team. Viscous lidocaine and warmsaline for irrigation through an IV set-up may be helpful when examininga child who has an acute straddle injury and bleeding. Can you guess the cause of the patients bleed? Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. Vulvovaginitis in children may also be caused by a variety specific pathogens such as group A or group B b-hemolytic streptococci, Haemophilus influenzae, and Shigella boydii ; Neisseria gonorrhoeae, Trichomonas vaginalis, and Chlamydia trachomatis may also be responsible in cases associated with abuse but are significantly less common. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection.
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