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. 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.". The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . Learn how doctors should perform a bedside swallow evaluation! Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. 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. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. 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. Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. This may create considerable and understandable anxiety in the child and parent. The Pelvic Exam. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. Power your marketing strategy with perfectly branded videos to drive better ROI. 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. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. Examination of the Female Genitourinary System. 25:50. The second phase of the examination involves evaluation of the vagina . Stanford ENT Free Oral Screening November 2nd. Nonspecific vulvovaginitis. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. Stanford 25 Skills Symposium 2016 Announced! Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. Pokorny SF. Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus. 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). 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. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . 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 normal vagina of a prepubertal child is colonized by an average of nine different species of bacteria: four aerobic and facultative anaerobic species and five obligatory anaerobic species. Pokorny SF: Configuration of the prepubertal hymen. 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. Watch the video to learn how Dr. Scott teams up with specialists from urinary and gastrointestinal medicine to develop a holistic approach to identifying and managing chronic pelvic pain in adolescent girls. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Clin Obstet Gynecol 1987;30:643, 7. 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. Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. Yuwoko. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. Whats the diagnosis? The color ranges from white or gray to yellow or green. 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. The child is told to have her abdomen sag into the table. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. A hand lens or otoscope often is helpful. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. Many adolescent girls do not want other observers, such as mothers, in the examining room. One excellent technique is for the physician to sit, not stand, during the initial encounter. 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. Pads should be placed in the mothers lap because examination often is associated with urination. Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Your patient gets this rash, whats the diagnosis? Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. 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. What will bedside manner look like for new data-driven physicians? Introduction to the Basic Pelvic Exam. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. The severity of vulvovaginitis symptoms varies widely from child to child. Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics(Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies). 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. 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. Teens don't usually get pelvic exams. . Emphasize that the most important part of the examination is just looking and that there will be conversation during the entire process. Some healthcare professionals listed on our website have medical privileges to practice at Childrens Hospital Colorado, but they are community providers. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . The relative size ratio of cervix to uterus is 2:1 in a child. In addition, periods may exacerbate other medical issues or they may prefer to have no periods due to hygiene or other concerns. 0:31. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. Uterine bleeding that is coming more often than every three weeks, lasting longer than seven days in a row, or resulting in excessive product use and frequent bleeding through clothes should be evaluated. 5 Minute Pelvic Exam Video. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation. In this setting it may be helpful to use the extinction phenomenon, in which the examiner provides pressure on the perineum lateral to the introitus before insertion of the speculum. Noninfectious causes of vulvovaginitis also are common. Usingthis position and an otoscope head for magnification and light, you willbe able to visualize the lower vagina, and usually the upper vagina andcervix, in 80% to 90% of prepubertal girls.3. Physiologic leukorrheacan be confused with vulvovaginitis. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. The child lies prone and places her buttocks in the air with legs wide apart. A pelvic exam usually lasts only a few minutes. 12.2 ). Affiliated with the University of Colorado School of Medicine. There is no significant geographic barrier between the vagina and anus. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. What Is The Specific Cause of This Patients Clubbing? Most such traumas involve straddle injuries. An interesting illustration of the physical exam. Specific vulvovaginitis. A mounding of hymeneal tissue is often called a bump. 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. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. An older child should be asked whom she prefersto have in the room during the examination. One way to describe genital area and breasts is to call them private areas and define this as meaning areas that are covered by a bathing suit. Abraham Verghese Asks: Why Are We Doing This Teaching? Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Intestinal parasitic invasion with pruritus. You might have a pelvic exam as part of your regular checkup. Pelvic Exam; Breast Exam; Self Breast Exam; Bimanual Exam; Pap Smear Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common. Inspect the child's breasts and palpate themfor signs of puberty. 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. Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. This provider either practices in a department or specialty that we currently do not survey, or does not have at least 10 ratings in the last 12 months. This is a difficult decision and is based on the extent of the childs anxiety in relation to the severity of the clinical symptoms. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. There is nothing specific about the symptoms or signs of childhood vulvovaginitis. From AccessMedicine. For non-life-threatening medical needs when your pediatrician is unavailable, visit one of our urgent care locations. Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole. 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. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. Your questions should address the onset of symptoms; the type,frequency and timing of discharge; associated bleeding, pain, or pruritus;foreign body insertion; perineal hygiene; recent infections in the patientor her family (such as streptococcal pharyngitis or pinworms); recent antibiotictherapy; masturbation; and a history of sexual abuse. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. Employee communication. 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. These are the organs related to your monthly menstrual cycles, to sexual activity, and to pregnancy and childbirth. Female Pelvic Exam. Change gloves, lubricate the rectum, and then gently . Patient has this new skin finding, what should you worry about? If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. Philadelphia, PA, Raven-Lippincott, 1998, 2. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. Dr. Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . The differential diagnosis of persistent or recurrent vulvovaginitis not responsive to treatment should include considerations of a foreign body, primary vulvar skin disease (allergic or contact dermatitis), ectopic ureter, and child abuse. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. From AccessMedicine. One method is to use the knee-chest position (see Fig. Bates' Visual Guide features head-to-toe and systems physical exam videos completely reshot with an emphasis on clinical accuracy and patient care. Occasionally it is best to defer the genital examination until a second visit . The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). Pay special attention to anatomic and pathophysiologicdifferences in the child. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . Obtaining a history from a child is not an easy process. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. 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. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. Obstet Gynecol Clin NorthAm 1992;19:39, 10. The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. Leukorrhea may be present. EMANS is Chief, Adolescent Division, Children's Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston. 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. When indicated, both vaginoscopy and hysteroscopy procedures can be performed by a pediatric and adolescent gynecologist at Childrens Hospital Colorado. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse. 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. During the exam, your doctor will check your vagina, uterus, and ovaries. 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. The history is critical in terms of making a diagnosis, but it also providestime for you to establish rapport with the patient and elicit her understandingof her symptoms and expectationsof the visit. Sometimes doctors do pelvic exams if they think there's a problem. Menstrual bleeding in adolescents can be chaotic. 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. The atrophymay distort the anatomy of the labia and clitoris. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. For example, if a girl complains of . Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. 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. In addition, she reviews the potential for ovarian torsion, including signs and symptoms, evaluation and management. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as childrens posters are present. Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. First gynecological exam is about establishing care and a relationship not a pelvic exam. 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. Children usually are asymptomatic,but they may present with secondary infection. What is it? 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 ( ). Before the exam, you will need to undress and put on a gown. Pediatrics 1990;86:428, 9. Many gynecologic conditions in children may be diagnosed by inspection . The source maybe the vulva, vagina, endometrium, and occasionally the urethra. The evaluation of young girls is age dependent. 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. 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. 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. 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. Pinworms are another cause of vulvovaginitis in prepubertal children. Not sure if you need urgent or emergency care? Different positions for performing a gynecologic examination on a child. The most common malignancy in preadolescent girls is a germ cell tumor. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. A successful gynecologic examination of a child demands that the physician employ an exam pace that conveys both gentleness and patience with the time spent, without seeming to be hurried or rushed. 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. 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. You can also ask the child to cough in order todistract her and cause her hymen to open. A history of trauma--whetheraccidental, intentional (for example, scratching due to pinworm infection)or caused by sexual abuse--also should be elicited. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. 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. There will also be an extra sheet you can use to cover yourself. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. 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. Childrens clothing is often tight fitting and nonabsorbent, which keeps the vulvar skin irritated, warm, moist, and at risk for vulvovaginitis. Pokorny has described another method for collecting fluid from a childs vagina using a catheter within a catheter ( ). The most important technique to ensure cooperation is to involve the child as a partner. Below is a collection of all our Stanford 25-generated videos also found throughout the website. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit. 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. HPV is also verticallytransmitted and lesions may appear in the first few years of life. Philadelphia, PA, WB Saunders, 1981, 5. It is important to give the child a sense that she will be in control of the examination process. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. 0:38. Show Transcript. Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Newborns will exhibit maternal estrogen effects:the labia majora, labia minora, and clitoris will be relatively large, theepithelium a dull pink color, and the hymen often thick and redundant. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. This can be accomplished without the insertion of any instruments. 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. The child can assist you by holding herlabia apart. Pokorny SF. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. 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. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. The American Academy of Pediatrics (AAP) promotes the inclusion of the pelvic examination in the primary care setting within the medical home. A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. ObstetGynecol 1971;37:462, 13. Obtaining cultures. Approach to evaluation of premenarcheal child with a gynecologicproblem. 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. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. 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 work-up for vaginal bleeding includes a careful inspection of thevulva and vagina, wet preparation and bacterial cultures, and cultures forsexually transmitted infections if indicated. In: Emans SJ, Laufer MR, Goldstein DP, eds. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. Inspect her for pubic hair and note the condition of the urethra,size of the clitoris, any signs of estrogenization, configuration of thehymen, and perineal hygiene. The classic symptom of pinworms is nocturnal vulvar and perianal itching. Topics for the pediatric nurse practitioner to be aware of. Menstrual pain and cramps are very common in women and affect 50% to 90% of female teens. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics.
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