If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. HPV is also verticallytransmitted and lesions may appear in the first few years of life. In this video, adolescent gynecologist Eliza Buyers, MD, reviews the pathophysiology and diagnosis of PCOS in adolescent patients. Approach to evaluation of premenarcheal child with a gynecologicproblem. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. This can be accomplished without the insertion of any instruments. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. 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 majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). Routine biopsy of the normal-appearing contralateral ovary should be avoided. Urethral prolapse also can present with bleeding. 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 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. Visualizing the hymen. 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. All children should have a chance for a healthy future. ObstetGynecol 1971;37:462, 13. Pinworms are another cause of vulvovaginitis in prepubertal children. Am J Obstet Gynecol 1987;156:581. Physiologic leukorrheacan be confused with vulvovaginitis. A nurse retrieves the patient from the office and takes her to an exam room. Many adolescent girls do not want their mother, guardian, or other observers in the examining room, and in many adolescent gynecology visits, a full pelvic examination is unnecessary ( ). Leukorrhea may be present. Gynecological examination of the prepubertal girl can be challenging. Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. An older child should be asked whom she prefersto have in the room during the examination. 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. Teens don't usually get pelvic exams. Menstrual bleeding in adolescents can be chaotic. 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. 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. Pediatrics 1980;65:758, 4. Vaginal burning, itching or foul-smelling discharge. 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. Adolescents often come for examinations with the preconceived idea that it will be very painful. The entire exam takes about only 5 minutes. Philadelphia, PA, WB Saunders, 1981, 5. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. Opening questions can include inquiriesabout the family structure and recent changes, school, friends (such aswhether she has a best friend), and the types of activities she enjoys.It is important to assess who cares for the child and to uncover--both fromthe parent and from the child--information about any history of sexual abuseor current concerns in that regard. Pads should be placed in the mothers lap because examination often is associated with urination. 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. Not sure if you need urgent or emergency care? It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 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. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. In 2019, there were over 1.7 million new cases of cancer, with 10,270 cases occurring among children ages 0 to 14 years of age and 70,000 occurring in adolescents and young adults. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. A gentle, patient approach is important when examining a prepubertal girl. 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. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. 12.4 ). 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 ) ( ). Diagnosing and treating PCOS in adolescents. 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. 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. Tricia Huguelet, MD, Chief of Pediatric and Adolescent Gynecology, describes the typical presentation of hymen imperforations in adolescents and young adults, as well as obstructing and non-obstructing mllerian anomalies. Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass. Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. Employee communication. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. The source maybe the vulva, vagina, endometrium, and occasionally the urethra. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. Girls should have their first gynecological exam between the ages of 13 and 15. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. Below is a collection of all our Stanford 25-generated videos also found throughout the website. 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. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. Hysteroscopy is performed in the operating room under general anesthesia. Support Lucile Packard Children's Hospital Stanford and child and maternal health. However, if the reason for the visit is urgent, such assignificant vaginal bleeding, and a child is uncooperative, you may haveto perform the exam under anesthesia. The child should be instructed to void with her knees spread wide apart (even while facing the toilet to improve urine draining) and taught to wipe from front to back after defecation. Sometimes doctors do pelvic exams if they think there's a problem. 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. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. 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. The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Often the first awareness comes when the mother notices staining of the childs underwear or the child complains of itching or burning. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. A gentle, patient approach is important when examininga prepubertal girl. 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. Stanford 25 Skills Symposium 2016 Announced! Many young childrens primary contact with providers involves immunizations; children should be assured that this visit does not involve any shots. It is also helpful to assure the adult accompanying the child that speculums are not part of the examination. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. The atrophymay distort the anatomy of the labia and clitoris. The vagina of a child is 4 to 5 cm long and has a neutral pH. Many gynecologic conditions in children may be diagnosed by inspection . However, young children can help define their exact symptoms on direct questioning. Vulvovaginitis: causes and management. 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. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. Historically, these masses were surgically removed, often involving removal of the entire ovary. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. In addition, periods may exacerbate other medical issues or they may prefer to have no periods due to hygiene or other concerns. These procedures are usually performed under anesthesia. An infant may be examined on her mothers lap. 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. 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 referred to as nonspecific vulvovaginitis. The evaluation of young girls is age dependent. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. A child should never be restrained for a gynecologic examination . Diagnose this skin lesion with newest Stanford 25 video and topic. It is important to give the child a sense that she will be in control of the examination process. Having a relationship with a pediatric gynecologist can help girls take . 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. Host virtual events and webinars to increase engagement and generate leads. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. A foreign object and the cervix may be visualized using this technique. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. The film opens with a woman sitting in an office of a physician. 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. With puberty , the prepubertal vagina becomes acidic under the influence of bacilli dependent on a glycogenated estrogen-dependent vagina. 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. The vulva and anus. Hymens are often crescent shaped but may be annular or ringlike. The quantity of discharge can vary greatly, from minimal to copious. The pediatric gynecologic visit may be unique to both the child and the parent. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. Abraham Verghese Asks: Why Are We Doing This Teaching? Pediatrics 1987;79:778, 8. 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. First gynecological exam is about establishing care and a relationship not a pelvic exam. Cultures from the vagina indicate normal rectal flora or Escherichia coli. 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. Female Pelvic Exam. Using Google Glass to Examine the Hand with Dr. Verghese. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. Many dermatologic disorders, suchas atopic dermatitis, seborrhea, and psoriasis, can manifest as vulvitisor vulvovaginitis. 25:50. 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. Instructing patients to use nonmedicated, nonscented wipes rather than toilet paper may prevent the self-inoculation of the vagina with small pieces of toilet paper, which can initiate a chronic discharge. Ideally children should feel they are part of the examination rather than having an exam done to them.. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. Whenever possible, addressquestions directly to the child. A tape testmay be useful for suspected pinworm. 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. 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. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. Some healthcare professionals listed on our website have medical privileges to practice at Childrens Hospital Colorado, but they are community providers. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). 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. In addition to your doctor, there will be a nurse or an assistant in the room during . 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. Macleod's Physical Examination - Head, Eyes and Ears Examination - OSCE Guide 2017. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. 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. 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. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . 12.3 ). For non-life-threatening medical needs when your pediatrician is unavailable, visit one of our urgent care locations. Bates' Visual Guide features head-to-toe and systems physical exam videos completely reshot with an emphasis on clinical accuracy and patient care. 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. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. 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. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. A history of trauma--whetheraccidental, intentional (for example, scratching due to pinworm infection)or caused by sexual abuse--also should be elicited. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Will the Healing Touch Go Out the Door With the Stethoscope? Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse.