Children usually are asymptomatic,but they may present with secondary infection. An ectopic ureter can present as persistent wetnessor purulent discharge. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. 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. 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. A patient presents with foot pain and these chronic findings? Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. 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. Prep for OSCEs! NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Gynecological examination of the prepubertal girl can be challenging. Join Childrens Hospital Colorado pediatric experts for a virtual Were passionate about providing answers, treatment and care for the full range of female reproductive health concerns, from infancy through adolescence and into adulthood. Slang terminology for speculums among teens includes the threatening label the clamp. Teens should be assured that although the examination may include mild discomfort, it should not be painful . Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Addressing the Youth Mental Health Crisis, Department of Pediatric and Adolescent Gynecology, Fertility Preservation and Reproductive Late Effects Program, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome, Insurance, billing and payment information. 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. Those in middle or late adolescence (aged 15 to 19 years) may be more accepting of the idea of an examination and more likely to cooperate with the proper counseling and in the appropriate setting. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. The extent of labial adhesions and associated symptoms are variable (seefigure "B"). The film opens with a woman sitting in an office of a physician. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. Pokorny SF: Configuration of the prepubertal hymen. 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. 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 . Interruptions should be avoided. 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. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. The last step in the pelvic examination may be a rectal examination. The relative size ratio of cervix to uterus is 2:1 in a child. The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. 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. Obtaining cultures. Am J Obstet Gynecol1987;157:950, 6. 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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. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. Emphasize setting the stage to make the examinationa positive experience for your young patient. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. The history shouldassess the child's growth and development; signs of puberty such as breastdevelopment, axillary hair, pubic hair, growth spurt, and leukorrhea; genitaltrauma; vaginal discharge; and a history of foreign body insertion. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. 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. 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. Stanford Medicine 25 Clinical Pearl Award, Measuring Central Venous Pressure with the Arm, Resident Education: Internist Physical Exams, Body as Text: Teaching Physical Examination Skills | Stanford Medicine 25. Dr. 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. Much of the history must be obtained from the parents . Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. . 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. Introduction to the Basic Pelvic Exam. 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. The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. 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. Chronic pelvic and abdominal pain can be debilitating for a young girl. From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. A nurse retrieves the patient from the office and takes her to an exam room. Obstet Gynecol Clin NorthAm 1992;19:39, 10. Leukorrhea may be present. What is it? 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. Female Pelvic Exam. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. Hysteroscopy is performed in the operating room under general anesthesia. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. If you put your stethoscope over this, what will you hear? Recurrent vulvovaginitis, persistent bleeding, suspicion of a foreign body or neoplasm, and congenital anomalies may be indications to perform a vaginoscopy and examine the inside of the vagina. Making the examination a positive experience, ifpossible, therefore is critical.2. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers. 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. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . Most such traumas involve straddle injuries. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Children often cannot hold still for long intervals while instruments are being located. The signs of vulvovaginitis are variable and not diagnostic, but they include vulvar erythema, edema, and excoriation. McCann J, Wells R, Simon M, et al: Genital findings in prepubertalgirls selected for nonabuse: A descriptive study. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.12 Another method ofobtaining samples, used by Pokorny and Stormer, consists of a catheter-in-a-cathetertechnique.13 The proximal end of an IV butterfly catheter isinserted into the distal end of a size 12 bladder catheter, and a 1-mL tuberculinsyringe with 0.5 to 1.0 mL of sterile saline is attached to the hub of thebutterfly tubing. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus.It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact. A handheld mirror may help in some instances when discussing specifics of genital anatomy. An imperforate hymen appearsas a thin membrane, and will bulge if hydromucocolpos is present. 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. What questions should PNPs consider related to womens health? In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. 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. 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 pediatric gynecologic visit may be unique to both the child and the parent. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. 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. 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. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. 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. 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. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. Below is a collection of all our Stanford 25-generated videos also found throughout the website. In addition to your doctor, there will be a nurse or an assistant in the room during . 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. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). Pokorny has described another method for collecting fluid from a childs vagina using a catheter within a catheter ( ). 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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. Yuwoko. Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. 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. The most common gynecologic condition of children is vulvovaginitis . The surgical therapy of an ovarian neoplasm in a child should have two goals: the appropriate surgical removal of the neoplasm and the preservation of future fertility. 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. Support Lucile Packard Children's Hospital Stanford and child and maternal health. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as childrens posters are present. Pay special attention to anatomic and pathophysiologic differences in the child. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. Sources of accidental trauma areusually straddle injuries. 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. 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. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. 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. The Stanford Medicine 25 program for bedside medicine at the Stanford School of Medicine aims to promote the culture of bedside medicine to make current and . With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. The child is told to have her abdomen sag into the table. Positive identification of gonorrhea or chlamydia in a child with premenarcheal vulvovaginitis is considered diagnostic of sexual abuse. The classic symptom of pinworms is nocturnal vulvar and perianal itching. A mounding of hymeneal tissue is often called a bump. During the exam, your doctor will check your vagina, uterus, and ovaries. 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. Menstrual pain and cramps are very common in women and affect 50% to 90% of female teens. However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. 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. 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. 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. Contemporary Pediatrics Resident Writer Program, Food Insecurity and the Dangers of Infant Formula Dilution, Getting into the Roots of Childhood Atopic Dermatitis, Opt-Out Chlamydia Screening in Adolescent Care, The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, Choose article sectionPrinciples of gynecologic assessmentTaking the historyBeginning the examinationExamining the external genitaliaExamining the vaginaConcluding the examinationSIDEBAR: Common gynecologic findings in the prepubertal girlVulvovaginitisVaginal bleedingLabial adhesions, | Obstetrics-Gynecology & Women's Health, | Contemporary Pediatrics Resident Writer Program, | Food Insecurity and the Dangers of Infant Formula Dilution, | Getting into the Roots of Childhood Atopic Dermatitis, | Opt-Out Chlamydia Screening in Adolescent Care, | The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, | Update in Pediatric COVID-19 Vaccines. 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. 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. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Topics for the pediatric nurse practitioner to be aware of. She also explains why it is important to check ferritin levels for iron deficiency and discusses the etiology of abnormal uterine bleeding, with most heavy menstrual bleeding in adolescents and young adults due to ovulatory dysfunction or inherited bleeding disorders. 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. A carefulhistory is important; a history of hormonal medications or signs of precociouspuberty may suggest the cause of the bleeding. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). 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. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . If extensive labial adhesions are present, you maynot be able to adequately examine the hymen and vagina and will need toreexamine the child after she has successfully completed treatment withlocal hygiene measures and topical estrogen (see Sidebar, "Common gynecologicfindings in the prepubertal girl"). Abraham-Vergheses-TED-Talk:-Over-one-million-views! After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later). Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). Managing vulvovaginitis. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. 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. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. Nonspecific vulvovaginitis. Children are not skilled historians and will often ramble, introducing many unrelated facts. Pelvic pain is common in adolescent girls. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. Not sure if you need urgent or emergency care? The history should include the quality of the discharge(color, odor, presence of blood), hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions. A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. From Pierce AM, Hart CA. 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. We see more, treat more and heal more children than any hospital in our seven-state region. 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. Vulvovaginitis also may be associated with aspecific infectious agent. 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 .

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