The Pelvic Exam. Before puberty, the girls reproductive organs are in a resting, dormant state. When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. HPV is also verticallytransmitted and lesions may appear in the first few years of life. The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Afterthe newborn period, the average size of a normal clitoral glans in a premenarchalchild is 3 mm in length and 3 mm in transverse diameter.4 Inprepubertal girls, the vaginal mucosa and perihymenal tissue will be moreatrophic and appear thin and red. 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. Includes menu so you can select the portion of the video most applicable to you. . 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. Forunusually persistent cases, it is appropriate to prescribe a 10-day trialof antibiotics (amoxicillin, amoxicillin-clavulanate, or a cephalosporin)or occasionally a two- to three-week course of an estrogen cream. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later). 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. Chronic pelvic and abdominal pain can be debilitating for a young girl. View a sample video. 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. 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. Stanford 25 Skills Symposium 2016 Announced! Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. In some patients, particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. An ectopic ureter emptying into the vagina may only intermittently release a small amount of urine; thus this rare congenital anomaly should be considered in the differential diagnosis in young children. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. Gidwani GP. Group A streptococciand Shigella are the most common causes. During the exam, your doctor will check your vagina, uterus, and ovaries. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Clin Obstet Gynecol 1987;30:643, 7. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. 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. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. In this. Female Pelvic Exam. . Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. In: Emans SJ, Laufer MR, Goldstein DP, eds. Children's Hospital Colorado partners with NRC Health to gather star ratings and reviews from patients, residents and family survey data. 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. This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. Learn how doctors should perform a bedside swallow evaluation! An Initiative of the Program for Bedside Medicine, Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. Gynecological examination of the prepubertal girl can be challenging. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. The last step in the pelvic examination may be a rectal examination. An imperforate hymen appearsas a thin membrane, and will bulge if hydromucocolpos is present. What Stands in the Way of Bedside Teaching? Stanford ENT Free Oral Screening November 2nd. 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 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. 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. These procedures are usually performed under anesthesia. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. Ideally children should feel they are part of the examination rather than having an exam done to them.. The vagina will then fill with air, aiding the evaluation. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. Prep for OSCEs! The source maybe the vulva, vagina, endometrium, and occasionally the urethra. All children should have a chance for a healthy future. Thefinding of genital herpes type 2 is a strong indication of sexual abuse.Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.14Trichomonaswill rarely cause symptoms in the newborn period and spontaneously resolveswith waning of estrogen levels. Emphasize setting the stage to make the examination a positive experience for your young patient. Often reassurance and sometimes delay until another day are the best approaches. One excellent technique is for the physician to sit, not stand, during the initial encounter. Visualizing the hymen. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. Bates' Visual Guide features head-to-toe and systems physical exam videos completely reshot with an emphasis on clinical accuracy and patient care. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Urethritis can be caused by an infectiousagent, irritation, or trauma. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. W Webcam. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. The normal prepubertal uterus and ovaries are nonpalpable. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. 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. 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 examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. 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. The relative size ratio of cervix to uterus is 2:1 in a child. Loose-fitting cotton undergarments should be worn. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. 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. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. A child should never be restrained for a gynecologic examination . However, young children can help define their exact symptoms on direct questioning. In life-threatening emergencies, find the emergency room location nearest you. After your examination is complete, congratulate the child for her cooperationand bravery. 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. 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. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. Some healthcare professionals listed on our website have medical privileges to practice at Childrens Hospital Colorado, but they are community providers. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). Not every variant of hymen is normal, and transections between 3 and 9 oclock should raise a suspicion for abuse because these are likely acquired rather than congenital (discussed further in Chapter 9 ). Historically, these masses were surgically removed, often involving removal of the entire ovary. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. Nonspecific vulvovaginitis. Teens don't usually get pelvic exams. There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). There is nothing specific about the symptoms or signs of childhood vulvovaginitis. This may create considerable and understandable anxiety in the child and parent. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. 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. 3 simple steps. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. Many gynecologic conditions in children can be diagnosed by inspection alone. Vulvovaginitis is the most common gynecologic problem in prepubertal girls. 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. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. Childrens Hospital Colorado providers are faculty members of the University of Colorado School of Medicine. However, many infants are infected with Chlamydia trachomatis during birth and remain infected for up to 2 to 3 years in the absence of specific antibiotic therapy. Inspect the child's breasts and palpate themfor signs of puberty. This includes feeling a girl's uterus and ovaries to be sure everything's normal. The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. Show Transcript. Obtaining a history from a child is not an easy process. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. Prepubertal vulvovaginopathies. 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. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . 12.3 ). A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). Happy Halloween! This conveys an unhurried approach. 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. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. The typical location is the anterior vaginalwall near the cervix. Dr. Often the first awareness comes when the mother notices staining of the childs underwear or the child complains of itching or burning. The extent of labial adhesions and associated symptoms are variable (seefigure "B"). Newborns and pubescent girls sometimeshave significant vaginal secretions because of estrogen effect. 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. Learn more about patient ratings and reviews. Small follicular cysts in preadolescent girls are usually self-limiting. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. 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. It's also not true that the pelvic exam is a "test" to see if you are a virgin. When alone withan examiner, a child may disclose abuse or other concerns, and allowingher to be interviewed or examined alone may give her a greater sense ofcontrol and responsibility for her own health. Vulvovaginitis: causes and management. In addition, periods may exacerbate other medical issues or they may prefer to have no periods due to hygiene or other concerns. The vagina of a child is 4 to 5 cm long and has a neutral pH. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. 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. Can you guess the cause of the patients bleed? What is it? 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. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. We see more, treat more and heal more children than any hospital in our seven-state region. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications.