2014 Pediatric & Adolescent Gynecology

PEDIATRIC & ADOLESCENT GYNECOLOGY
September 2014

SHEILA MARIE G. PINEDA-ALMAZAN, MD,FPOGS,FPSUOG

POP QUIZ

QUESTIONS
1. What examination position can best
evaluate the cervix and the vagina of a
pre-menarcheal child?
2. Give one indication for performing a
rectal examination in a child.

QUESTIONS
3. Give one classic symptom of
vulvo-vaginitis.

4. What is a reliable physical examination
sign that the vaginal ph is shifting to an
acidic environment during puberty?

QUESTIONS
5. What is the major risk factor for
childhood vulvovaginitis?
6. What condition should always be on
alert when posterior fourchette scarring
with labial adhesion beyond 6 y/o is
identified on physical examination?

QUESTIONS
7. What is the most likely microscopic
finding in physiologic leukorrhea of
children?
8. What is the most common cause of foul,
blood to purulent vaginal discharge in
children?

Questions
9. What is the most common cause of
genital trauma in a child?
10. What is the most common ovarian
mass in pediatric and adolescent age
group?

OUTLINE:
1. Pediatric Examination

2. Special Needs Of Adolescents
3. Gynecologic Complaints

Examination of The Child
General considerations:
1. Physiology, psychology and
developmental issues
2. Consent of parent or guardian
3. Exam pace gentle and unhurried
4. Ambiance familiar and friendly
5. Interruptions must be avoided

History
1. obtained through the parent or care giver
2. young children supplemental data
3. information about vaginal discharge,
itching, pain or bleeding
4. onset, timing, duration, exacerbating or
alleviating factors, previous treatment

5. associated symptoms or disturbed behaviors
6. inappropriate touching or sexual abuse
7. The child should be engaged in conversation
with specific questions that allow her to know
the importance of the information she
supplies.
8. Allow her to ask questions and to answer
them honestly .

Physical Examination
1 sense of control
2. include general assessment, height
and weight, heart, lungs, abdominal
palpation
3. Breast evaluation for Tanner staging

QUESTION
What is a reliable physical
examination sign that the
vaginal ph is shifting to an
acidic environment during
puberty?

Tanner Breast Staging

3

1
2

5
4

4. Lymph node examination
5. Gynecologic examination :
Inspection : vulva
vagina
cervix
•
Rectal exam

 Reassurance
 Counselled does not involve “shots”
 A medical assistant is important
 Defer exam until a second visit until

enough rapport is established
 Draping gives more anxiety and is
unnecessary

Position/s

 Infant/toddler:
 Young children:
 2 and older:

mother’s lap
frog leg position
lithotomy with stirrups

Involve the child as a partner
 Place child hand on top of MD

hand if she is fidgeting or
ticklish
 “Child friendly” objects
 Allowed to visualize and
handle instruments
 Hand-held mirror when
discussing genitalia

 All tools, culture

tubes and
equipments within
easy reach.
 IV sedation or

General anesthesia
to complete
essentialexams

1.External Genitalia
 hairless labia majora

 clitoris <0.5 cm
 lacks fat
 small minora
 thin, reddened

vestibule
 short distance vaginal
vestibule & anus

2. Vulva & Introitus
 Hymens

crescent shaped

- majority

annular or ring-like

- fimbriated or redundant

 3 and 9 o’clock complete hymenal transection

are most likely ACQUIRED
 Accidental trauma - Anterior vulva
 Penetrating injuries - Posterior forchette

QUESTION
What condition should always be on alert
when posterior fourchette scarring with
labial adhesion
beyond 6 y/o is
identified on physical examination?

QUESTION

What examination position can best
evaluate the cervix and the vagina
of a pre-menarcheal child?

3. Vagina
Knee chest position
• prone position
• buttocks in the air
• legs wide apart
• abdomen sag to the table
• pulls upward & outward
the labia majora

• Oto-ophthalmoscope

for magnification and
as light source
• NOT INSERTED
 Usual findings:
 red, narrow & thin
 4-6 cm long
 lacks distensibility
 neutral or alkaline
secretions

4. Cervix
appears as a transverse ridge or pleat that
is redder than the vagina

Transverse ridge

 Foreign object

 Specimens for microscopic examination and

culture.

Vaginoscopy
 indications:

recurrent vulvovaginitis
persistent bleeding
foreign body
neoplasm (EST; Sarcoma
botryoides)
congenital anomalies

 Cystoscopes & Hysteroscopes
• indications:

facilitates lavage

4. Rectal Exam
 most distressing
 usual findings:
 NON PALPABLE pre-pubertal uterus &

ovaries
 Relative size ratio of cervix to uterus: 2:1
 Any mass other than the cervix is
ABNORMAL

QUESTION
Give one indication for performing a
rectal examination in a child.
 Reasons: genital tract bleeding

pelvic pain
foreign body or
pelvic mass

Adolescent Examination

General Considerations:
 Spheres of Development:
Physical
Cognitive
Psychosocial
Sexual
 Difficulties of the adolescent relates to the
developmental tasks in each of these
spheres within a social, cultural and
economic climate

 Open, friendly, respectful, non-judgemental
 Avoid sermon or lectures

 verbal and non verbal cues
 Interactive sessions
 confidentiality concept
 occasionally can be breached if suicide,

homicide or abuse is at issue
 Facilitate communication

The GYN Visit
 screening
 preventive guidance

 establishing health care relationship
 discussion of any health care concerns
 1st visit ideally at 13 to 15 years old

History:
 Menstrual, pubertal

 Past medical & family history
 observes interaction b/w parent and teen
 who answers the questions

 how articulate and knowledgeable is the teen,
 is there a discord,
 is the mother encouraging or protective/

overprotective.

• Social History
 functioning in school, extracurriculars,
relationships
• Sexual History
 dating behaviour
 “Tell me about your partner”
(use gender neutral questions)
 Partner’s age (partner violence)
 type and range of sexual activity
 Past efforts to protect from STD
and pregnancy (assess knowledge on issues)

 Review of systems:
 gynaecologic and endocrine function, GI/GU
symptoms, signs of depression and frequency
of suicidal ideation.
 Disordered eating
- general impact on general and GYN health,
- weight loss/gain
- feeling about current weight
- efforts to diet

 Give opportunity to ask any concerns or

address prevalent myths:
“Oral sex as an alternative to maintain technical
virginity”
“ You can’t get pregnant the first time you have
sex.”
“You can’t get pregnant standing up.”
“If you haven’t had sex by age 17 you’ll never be
normal.”
“You cannot get STI from clean or nice people”

Private Conversation With The Parent
 give additional information, and assess parenting

skills.
 Importance of parental monitoring.
 Encourage to have discussion on:
 responsible sexual decision making
 healthy sexuality, abstinence
 role of media, values and beliefs
 necessity for preparation and readiness for
parenting.

Physical Examination
 Informed Consent
 Many do not want other observers in the

examining room
 Full pelvic Exam is often unnecessary
 Often come with preconceived ideas that
it is painful

 Goals :
identify the disease
signs of androgen excess

sexually transmitted infections
 The sequence of physical development
 PUBERTY proceeds in an orderly

fashion between 8-12y/o.


PUBERTY
 Increase in growth velocity
 Breast development
 Appearance of pubic hair
 Period of maximal growth (9cm/year)
 Menarche
A description of breast and pubic hair growth

1

2

3

4

5

 If NORMAL- emphasize that to the teen
 STI – the findings of the lab test presented to

adolescent privately first.
 A final meeting findings/plans are shared

(to the extent that the adolescent has
granted permission)
 An annual visit should take place for
guidance, screening and treatment

Gynecologic Complaints

Vulvovaginitis
 Most common prepubertal
 introital irritation and discharge
 Nonspecific or Infectious
 Pathophysiology:

 primary vulvar irritation with secondary

involvement of the lower 1/3 of the vagina
most cases by rectal flora E. Coli

QUESTION

What is the major risk factor for
childhood vulvovaginitis?

 Poor vulvar hygiene
 Inadequate front and back wiping after BM
 Foreign body insertion into the canal
 Chemical irritants : soaps, bubble baths,

shampoos
 Co-existent eczema or seborrhea
 Chronic disease and altered immune status
 Sexual abuse

Susceptibility:
 Vulva and vagina exposed to bacterial

contamination from the rectum
 lack of labial fat pads and pubic hair
 anatomic proximity of the rectum and vagina
 lack of protective effects of estrogen
 neutral or alkaline ph of vaginal epithelium
 Lack of glycogen, lactobacilli and antibodies to
help resist infection
 poor perineal hygiene

 Pinworms: 20%
 classic symptom of nocturnal vulvar & perianal

itching
 Scotch tape swab
 Group A B-Hemolytic Streptoccocus (7-20%)
• most common specific infectious agent in

prepuberty
 Greenish, yellowish, malodorous discharge
 Bright beefy red tender vulva

QUESTION
Give one classic symptom of
vulvo-vaginitis.

Signs /Symptoms:
 staining of child’s underwear
 itching or burning
 minimal to copious discharge
- bloody and purulent: foreign body
shigela vaginitis
 vulvar erythema, edema, excoriations

Persistent/Recurrent

Differential Diagosis:
foreign body


vulvar skin disease



ectopic ureter



child abuse

Treatment

 Improvement of local perineal hygiene
 Burrow’s solution for acute weeping

lesions
 baking soda Sitz bath
 Behavioral changes
 Recurrent: topical zinc creams, low
potency steroids, antibiotics based on
vaginal cultures
 ST organisms alert for sexual abuse

Adhesive vulvitis
Pathology

 Occurs in 1-5%
 Labia minora adhered at the midline
 Labial denuded epithelium fusion

 Translucent, partial vertical midline

raphe
 involves the upper or lower aspect of the
vagina, rare to be complete
 2-6 years, estrogen nadir

 Symptoms:
 voiding difficulties

-dribbling, UTI, urethritis
 recurrent vulvo- vaginitis
 discomfort from
the adhesion
 Labial agglutination &
scarring of the posterior
fourchette - r/o sexual abuse

Differential diagnosis:
 Imperforate hymen

 - labia minora appear like an

upside down V
 - no hymenal fringe at the introitus
 Vaginal agenesis
 -Hymenal fringe is normal
 -canal ends blindly behind the

fringe

Treatment
 No treatment is mandatory, spontaneous
separation occur
 Topical estrogen x 2-8 weeks
 Local anesthetics to tweeze the adhesion
apart
 zinc oxide or petroleum jelly to raw edges
for one month to prevent recurrence
 Introitoplasty

Physiologic discharge
 Early stage of puberty

 gray white color- light yellow
 Transition shedding
 desquamation of vaginal epithelium by

the acids produced by the normal vaginal
bacilli flora
 Reassurance that it is a normal process
 subsides/resolves in time

QUESTION
What is the most likely microscopic finding
in physiologic leukorrhea of children?

sheets of vaginal epithelium*

Lichen sclerosis atrophicus
 Prepubertal children
 Auto immune condition
 Pruritus, vulvar discomfort, bleeding and dysuria
 Hour glass involving the genital and perianal area
 Appears whitened, lichenifined with parchment like

appearance

 Small punch biopsy under GA:

Thinning of vulvar epithelium with loss of rete
pegs

 Treatment:
 avoidance of irritation and trauma
 Avoid straddle activities
 Sitz bath
 Clobetasol, with tapering after a 2 week

interval response to prevent adrenal
supression
LS improves with puberty

QUESTION
What is the most common cause of foul,
blood to purulent vaginal discharge in
children?

FOREIGN BODIES
 4% OPD GYN visits
 3-9 years old, often are repeat performers
 most common: wads of toilet paper
 Inserted because the genital area is pruritic or from






self exploration
Adolescent: unable to retrieve a forgotten tampon or
condom
Symptom: foul , bloody discharge, often purulent
Unexplained bleeding : Vaginoscopy to r/o out
malignant tumors
Grasp object by forceps or wash out by irrigation
Use wipes instead of toilet paper

Question
What is the most common cause
genital trauma in a child?

of

Accidental Genital Trauma
 Blunt, minor, accidental

 Fall is the usual cause
 75% is straddle injury
 r/o sexual abuse for hymenal transections
 Vulvar Trauma & Lacerations
 Vulvar Hematoma

Trauma & Lacerations
 unilateral and superficial injury
 rarely involves the hymen,

 Examiner ascertain the site ,extent, and








amount of bleeding
Exclude intraperitoneal damage if penetrating
Tetanus toxoid booster dose
Superficial lacerations generally do not require repair
Adequate pain control
Hemostasis
Restoration of normal anatomy

Vulvar Hematoma
 Vulva strikes a blunt object, automobile and bicycle

accidents, kicks or self inflicted wounds, sexual
abuse
 visualization and palpation of site & extent

 none expanding: observation

icepack /sitz bath

Explore > 4cm

Question
What is the most common ovarian mass
in pediatric and adolescent age group?

Ovarian masses

 Most are functional and
physiologic from
hormonal stimulation,
management is essentially
expectant
 Tumor :
 75-85% benign teratoma

(dermoid cyst) solid/cystic
component in ultrasound

 Usually unilateral
 Malignancies (15-25%)

germ cell dysgerminoma;
Sex cord granulosa/theca cell tumor
 Recurrent abdominal pain, fullness or
bloatedness
 Hormone secreting cysts leads to
Isosexual or heterosexual precocious
puberty

 Ultrasound, CT, MRI to establish origin
 Tumor marker determination

 vital to be conservative for future fertility
 Opposite ovary carefully inspected &

palpated
 oncology referral for complete sampling

Ovarian Torsion

 Secondary to a pelvic mass or mechanical

factors
 Early puberty ovarian pelvic drop
 2/3 right side
 Acute onset pain ,nausea and emesis
 gentle untwisting, stabilization with sutures
 unless with severe vascular compromise

Sexual abuse
 most perpetrators are male aquaintances

 urgent evaluation in72 hours for forensic evidence
 Interview prior to a genital exam
 Sexual abuse team referral:

o community resources
o Local child protective service
o Mental health provider (social worker/
psychologist)
 Appropriate filing of abuse reports

Physical examination
 General exam

 Skin for bruising, lacerations or trauma
 Signs of physical abuse documented
 Careful collection of forensic evidence

 Clothing and undergarments
 Motile sperm within the vagina 8 hours

non motile in 24 hours
 Rape kits contains protein specific to prostate
 Vaginal swabs for culture (NG/Chlamydia)