Pediatric Gynecology Baru
Content
Pediatric Gynecology
M. Thamrin Thamrin Tanjung, Prof.Dr.dr.Sp.OG(K) M. Rusda Rusda Harahap, dr dr.Sp.OG(K) .Sp.OG(K)
Gynecological care begins in the delivery room as part of the newborn examination with palpation of the breast buds and examination of the external genitalia
Gynecological care Evaluation of the external genitalia continues through routine well-child examinations, permitting early
detection of infections, labial adhesions congenital anomalies, and even genital tumors. A complete gynecologic examination is indicated when a child has symptoms or signs of a genital
disorder.
Specially designed equipment To prevent undue discomfort and consequent anxiety about future examinations. vaginoscope, virginal vaginal speculum
The rst few wees of life.
uring the !rst few wee"s of life, residual residual maternal sex hormones may produce
physiologic e#ects occurs on the in newborn. !reast budding nearly all female infant born at term. $n some cases, breast enlargement
%ay be "uid discharge &o treatment is indicated.from the nipple.
The rst few wees of life The labia ma'ora are bulbous, and the labia minora #$ont.% are thic" and protruding
The clitoris is relatively large, with a normal index of &.' cm( or less.
The hymen initially is turgid, )aginal discharge covering is common, comprised mainly of cervical mucus and exfoliated vaginal cells. The uterus is enlarged () cm in length* and without axial +exion the ratio between the cervix and the corpus is - /. )aginal bleeding bl eeding may occur as estrogen levels decline following birth and the stimulated endometrial lining is shed. 0uch bleeding usually stops within 12/3 days.
#&-' years% *arly childhood #&-'
The female genital organs receive little estrogen stimulation. The labia ma'ora +atten and the labia
minora and hymen become thin The clitoris remains relatively small, although the clitoral index is unchanged. The vagina, lined with atrophic mucosa with relatively few rugae, o#ers very little resistance to trauma and infection.
0ince vaginal fornices do not develop until puberty, the cervix in childhood is +ush with the
vaginal vault, its opening appearing as a small slit. The uterus regresses in si4e, regaining the si4e present at birth at around age 5.
As the child the ovaries to enlarge and matures, descend into the truebegin pelvis. The number and si4e of ovarian follicles increase. They may attain signi!cant si4e and then regress. regress.
+ate childhood (age 12 year* The /3 exter external nal genitalia again show signs of estrogen stimulation
the mons pubis thic"ens, the labia ma'ora !ll out, and the labia minora become rounded.
The hymen thic"ens, thic"ens, losing its thin, transparent character.
*arly puberty #age #age &- uring* early puberty #age &- years *, years
the genitalia ca"e on adult appearance. The ma'or glands gland s (6artholin7s glands* gland s* begin to produce 'ust prior to menarche. The vagina reaches adult adu lt (/38/9 cm* and becomes more distensible, the mucosa thic"ens,vaginal secretions grow more
acidic and lactobacilli reappear. reappear. :ith the developme development nt of vaginal fornices, the cervix becomes separated from the vaginal vault
;istory < Physical Exam Give child an opportunity to spea" with you alone when appropriate
Give child as much control as possible over situation < get them involved in the exam if possible
6e mindful of abuse and be aware of appropriate steps in suspicious
cases
&ever restrain a child (general anesthetic may be required* ;ave parents sit on table with child =se frog leg and "nee>chest
positions in younger children $nspect hymen carefully for signs of brea"s or trauma as minor
exter external nallesions in'uries may hide serious vaginal $nspect anal region but do vaginal>rectal vaginal>r ectal exams only when needed (imaging often better option*
$nstruments
%ay need instruments to visuali4e the upper />-2 />9 of the vagina ?@ce vaginoscope can be tried (3. cm in infancy>childhood < 3.B cm in premenarcheal girls* :ater cystoscope allows some distention of vagina < cleans debris Can use urethroscope>laparoscope
Topical T opical lidocaine to anestheti4e vulva
General Anesthesia if exam not easy ;u#man2Graves < Peders Pedersen en specula
should be used for adolescents 0aline soa"ed swabs are used for vaginal samples in children because this is adequate given gi ven immature lining
0peculum exam with Cx cultures may be necessary in adolescent
DA Calgiswab for obtaining vaginal specimens in the prepubertal girl. 6 Assembled catheter2within2a2 catheter, for obtaining specimens from a prepubertal child. (Drom Po"orny 0D, 0tormer F&. Atraumatic removal of secretions from the prepubertal prep ubertal vagina. Am ?bstet Gynecol /HB1/5B/ with permission.*
Types of specula (from Types (from left to right* infant, ;u#man, Pederson, and Graves.
?toscope (without a speculum* for visuali4ing hymen and vagina.
(A* Examination of patient under anesthesia, (6* using a Iillian nasal speculum with !beroptic light (obtained from Codman and 0hurtle#, $nc., $ nc., Pacella rive, Jandolph, %A*.
%ethodes of examination lacing a child up to years of age on her parent/s lap a#ords a better opportunity to perform an adequate examination (Dig -/2
)*. ?lder children may be placed on the examination exam ination table, but the use of stirrups stirrups is not generally the patient is as"ed to +ex hernecessary "nees andif abduct her legs. The nee-chest position is useful in visuali4ing the upper vagina and cervix.
D$G. /2). Positioning Positioning the child in the frog2leg position with the aid of her mother. (Courtesy of r. Trina Anglin, ?@ce of Adolescent ;ealth, ;ealth Jesources and 0ervices Administration (;J0A*, :ashington, C.*
Positioning the prepubertal child in the frog2leg position. 0he can lie hori4ontally or with the head of the examining examinin g table tabl e raised. raised . KCourtesy KCour tesy of r. r. Trina Trina Anglin, ?@ce of Adoles Adolescent cent ;ealth, ;ealth Jesources and 0ervices Administration (;J0A*, :ashington, C.L
Positioning the child in the lithotomy position with the use of stirrups. (Courtesy (Co urtesy r.. Trina Trina Anglin, A nglin, (Cou rtesy of r An glin, ?@ce ? @ce of Adolescent ;ealth, ;ealth Jesources and 0ervices Administration (;J0A*, :ashington, C.*
Positioning the child in the lithotomy position with the aid of her mother. (Courtesy of r. Trina Anglin, ?@ce of Adolescent ;ealth, ;ealth Jesources and 0ervices Administration (;J0A*, :ashington, C.*
Examination of the prepubertal child in the "nee chest position.
The Tanner Tanner stages stages of huma human n breast breast development. development. (Adapte (Adapted d from Grumbach %%, 0tyne %. Puberty ?ntogeny, neuroendocrinology, physiology and disorders. $n :ilson , Doster :, eds. :illiams textboo" textboo " of endocrinology, endocrinology, Bth ed., Philadelphia :6 0aunders, /HH9 and from %arshall :A, Tanner %. Fariations in pattern of pubertal changes in girls. Arch is Child /H5H))9H/.* /H5H))9H/.*
The Tanner Tanner stages stages for the dev development elopment of female female pubic hair hair.. (Adapte (Adapted d from Grumbach %%, 0tyne %. Puberty ?ntogeny, neuroendocrinology, physiology and disorders. $n :ilson , Doster :, eds. :illiams textboo" of endocrinology, endocrinology, Bth ed., Philadelphia :6 0aunders, /HH9 and from %arshall :A, Tanner %. Fariations in pattern of pubertal changes in girls. Arch is Child /H5H))9H/.* /H5H))9H/.*
External genitalia of the prepubertal child.
Examination of the vulva, hymen, and anterior vagina by gentle lateral retr retraction action (A* and gentle gripping of the labia and pulling anteriorly (6*.
Types of hymens (photographed throu Types through gh a colposcope* (A* crescentic colposcope* crescentic hymen, (6* annular hymen, and (C* redundant hymen with crescent appearance after retraction.
Types of hymens Types hymens (A* nor normal, mal, (6* imperforate imperforate,, (C* microperforate, (* cribriform, and (E* septate.
%icroperforate hymen.
%icroperforate septate hymen.
%icroperforate septate hymen.
$mperforate hymen.
0eptate vagina.
%icroperforate hymen. A ?pening di@cult to %icroperforate visuali4e. 6 ?pening gently probed. p robed.
;ymenal tags.
Child and Ado Adolescent lescent Gynecologic Problem
Gonadal disgenesis Turner syndr Turner syndrome ome (),M* 0weyer syndrome ()5,MN*
%ixed gonadal dysgenesis (),M > %ixed )5,MN* Abnormalities of the M
chromosome
Pediatric Gynecologic isorders $. F=F? FAG$&A E0$?&0 $$.
&E?PA0%0
$$$. $F. $F.
C?&GE&$TA A&?%A$E0 EFE?P%E&TA EFE?P%E&T A EDECT0 EDECT0 &?J%A < A6&?J%A
F.
P=6EJTA EFE?P%E&T F$. 0PEC$A PJ?6E%0 ?D T;E A?E0CE&T
Pediatric Gynecologic isorders $. F=F?F F= F?FAG$&A AG$&A E0 E0$?& $?&0 0 /. ichen sclerosis et atrophicus 9. Trauma -. abial adhesion ). Prolapsed urethra . Faginal discharge discharge
Faginal ischarge &ormal mucoid discharge it results from maternal estrogen estrogen
Pathologic $nfections discharge ◦
◦
◦
◦
◦
;emolytic streptococcal vaginitis bloody or serosangguineou serosangguineous s discharge %onilial vaginitis A foreign body persistent vaginal discharge &onspecivic vaginitis
abial adhesion Adhesion of labia minora in the midline Jesult from in+ammation or s"in disease
Encourages retention retention of urine ur ine < vaginal secret secretions. ions. %anagement
2 improve hygiene 2 ubrication of the labia < gentle manual separation 2 T Topical opical estrogens 2 surgical
$$. &E?PA0%0 FAG$&A
◦
0arcoma botryoides
?FAJ$A& 2 &on germ cell origine ◦
◦
ipoid cell tumors(estrogen tumors(estrogen producing* Granulosa2theca cell tumors(estrogen tumors(estr ogen producing*
2 Germ cell origine
0arcoma 6otryoides Drom mesnc mesnchymal hymal tissu tissue e of the cervix>vagina
Appears edematous, edematous, grape2li" grape2li"e e mass, bleeds readily on touch %anagement a combination of surgery and chemotherapy
?varian tumors Germ cell tumors 6enigne cystic teratoma 6enign cyst Arrhenoblastoma (androgen producing* ysgerminomas < gonadoblastomas Endodermal sinus tumors Embryonal carcinoma (hCG secreting tumors*
$mmature teratomas(malignant*
$$$. Congenital Anomalies %ullerian agenesis %ayer2von Jo"itans"y2Iuster2;auser(%JI;*
syndrome Ectopic ureter with vaginal terminus
Faginal ectopic anus
$F. evelopmental efect of the External Genitalia (Ambiguous Genitalia* Congenital adrenal hyperplasia (CA;* Adr Adrenal enal tumors %aternal ingestion of androgens Childhood ingestion of androgens Androgen insensitivity syndrome (testicular femini4ation* True T rue hermaphroditism %aternal virilising tumor during pregnancy(luteoma of pregnancy*
F. &ormal < Abnormal Puberty 0. 1ormal puberty
!. 1ormal physical changes
◦
◦ ◦
◦
Growth spurt Thelarge Adrenarche and pubarche %enarche
$. recocious puberty
◦ ◦
Central Peripheral
2. 2elayed puberty
◦
◦
;ypergonadotropic hypogonadism ;ypogonadotropic hypogonadism
&ormal Puberty
&ormal physical changes . 9.
-.
Growth spurt, / yr before menarche, pea" //2/9 yr Thelarge Thelarge onset of breast development, begins between H2// yr, a sign of ovarian estrogen production, completed - yrs Adrenarche and production pubarche. of pubarche. Adrenarchethe androgens. Pubarchedevelopment of axillary and pubic hair that results from adrenal and gonadal
androgens
*xamination of the 1ewborn 3nfant 0. G*1*40+ *506310T371 !. $+3T743S $. )0G310 2. 4*$T70!276310+ *506310T371
0. General *xamination may reveal abnormalities suggesting genital anomaly eg webbed nec",
◦
◦
abdominal mass, edema of the hands and legs, coarctation of the aorta The external genitalia are inspected and palpated and evaluated oes it appear normalO $s it in its proper locationO :illl it function normally later in lifeO :il ◦
◦
◦
◦
A6$A A;E0$?&0 Agglutination of the labia minora, termed labial adhesions or, in the lower half, vulvar adhesions, occurs primarily in young girls aged - months to 5 years abial adhesions are not seen in newborns because of estrogen e#ects on the vulva.
?ccasionally, adhesions occur for the !rst time after age 5, and adhesions presenting at any age may persist to the time of puberty.
Fulvar irritation may play a role in causing the formation of the
adhesions or the progr progression ession from initially small posterior adhesion toan a near2total fusion.
The vaginalcovered, ori!ce may be poor completely causing drainage of vaginal secretions.
Parents often become alarmed because the vagina appear absent
The diagnosis of labial adhesions is made by visual inspection of the vulva. The treatment of labial adhesions remains
controversial. 0pontaneous separation may occur, particularly with small vulvar adhesions at the posterior fourchette and with estrogeni4ation at puberty. puberty. $f the opening in the agglutination is large enough for good vaginal and urinary drainage, lubrication of the labia with a bland ointment and gentle separation applied by the mother over several wee"s, may be helpful.
Dor adhesions that impair vaginal or urinary drainage, the most e#ective treatment is the application of an estrogen2containing cream
:e prescribe an estrogen2containing cream (e.g., Premarin* twice daily for - wee"s and then at bedtime for another 9 to - wee"s. Appro Approximately ximately half of adhesions will resolve in 9 to wee"s (/3*, and therapy can then
be changed to ointment.
After separation has occurred, occurred, the labia should be maintained apart by daily baths, good hygiene, and the application of a bland ointment at bedtime for 5 to /9 months.
Dorceful separation is contraindicated because it is traumatic for the child and may cause the adhesions to form again.
abial abscess.
ipoma of labia in an B2year2old girl who had had a labial mass for / year.
!. $litoris The clitoris deserves particular attention, because
◦
◦
congenital almost always *nlargement associated with adrenal adrenal hyperplasia. ?ther causes true hermaphroditism, male pseudohermaphroditism.
Enlargement of
Clitories
Two newborn girls with virili4ation and salt2losing Two congenital adrenocortical adrenocortical hyperplasia (A* and a nd (6* patient 0.C., (C* patient %.T.
$. ) agina agin a )agina The vaginal ori!ce abia are separated or retracted. $f it is not, it can be found by gently inserting a
small, well lubricated pediatric feeding tube :hen an opening cannot be found, the infant most li"ely has an imperforate hymen or vaginal agenesis.
$nfrequently, $nfrequen tly, associated inguinal hernias suggest the possibility that the child is a genetic male, particularly when there is a mass in the hernial sac. $f the vaginal ori!ce cannot be located, further investigation is warranted.
$mperforate hymen in a baby.
$mperforate ;ymen
2. 4ectoabdominal *xamination To complete To the primary evaluation, eval uation, a rectoabdominal examination is performed. =sually, the uterus and adnexa in the newborn cannot be palpated on rectal examination. ?ccasionally, a small central mass representing the uterine cervix can be felt on examination. :hen an ovary is palpable, it denotes a mar"ed enlargement and warrants further investigation
(eg, ultrasonography* to rule!ndings out theare presence of an ovarian tumor. &egative tumor. valuable because they generally g enerally exclude a pelvic pe lvic tumor. tumor. Jectal examination also c con!rms on!rms patency of the anorectal canal.
*xamination of the premenarcheal child Docus on the main symptoms identi!ed in this population pruritus, dysuria, sin
color changes, and discharge. Placing a child up to years of age on her parent7s lap ?lder children may be placed on the
examination exam ination table, but the usepatient of stirrups not generally necessary if the is is as"ed to +ex her "nees and abduct her legs. The "nee2chest position is useful in
visuali4ing the upper vagina and cervix.
*xamination of the premenarcheal child 0. 89S3$0+ *506310T371 . General inspection. (. !reasts . 0bdomen :. Genitalia. !. )aginoscopy
C?&GE&$T C?&GE&$TA A A&?%A$ A&?%A$E0 E0 FAG$&A =TEJ=0 ?FAJ$=% =JET;JA A&=0
01760+3*S 7; T8* )0G310 . 36*4;740T* (. T401S)*4 T401S)*4S* S* )0G310+ S*T<6 (. +71G3T<231 71G3T<2310+ 0+ )0G310+ S*T<6 . )0G310+ 0G*1*S3S :. 04T30+ )0G3 0G310+ 10+ 0G*1 0G*1*S3S *S3S
01760+3*S 7; T8* <T*4<S . 4<236*1T049 <T*431* 8741 (. <13$741<0 <13$741<0T* T* <T*4<S <T*4<S =3T8 0406*S71*843$ 0406*S71*843$ $9ST
A&?%A$0 ?D T;E ?FAJ$=%
drawn by the round ligament into the inguinal canal or the labium ma'us. A !rm inguinal mass should alert the examiner to
the possible presence of an aberrant gonad possibly containing testicular elements, even , though the external genitalia are female. A "aryotype should be obtained when a girl presents with an inguinal gonad. At the time of hernia repair, the gonad should be biopsied. $f it proves to be an ovary, it should be returned to the peritoneal cavity and the hernia repaired. $f a testis is identi!ed, the gonad should
be removed.
Sarcoma botryoides botryoid rhabdomyosarcoma ?ne of rare mesenchymal tumors, grows in the form of polypoid grapeli"e masses and derives its name from this gross appearance $linical characteristics The most common clinical !nding is vaginal
bleeding. They may appear as a polypoid mass, somewhat yellow in color and are friable thus, they (possibly* may brea" o#, leading to vaginal bleeding or infections.
*pidemiology 0arcoma botryoides normally is found in children
under B years of age. ?nset of symptoms occurs at age - years (-B.- months* on average. Cases of older women with this condition have also been reported.
Treatment and prognosis The disease used to be uniformly fatal, with a 2 year survival survival rate between /3 to -Q. Q. As a result, treatment was radical surgery. &ew multidrug chemotherapy regimens with or without radiation therapy are now used in combination with less radical surgery with good results, although outcome data are not yet
available.
