The components of a complete pediatric examination include a history, inspection with visualization of the external genitalia and noninvasive visualization of the vagina and cervix, and, if necessary, a rectal examination ( ). Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The most important technique to ensure cooperation is to involve the child as a partner. Cultures from the vagina indicate normal rectal flora or Escherichia coli. We see more, treat more and heal more children than any hospital in our seven-state region. The severity of vulvovaginitis symptoms varies widely from child to child. 1. There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. From AccessMedicine. 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. This is to help girls understand that there is a doctor dedicated to their reproductive health. In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases. Stanford Medicine 25 Launches New Website, Medical Errors and Adverse Events from a Missed or Inadequate Physical Exam, Announcing the Stanford 25 Skills Symposium, Thyroid Nodule Overview - The Thyroid Exam. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. 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. Sometimes doctors do pelvic exams if they think there's a problem. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Event marketing. The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Vaginal burning, itching or foul-smelling discharge. 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. An older child should be asked whom she prefersto have in the room during the examination. Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. This canbe accomplished by establishing rapport with the child, keeping the paceunhurried, proceeding from less to more intrusive examinations and askingfor consent before proceeding, and allowing the child to be an active participantin the process as much as possible.2, Another important consideration when performing a gynecologic assessmentis providing anticipatory guidance to the patient and her parents. A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal abuse. The atrophymay distort the anatomy of the labia and clitoris. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. McCann J, Wells R, Simon M, et al: Genital findings in prepubertalgirls selected for nonabuse: A descriptive study. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. Stanford 25 Skills Symposium 2016 Announced! This chapter considers gynecologic diseases of children from infancy through adolescence. Home | Bates' Visual Guide So this is the scariest picture weve got! Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. Menstrual pain and cramps are very common in women and affect 50% to 90% of female teens. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. It is important to give the child a sense that she will be in control of the examination process. The film opens with a woman sitting in an office of a physician. An infant may be examined on her mothers lap. "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. Although anovulatory cycles are common in the years after menarche, there are established norms and, alternatively, abnormal findings that require further investigation. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. ObstetGynecol 1971;37:462, 13. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 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. Managing vulvovaginitis. With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. 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. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. All children should have a chance for a healthy future. Employee communication. Videos : Exams. 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. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Learn Peds Genitourinary 04 Genital Exam Intro from UBC Learn Pediatrics on Vimeo. Help me decide. Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common. 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. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. It is not diagnostic since few vaginal diseases can be diagnosed visually. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. The pathophysiology of the majority of instances of vulvovaginitis in children involves a primary irritation of the vulva, which may be accompanied by secondary involvement of the lower one-third of the vagina. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. You may need a pelvic exam sooner if you are experiencing problems with your period or have other symptoms, including: Pain in your lower abdomen or pelvic area. 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. . Hymens are often crescent shaped but may be annular or ringlike. Am J Obstet Gynecol 1987;156:581. The classic symptom of pinworms is nocturnal vulvar and perianal itching. When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. An imperforate hymen appearsas a thin membrane, and will bulge if hydromucocolpos is present. For example, if a girl complains of . The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. The significance of the diameter of the hymenalorifice is controversial; a large orifice may be consistent with a historyof sexual abuse, but it is not an absolute criterion.7,8. 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. The child can assist you by holding herlabia apart. 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. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement. It's also not true that the pelvic exam is a "test" to see if you are a virgin. Pinworms are another cause of vulvovaginitis in prepubertal children. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. There are many narrow-diameter endoscopes that will suffice, including the Kelly air cystoscope, contact hysteroscopes, pediatric cystoscopes, small-diameter laparoscopes, plastic vaginoscopes, handheld disposable hysteroscopes (e.g., Endosee Handheld Hysteroscopy System, CooperSurgical Inc., Trumbull, CT), and special smaller, narrower speculums designed by Huffman and Pederson. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . . 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 differential diagnosis of persistent or recurrent vulvovaginitis not responsive to treatment should include considerations of a foreign body, primary vulvar skin disease (allergic or contact dermatitis), ectopic ureter, and child abuse. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. 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. 0:31. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. A pelvic exam usually lasts only a few minutes. The normal prepubertal uterus and ovaries are nonpalpable. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. 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. Routine gynecologic examinationof infants and children can help prevent future health problems such asvulvovaginitis by giving the clinician the opportunity to educate parentsabout perineal hygiene.1 During the annual genital inspection,the pediatrician also may discover such significant abnormalities as clitoromegaly,signs of early puberty, vulvar dermatoses, or rarely hymenal or vaginaltrauma. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. Genital Exam | Learn Pediatrics - University of British Columbia 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.
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