DR. KAHN is Assistant in Medicine, Children's Hospital, Boston, and Instructor in Pediatrics, Harvard Medical School, Boston, MA.DR. Treatment for extensivelabial adhesions is topical estrogen cream applied along the adhesion withgentle pressure twice a day for three weeks, then at bedtime for three weeks.Once the adhesion has resolved, a barrier ointment should be used to preventrecurrence. Emphasize that the most important part of the examination is just looking and that there will be conversation during the entire process. Most young children will prefer to have aparent--usually their mother--in the room at all times. 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. 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. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. The evaluation of young girls is age dependent. Sources of accidental trauma areusually straddle injuries. Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. A pelvic exam is where a doctor or nurse practitioner looks at a girl's reproductive organs (both outside and internally). Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus. However, it is when the pain gets progressively worse and occurs outside the menstrual cycle, that it might be time to consider a pathological cause, such as endometriosis. 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 vulva and anus. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. Girls should have their first gynecological exam between the ages of 13 and 15. 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. The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases. Making the examination a positive experience, ifpossible, therefore is critical.2. Abraham-Vergheses-TED-Talk:-Over-one-million-views! These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). This conveys an unhurried approach. Pokorny has described another method for collecting fluid from a childs vagina using a catheter within a catheter ( ). The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse. An interesting illustration of the physical exam. Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. Support teaching, research, and patient care. Power your marketing strategy with perfectly branded videos to drive better ROI. 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 history is critical in terms of making a diagnosis, but it also providestime for you to establish rapport with the patient and elicit her understandingof her symptoms and expectationsof the visit. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. However, young children can help define their exact symptoms on direct questioning. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. Vaginoscopy in a prepubertal child most often requires sedation with a brief inhalation or intravenous anesthetic, but in select circumstances it can also be performed in the office with older, cooperative children. In addition to your doctor, there will be a nurse or an assistant in the room during . Before the exam, you will need to undress and put on a gown. Visualization of the introitus is better achieved using the previously described traction and the Valsalva maneuver than separation because it gives a deeper view of the structures and partial visualization of the vagina. Learn about our mission and more, or search for opportunities to join our team. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . Clin Obstet Gynecol 1987;30:643, 7. In noncooperative children, treatment should not be withheld if a specimen cannot be collected and empiric treatment may be started., many techniques have been described for attempting to collect a specimen, including the use of a very slim urethral Dacron swab moistened with nonbacteriostatic saline (used for collection of male urethral cultures). Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. Cultures from the vagina indicate normal rectal flora or Escherichia coli. After viewing, providers will be better able to counsel patients and their families on treatment methods as well as provide them with updated resources on this topic. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. It is important to give the child a sense that she will be in control of the examination process. Female Urethral Catheterization Male Urethral Catheterization Female Genital Exam Male Genital Exam Don't forget to watch the Why Urology video! This chapter considers gynecologic diseases of children from infancy through adolescence. It can also present as a chronic colonization (diaper rash) in patients using diapers. 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. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. These interactions between the physician and the adolescent girl allow the physician an opportunity to gain the patients trust and educate the pubertal teenager about pelvic anatomy and reproduction. 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. 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. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. 14 mins, 33 secs. The most important technique to ensure cooperation is to involve the child as a partner. The majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). Cystic ovarian masses commonly occur in infants, children and adolescents. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. 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. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. 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. Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics(Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies). At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. Hysteroscopy is performed in the operating room under general anesthesia. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. 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. The American Academy of Pediatrics (AAP) promotes the inclusion of the pelvic examination in the primary care setting within the medical home. 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. Videos : Exams. 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. "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. Dr. Appiah also reviews the expert consensus position statements that provide guidance on how providers should care for this population, including informing patients about options for fertility preservation and future reproduction prior to treatment. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. There often are predisposing factors that lead to vulvar irritations, such as the use of perfumed soaps or the pressure from tight seams of jeans or tights, which create denudation, allowing the rectal flora to easily infect the irritated epithelium. Forpersistent cases, prescribe a one- to three-month course of a low-potencytopical steroid preparation, such as hydrocortisone 1% or 2.5%, followedby careful hygiene and use of emollients. Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common. Much of the history must be obtained from the parents . Happy Halloween! 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. However, if the reason for the visit is urgent, such assignificant vaginal bleeding, and a child is uncooperative, you may haveto perform the exam under anesthesia. Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. Urethritis can be caused by an infectiousagent, irritation, or trauma. Observation alone is appropriate for small adhesions. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Group A streptococciand Shigella are the most common causes. N gonorrhoeaerarely persists beyond the newborn period without symptoms. 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. Female Pelvic Exam. Examination of the vulva, hymen, and anterior vagina by gentle lateral retraction (. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. 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. The medical history should be guided by the presenting complaint anddifferential diagnosis. 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. 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. The major factor in childhood vulvovaginitis is poor perineal hygiene. Pediatrics 1980;65:758, 4. 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. The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin.If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Ideally children should feel they are part of the examination rather than having an exam done to them.. However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. The usual cause of genital trauma during childhood is an accidental fall. From AccessMedicine. 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. 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. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. In some patients, particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. 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. Emphasize setting the stage to make the examination a positive experience for your young patient. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. Young children may be examined in the frog leg position, and children as young as 2 to 3 years of age may be examined in the lithotomy position with use of stirrups, although this is generally used for girls aged 4 to 5 years and older. Approach to evaluation of premenarcheal child with a gynecologicproblem. While the light from the otoscope or ophthalmoscope is shone into the vagina, the examiner can evaluate the vaginal walls and visualize the cervix as a transverse ridge, or flat button, that is redder than the vagina. 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. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. Providers can counsel patients that they will inform them of each step in the process and then ask the teen if she is ready before performing each step. Office evaluation of the child and adolescent. 5 Minute Pelvic Exam Video. Treatment is the same as for labialadhesions. Pay special attention to anatomic and pathophysiologicdifferences in the child. This may create considerable and understandable anxiety in the child and parent. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. 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. In a microperforate hymen, it may be difficult to identify an opening.To establish its presence, try squirting a small amount of warm water orsaline with a syringe or angiocath, placing the girl in the knee-chest position,or probing with a small urethral catheter, feeding tube, or nasopharyngealCalgiswab moistened with saline or vaginal lubricant (Figure 8). A hand lens or otoscope often is helpful. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. Different positions for performing a gynecologic examination on a child. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. 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. 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. 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. 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In this video, Veronica Alaniz, MD, provides guidelines for examining and understanding genital lacerations and hematomas resulting from vulvovaginal trauma, including blunt trauma or straddle injury and penetrating. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. 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. Historically, these masses were surgically removed, often involving removal of the entire ovary. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. What Stands in the Way of Bedside Teaching? 12.1 ). It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. 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. Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. 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. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. 25:50. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. 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. Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse. Noninfectious causes of vulvovaginitis also are common. The child is told to have her abdomen sag into the table. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. 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. Many adolescent girls do not want other observers, such as mothers, in the examining room. Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. However, it is important to do a thorough workup because of the serious sequelae of some of the causes of vaginal bleeding. You can use this section to discover where and how this . Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Can you guess the cause of the patients bleed? 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.
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pediatric pelvic exam video