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

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:

mothers 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 oclock 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)
Partners 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 cant get pregnant the first time you have
sex.
You cant get pregnant standing up.
If you havent had sex by age 17 youll 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

 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 childs 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

Burrows 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)