Treatment is the same as for labialadhesions. ObstetGynecol 1971;37:462, 13. Stanford ENT Free Oral Screening November 2nd. The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. 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. Emphasize setting the stage to make the examination a positive experience for your young patient. Noninfectious causes of vulvovaginitis also are common. Observation alone is appropriate for small adhesions. Philadelphia, PA, Raven-Lippincott, 1998, 2. 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. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. The normal vagina of a prepubertal child is colonized by an average of nine different species of bacteria: four aerobic and facultative anaerobic species and five obligatory anaerobic species. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies. A genital examination might be indicated in relation to suspected or alleged: Sexually transmissible infection Pregnancy Pelvic pain or other genital symptoms or concerns Sexual assault Foreign body Cervical cytology screening is not 5currently recommended until the age of 25 years. This conveys an unhurried approach. The classic symptom of pinworms is nocturnal vulvar and perianal itching. For non-life-threatening medical needs when your pediatrician is unavailable, visit one of our urgent care locations. What is it? Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. Group A streptococciand Shigella are the most common causes. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds. Vulvovaginitis is the most common gynecologic problem in prepubertal girls. Hymens are often crescent shaped but may be annular or ringlike. In this. Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . 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. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. The normal prepubertal uterus and ovaries are nonpalpable. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. When indicated, both vaginoscopy and hysteroscopy procedures can be performed by a pediatric and adolescent gynecologist at Childrens Hospital Colorado. 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 the office setting, the examination should be limited to external inspection only; speculum exams should not be performed in pediatric patients. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). What Is The Specific Cause of This Patients Clubbing? Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. 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 ( ). Join Childrens Hospital Colorado pediatric experts for a virtual Were passionate about providing answers, treatment and care for the full range of female reproductive health concerns, from infancy through adolescence and into adulthood. Because the pubertal changes are often a cause of concern for adolescent girls and their parents, the gynecologist must offer the adolescent patient an empathetic, kind, knowledgeable, and gentle approach. This patient presents with chest pain. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . It's also not true that the pelvic exam is a "test" to see if you are a virgin. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. Girls should have their first gynecological exam between the ages of 13 and 15. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . Having a relationship with a pediatric gynecologist can help girls take . Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. 12.4 ). 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. Diagnosing and treating PCOS in adolescents. 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. Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. How To do a Pediatric Physical Exam Zachys 1.48K subscribers Subscribe 2.8K Share 1.1M views 7 years ago Today Nurse Lindsey demonstrates how to give a proper pediatric physical exam. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Vulvovaginitis: causes and management. 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. Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. The surgical therapy of an ovarian neoplasm in a child should have two goals: the appropriate surgical removal of the neoplasm and the preservation of future fertility. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. 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. A history of trauma--whetheraccidental, intentional (for example, scratching due to pinworm infection)or caused by sexual abuse--also should be elicited. 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. 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. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. The last step in the pelvic examination may be a rectal examination. The child is told to have her abdomen sag into the table. When this intervention fails, there should be greater suspicion of bacterial colonization; in this case a reasonable approach is the use of broad-spectrum oral antibiotics such as amoxicillin or trimethoprim/sulfamethoxazole given for 10 to 14 days. The most common malignancy in preadolescent girls is a germ cell tumor. In addition to your doctor, there will be a nurse or an assistant in the room during . This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina. Pokorny SF. Pediatrics 1990;86:428, 9. The typical location is the anterior vaginalwall near the cervix. 12.2 ). Symptoms of vulvovaginitis can occur if an adhesionis extensive enough to cause pooling of urine above the agglutinated tissue.If that is the case, a child may have symptoms of urethritis or a historyof urinary tract infections. Explain to the child that the most important part of the examinationis "looking," and that it is important for her to communicatewith you during the examination. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle. Learn how doctors should perform a bedside swallow evaluation! 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. Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. Includes speculum and bimanual exams. Gynecologic Examination with Pap Smear. Forunusually persistent cases, it is appropriate to prescribe a 10-day trialof antibiotics (amoxicillin, amoxicillin-clavulanate, or a cephalosporin)or occasionally a two- to three-week course of an estrogen cream. Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. Obtaining a history from a child is not an easy process. When is it best to reassure, and when is it necessary to evaluate? When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. A child should never be restrained for a gynecologic examination . The most common gynecologic condition of children is vulvovaginitis . Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse. This results from the anatomic proximity of the rectum and vagina coupled with the fact that, after toilet training, most youngsters are unsupervised when they defecate. A handheld mirror may help in some instances when discussing specifics of genital anatomy. Many gynecologic conditions in children can be diagnosed by inspection alone. DR. KAHN is Assistant in Medicine, Children's Hospital, Boston, and Instructor in Pediatrics, Harvard Medical School, Boston, MA.DR. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. The extent of labial adhesions and associated symptoms are variable (seefigure "B"). In: Emans SJ, Laufer MR, Goldstein DP, eds. This video demonstrates how to perform a comprehensive pelvic examination, including an examination of the external genitalia, a Papanicolaou test to screen for cervical dysplasia, a bimanual exami. 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. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. A parent or caretaker is usually present during the examination of ayoung child, and most children are comfortable with the parent sitting closeby or holding their hand. Adult pinworms maybe visible at night. "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. Usingthis position and an otoscope head for magnification and light, you willbe able to visualize the lower vagina, and usually the upper vagina andcervix, in 80% to 90% of prepubertal girls.3. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. If you put your stethoscope over this, what will you hear? Pokorny SF. 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. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. A patient presents with foot pain and these chronic findings? Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. For example, if a girl complains of . First gynecological exam is about establishing care and a relationship not a pelvic exam. Whats the diagnosis? Intestinal parasitic invasion with pruritus. Your pediatrician will describe each step of the exam. Pokorny SF: Configuration of the prepubertal hymen. The ideal pediatric endoscope is a cystoscope or hysteroscope because the accessory channel facilitates the retrieval of foreign bodies while at the same time allowing a vaginal lavage to be performed. The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. Not every variant of hymen is normal, and transections between 3 and 9 oclock should raise a suspicion for abuse because these are likely acquired rather than congenital (discussed further in Chapter 9 ). Sources of accidental trauma areusually straddle injuries. The severity of vulvovaginitis symptoms varies widely from child to child. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. Occasionally it is best to defer the genital examination until a second visit . Happy Halloween! While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. 0:38. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. Caring pediatric nurses are available 24/7 to help answer your questions. Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. Learn more about patient ratings and reviews. She also discusses the preferred diagnostic modality and when to consider surgery. 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. They schedule and bill separately for their services, and are not employees of the Hospital. 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. 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. Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus. 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. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. Visualizing the hymen. Opening questions can include inquiriesabout the family structure and recent changes, school, friends (such aswhether she has a best friend), and the types of activities she enjoys.It is important to assess who cares for the child and to uncover--both fromthe parent and from the child--information about any history of sexual abuseor current concerns in that regard. Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.Referral should be made to a gynecologist with experience in pediatric gynecology. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit. Using Google Glass to Examine the Hand with Dr. Verghese. Sometimes doctors do pelvic exams if they think there's a problem. The pediatric gynecologic visit may be unique to both the child and the parent. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. This includes feeling a girl's uterus and ovaries to be sure everything's normal. N gonorrhoeaerarely persists beyond the newborn period without symptoms. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. 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. 11 mins, 28 secs. With puberty , the prepubertal vagina becomes acidic under the influence of bacilli dependent on a glycogenated estrogen-dependent vagina. Stanford 25 Skills Symposium 2016 Announced! Stanford 25 YouTube Channel Abdominal Examination Examination of the Spleen (Stanford Medicine 25) Percussion of the Spleen (Stanford Medicine 25) Diagnosis Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) with Carnett's Sign - Abdominal Pain Ankle Brachial Index Ankle Brachial Index (ABI) Test: How to Perform Venous Testing Bedside Ultrasound A discharge that is both bloody and purulent is likely not from vulvovaginitis but from a foreign body (see Vaginoscopy for Prepubertal Bleeding without Signs of Puberty later in this chapter), although patients infected with some pathogens, particularly Shigella boydii, often present with a bloody or blood-tinged discharge . Inspect the child's breasts and palpate themfor signs of puberty. Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. Examination of the Female Genitourinary System. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. 12.1 ). Event marketing. Routine biopsy of the normal-appearing contralateral ovary should be avoided. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. The Stanford Medicine 25 program for bedside medicine at the Stanford School of Medicine aims to promote the culture of bedside medicine to make current and . Nonspecific vulvovaginitis. 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. These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. Not sure if you need urgent or emergency care? Female Pelvic Exam. If the issue is "vaginal" bleeding, the differential diagnosisincludes condyloma acuminatum, urethral prolapse, vascular lesions, precociouspuberty, hormonal medications, and (rarely) sarcoma botryoides, in additionto vulvovaginitis, foreign body, and lichen sclerosus. The exam can be done even if you have never had sexual intercourse, because the opening to your vagina is large enough to allow for the exam. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. Despite widespread belief, mycotic (yeast) vaginal infections are not common in prepubertal children because the alkaline pH of the vagina does not support fungal growth. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Managing vulvovaginitis. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. 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. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. An infant may be examined on her mothers lap. You can also ask the child to cough in order todistract her and cause her hymen to open. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. Historically, these masses were surgically removed, often involving removal of the entire ovary. After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.6 In premenarchal girls, the vagina is 4 to 5 cm long withthin, red epithelium. After observing an increase in the rate of syphilis cases, the Cleveland Clinic Ob/Gyn & Womens Health Institute has partnered with the Center for Pediatric Infectious Diseases to evaluate the effectiveness of current testing strategies. Rectoabdominal exam. However, young children can help define their exact symptoms on direct questioning. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. The introduction of any instrument into the vagina of a young child takes skillful patience. A hand lens or otoscope often is helpful. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding. This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam.
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