The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. This is to help girls understand that there is a doctor dedicated to their reproductive health. 12.2 ). Without continuation of the hygiene measures, however, broad-spectrum antibiotics will only offer temporary relief and the problem is likely to recur ( ). Inspect her for pubic hair and note the condition of the urethra,size of the clitoris, any signs of estrogenization, configuration of thehymen, and perineal hygiene. The introduction of any instrument into the vagina of a young child takes skillful patience. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. It is not diagnostic since few vaginal diseases can be diagnosed visually. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. 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 ). The majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. Lichen sclerosis also can present as vulvar discomfort or pruritus.It is characterized by atrophy of the vulvar skin, which may distort theanatomy of the labia and clitoris, producing ecchymoses and "bloodblisters.". Many young childrens primary contact with providers involves immunizations; children should be assured that this visit does not involve any shots. It is also helpful to assure the adult accompanying the child that speculums are not part of the examination. 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). Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. 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. 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. Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. However, many infants are infected with Chlamydia trachomatis during birth and remain infected for up to 2 to 3 years in the absence of specific antibiotic therapy. Children are not skilled historians and will often ramble, introducing many unrelated facts. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. This can be accomplished without the insertion of any instruments. You can also ask the child to cough in order todistract her and cause her hymen to open. 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. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). Nonspecific vulvovaginitis. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. 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. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. 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. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. In some patients, particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. A mounding of hymeneal tissue is often called a bump. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. 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. You canmodel for parents appropriate ways to discuss gynecologic issues with theirchild, and help parents and children understand the importance of discussingissues related to reproductive healthand sexuality during the prepubertalyears.1. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. Vulvarskin disorders are common, and often easily recognizable on exam. 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. Your patient gets this rash, whats the diagnosis? A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. 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. At the 44th National Association of Pediatric Nurse Practitioners Conference, data was presented on how to diagnose and treat polycystic ovarian syndrome in adolescent patients. 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. Caring pediatric nurses are available 24/7 to help answer your questions. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. Tailor your gynecologic examination to the presentingissue. Although rare, it isimportant to recognize sarcoma botryoides, or embryonal rhabdomyosarcoma.Such a tumor can present as a lower abdominal mass or as vaginal bleedingor passage of part of the tumor. 1. 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. Afterthe newborn period, the average size of a normal clitoral glans in a premenarchalchild is 3 mm in length and 3 mm in transverse diameter.4 Inprepubertal girls, the vaginal mucosa and perihymenal tissue will be moreatrophic and appear thin and red. Pay special attention to anatomic and pathophysiologicdifferences in the child. She provides an overview of the physiology and evaluation of AUB, including recommendations on when to consider referring patients to our Spots and Dots Clinic. A tape testmay be useful for suspected pinworm. From AccessMedicine. Newborns and pubescent girls sometimeshave significant vaginal secretions because of estrogen effect. A foreign object and the cervix may be visualized using this technique. Pokorny SF. 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 complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Before the exam, you will need to undress and put on a gown. If patients are going to be treated with antibiotics, one should attempt to collect a sample of the vulvovaginal discharge for culture before initiation of the antibiotics . Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina. Happy Halloween! It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. For non-life-threatening medical needs when your pediatrician is unavailable, visit one of our urgent care locations. 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. In this video, adolescent gynecologist Eliza Buyers, MD, reviews the pathophysiology and diagnosis of PCOS in adolescent patients.

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