Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal 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. In: Emans SJ, Laufer MR, Goldstein DP, eds. 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. Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. Group A streptococciand Shigella are the most common causes. W Webcam. The evaluation of young girls is age dependent. Interruptions should be avoided. 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. 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. Vulvovaginitis: causes and management. A gentle, patient approach is important when examining a prepubertal girl. 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. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. Intestinal parasitic invasion with pruritus. From AccessMedicine. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . In this video, adolescent gynecologist Eliza Buyers, MD, reviews the pathophysiology and diagnosis of PCOS in adolescent patients. When alone withan examiner, a child may disclose abuse or other concerns, and allowingher to be interviewed or examined alone may give her a greater sense ofcontrol and responsibility for her own health. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. View a sample video A foreign object and the cervix may be visualized using this technique. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits. 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. 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. 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. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. In some patients, particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. The quantity of discharge can vary greatly, from minimal to copious. Specific vulvovaginitis. The Pelvic Exam. Examination of the Female Genitourinary System. The most important technique to ensure cooperation is to involve the child as a partner. 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. However, young children can help define their exact symptoms on direct questioning. 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. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. A handheld mirror may help in some instances when discussing specifics of genital anatomy. It can also present as a chronic colonization (diaper rash) in patients using diapers. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. Pediatrics 1980;65:758, 4. Gynecologic Examination with Pap Smear. 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. The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. The usual cause of genital trauma during childhood is an accidental fall. Pelvic Exam; Breast Exam; Self Breast Exam; Bimanual Exam; Pap Smear Heavy menstrual bleeding is common in adolescents, with about 15% to 40% of teens experiencing heavy bleeding, but many teens dont recognize that their bleeding is abnormal. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. Because the child lacks the labial fat pads and pubic hair of the adult, when a child squats, the lower one-third of the vagina is unprotected and open. 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. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. An older child should be asked whom she prefersto have in the room during the examination. 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. Affecting approximately one in every 4,500 newborn girls, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome can be challenging to treat both medically and psychologically, due to the potential loss of fertility. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescents hormonal milieu. Making the examination a positive experience, ifpossible, therefore is critical.2. "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. Teens don't usually get pelvic exams. Support Lucile Packard Children's Hospital Stanford and child and maternal health. 12.4 ). 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 ( ). In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. Addressing the Youth Mental Health Crisis, Department of Pediatric and Adolescent Gynecology, Fertility Preservation and Reproductive Late Effects Program, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome, Insurance, billing and payment information. Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. An ectopic ureter can present as persistent wetnessor purulent discharge. 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. Managing vulvovaginitis. Pelvic Exam The pelvic exam is a vital part of every woman's preventative care and is also important towards making a number of diagnoses when presenting with abdominal or pelvic complaints. 12.3 ). Endocrinologic issues, such asneonatal bleeding due to maternal estrogen withdrawal, precocious puberty,exogenous hormone preparations, and hypothyroidism should be ruled out.Dermatoses such as lichen sclerosus can cause bleeding. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. Dealing with a foreign body. You can use this section to discover where and how this . 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. The introduction of any instrument into the vagina of a young child takes skillful patience. Tell the child that the examination willnot hurt, and if you are going to use instruments, that these tools areall specially designed for little girls.1Let the child look atand touch the instruments to be used, such as an otoscope or a hand lens.When talking with parents, it is important to carefully explain that thechild's hymen will not be altered in any way by the examination, becausemany parents do not fully understand the anatomy of the vagina and hymen.Basic diagrams of the anatomy may be helpful. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. 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. Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube 0:00 / 15:07 Dr. Ahmed Darwish - Pediatrics: General Examination Dr. Ahmad Darwish 13.1K subscribers Subscribe 1.5K 114K views 5. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina. Noninfectious causes of vulvovaginitis also are common. Many adolescent girls do not want their mother, guardian, or other observers in the examining room, and in many adolescent gynecology visits, a full pelvic examination is unnecessary ( ). Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. Nonspecific vulvovaginitis. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. One method is to use the knee-chest position (see Fig. Not sure if you need urgent or emergency care? Show Transcript. In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. Many dermatologic disorders, suchas atopic dermatitis, seborrhea, and psoriasis, can manifest as vulvitisor vulvovaginitis. All children should have a chance for a healthy future. If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.12 Another method ofobtaining samples, used by Pokorny and Stormer, consists of a catheter-in-a-cathetertechnique.13 The proximal end of an IV butterfly catheter isinserted into the distal end of a size 12 bladder catheter, and a 1-mL tuberculinsyringe with 0.5 to 1.0 mL of sterile saline is attached to the hub of thebutterfly tubing. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. Mycotic vaginal infections may be seen in immunosuppressed prepubertal girls such as those with human immunodeficiency syndrome (HIV) or diabetes or on chronic steroid therapy. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. A nurse retrieves the patient from the office and takes her to an exam room. Videos : Exams. Cultures from the vagina indicate normal rectal flora or Escherichia coli. In addition to your doctor, there will be a nurse or an assistant in the room during . At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. 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. . The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. 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 Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. The typical location is the anterior vaginalwall near the cervix. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. 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. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. There is nothing specific about the symptoms or signs of childhood vulvovaginitis. The child can assist you by holding herlabia apart. Many adolescent girls do not want other observers, such as mothers, in the examining room. When is it best to reassure, and when is it necessary to evaluate? Examination of the vulva, hymen, and anterior vagina by gentle lateral retraction (. The child lies prone and places her buttocks in the air with legs wide apart. A gentle, patient approach is important when examininga prepubertal girl. Physicians may elect to treat the primary symptoms of vulvovaginitis for 2 to 3 weeks, realizing that on rare occasions they could be missing something more serious. Sources of accidental trauma areusually straddle injuries. A tape testmay be useful for suspected pinworm. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers.