Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. 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). Thisarticle focuses on setting the stage so that the examination is a positiveexperience for the patient and her family, describes specific techniquesand strategies for performing an appropriate and non-traumatic examination,and reviews diagnosis of disorders commonly found in prepubertal children. 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. 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. 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. The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. Videos : Exams. Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse. 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. 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. Pads should be placed in the mothers lap because examination often is associated with urination. The signs of vulvovaginitis are variable and not diagnostic, but they include vulvar erythema, edema, and excoriation. The most common gynecologic condition of children is vulvovaginitis . Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. 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. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. 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. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. Stanford 25 Skills Symposium 2016 Announced! After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. Rectoabdominal exam. A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. Adolescent Gynecology Exam - Children's Volume 90% Video Chronic Pelvic Pain and Endometriosis: Part 2 Jeannette Lager, MD, describes a directed pelvic examination for chronic pelvic pain, including a general pelvic exam, Q-Tip test for vulvodynia, abdominal exam (including testing for Carnett's Sign), an exam of the pelvic floor muscles and an assessment of myofascial trigger points. The child lies prone and places her buttocks in the air with legs wide apart. A tape testmay be useful for suspected pinworm. Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. 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. A successful gynecologic examination of a child demands that the physician employ an exam pace that conveys both gentleness and patience with the time spent, without seeming to be hurried or rushed. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina. 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. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. A vaginal self-examination is a way to look at your vulva and vagina to better understand your body and to spot problems that may need medical attention. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. 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 . Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. 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, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). Pelvic Exams (for Teens) - Humana - Kentucky 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 ( ). 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. PDF Genital Examination of Young Girls - Royal Children's Hospital One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. These data can be used to inform the design of teaching interventions to improve skill in this area. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. Loose-fitting cotton undergarments should be worn. 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. The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. 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. 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. 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. Abraham Verghese Asks: Why Are We Doing This Teaching? Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. 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. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Support teaching, research, and patient care. The typical location is the anterior vaginalwall near the cervix. Help me decide. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. Learn how doctors should perform a bedside swallow evaluation! Once the child is positioned, the vulvar area and introitus should be inspected. Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. 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. 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. Diagnose this skin lesion with newest Stanford 25 video and topic. Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. Vaginalagenesis is characterized by thick vestibular tissue, and often there isa dimple surrounded by a vulvar depression where the hymen should be.6, Acquired hymenal abnormalities usually are caused by sexual abuse andrarely by accidental trauma. Girls should have their first gynecological exam between the ages of 13 and 15. The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. The severity of vulvovaginitis symptoms varies widely from child to child. After your examination is complete, congratulate the child for her cooperationand bravery. 1. OB/GYN - Physical Examination Resources - University of Iowa These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. 11 mins, 28 secs. W Webcam. Includes speculum and bimanual exams. PCOS occurs due to a complex interaction of genetic and environmental factors can affect the menstrual cycle, hair growth, skin, weight and the ability to have children. 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. Having a relationship with a pediatric gynecologist can help girls take . Includes menu so you can select the portion of the video most applicable to you. The pediatric gynecologic visit may be unique to both the child and the parent. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. Adult pinworms maybe visible at night. 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 child's buttocks will now be heldup in the air and her back and abdomen will fall downward (Figure 4). Examination of the Female Genitourinary System. 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. Gynecologic examination of the prepubertal girl - Contemporary Pediatrics 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. If extensive labial adhesions are present, you maynot be able to adequately examine the hymen and vagina and will need toreexamine the child after she has successfully completed treatment withlocal hygiene measures and topical estrogen (see Sidebar, "Common gynecologicfindings in the prepubertal girl"). Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. 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. This is to help girls understand that there is a doctor dedicated to their reproductive health. 5 Minute Pelvic Exam Video. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. This conveys an unhurried approach. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. The quantity of discharge can vary greatly, from minimal to copious. Emphasize setting the stage to make the examinationa positive experience for your young patient. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. Group A streptococciand Shigella are the most common causes. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Pokorny SF. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. 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. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. Gynecological examination of the prepubertal girl can be challenging. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescents hormonal milieu. Home | Bates' Visual Guide Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. For a small childwho is fearful of the exam, it may be best to have the mother sit on thetable in a semireclined position (feet in or out of stirrups) with the child'slegs straddling her thighs (Figure 3). Online Teaching Videos - Department of Urology Physiologic leukorrheacan be confused with vulvovaginitis. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. They may ask for their mothers to be there, be fearful of the examination concept, and need more than one visit to achieve the goals of the visit. In this setting it may be helpful to use the extinction phenomenon, in which the examiner provides pressure on the perineum lateral to the introitus before insertion of the speculum. Your pediatrician will describe each step of the exam. Condylomata acuminataalso can cause bleeding but may be difficult to recognize, because in prepubertalchildren, they often do not have the typical cauliflower-like appearance.Rather, genital warts typically present as exophytic lesions or papuleswith small red punctations over the surface. 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. Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. You might have a pelvic exam as part of your regular checkup. 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. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. 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. 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. The normal prepubertal uterus and ovaries are nonpalpable. It is important to give the child a sense that she will be in control of the examination process. Because of compassion and empathy, the gynecologist may underestimate the extent of the anatomic injuries. You can also ask the child to cough in order todistract her and cause her hymen to open. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. Will the Healing Touch Go Out the Door With the Stethoscope? Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. There are no reported cases of congenital absence of the hymen. 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. 12.2 ). 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. There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. Obtaining a history from a child is not an easy process. Adolescents often come for examinations with the preconceived idea that it will be very painful. Gidwani GP. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. 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. 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. In the period surrounding the time of puberty, children often develop a physiologic discharge secondary to the increase in circulating estrogen levels. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. 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. Pelvic Exam, The | Advanced Pediatric Associates | Pediatricians in Leukorrhea may be present. Emans SJ, Lanfer MR, Goldstein DP: Pediatric and Adolescent Gynecology,4th ed. The majority of cases of persistent or recurrent nonspecific vulvovaginitis respond to improved hygiene and treatment of irritation resulting from trauma or irritating substances. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. Hysteroscopy is performed in the operating room under general anesthesia. 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. 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 . Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. Positive identification of gonorrhea or chlamydia in a child with premenarcheal vulvovaginitis is considered diagnostic of sexual abuse. Vaginoscopy is a diagnostic procedure that can be used to evaluate the inside of the vagina and is recommended for girls who are too young for a speculum exam or cannot tolerate one. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. So this is the scariest picture weve got! 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. Sarah's Physical Exam with Pelvic Exam - YouTube Can you diagnose the cause of the patients lymphedema? 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. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. 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. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. The tape is subsequently examined under the microscope. Support Lucile Packard Children's Hospital Stanford and child and maternal health. 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. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. This includes feeling a girl's uterus and ovaries to be sure everything's normal. How to Perform a Vaginal Self-Exam - Verywell Health