Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation. All children should have a chance for a healthy future. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases. 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 second phase of the examination involves evaluation of the vagina . In life-threatening emergencies, find the emergency room location nearest you. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse. The entire exam takes about only 5 minutes. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. 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. Urethral prolapse also can present with bleeding. 12.2 ). Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. Uterine bleeding that is coming more often than every three weeks, lasting longer than seven days in a row, or resulting in excessive product use and frequent bleeding through clothes should be evaluated. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Childrens clothing is often tight fitting and nonabsorbent, which keeps the vulvar skin irritated, warm, moist, and at risk for vulvovaginitis. The child is told to have her abdomen sag into the table. Historically, these masses were surgically removed, often involving removal of the entire ovary. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. Buyers also reviews treatment options, including menstrual suppression, with a focus on key counseling points to help patients and families decide which method is best for them. 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. Whenever possible, addressquestions directly to the child. In determining the diagnosis, it may be helpfulto inquire about persistently wet underwear, recurrent fevers, unexplainedUTI, and abdominal or lower back pain. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. Often reassurance and sometimes delay until another day are the best approaches. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. 5 Minute Pelvic Exam Video. A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. Female Pelvic Exam. 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. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Learn Peds Genitourinary 04 Genital Exam Intro from UBC Learn Pediatrics on Vimeo. One method is to use the knee-chest position (see Fig. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. Loose-fitting cotton undergarments should be worn. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. Obtaining cultures. An interesting illustration of the physical exam. In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. 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. 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. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. This period of transition involves important physical and emotional changes. Topics for the pediatric nurse practitioner to be aware of. 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. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. 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. From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. The most important technique to ensure cooperation is to involve the child as a partner. Learn how doctors should perform a bedside swallow evaluation! Examination of the vulva, hymen, and anterior vagina by gentle lateral retraction (. This is a difficult decision and is based on the extent of the childs anxiety in relation to the severity of the clinical symptoms. OB/GYN - Physical Examination Resources - University of Iowa Event marketing. 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. Recurrent vulvovaginitis, persistent bleeding, suspicion of a foreign body or neoplasm, and congenital anomalies may be indications to perform a vaginoscopy and examine the inside of the vagina. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. You can also ask the child to cough in order todistract her and cause her hymen to open. Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs. 0:31. This canbe accomplished by establishing rapport with the child, keeping the paceunhurried, proceeding from less to more intrusive examinations and askingfor consent before proceeding, and allowing the child to be an active participantin the process as much as possible.2, Another important consideration when performing a gynecologic assessmentis providing anticipatory guidance to the patient and her parents. Emphasize setting the stage to make the examination a positive experience for your young patient. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Using Google Glass to Examine the Hand with Dr. Verghese. Clin Obstet Gynecol 1987;30:643, 7. Treatment is the same as for labialadhesions. Routine biopsy of the normal-appearing contralateral ovary should be avoided. The film opens with a woman sitting in an office of a physician. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. Menstrual bleeding in adolescents can be chaotic. Adult pinworms maybe visible at night. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. 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. 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. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Approach to evaluation of premenarcheal child with a gynecologicproblem. In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. The severity of vulvovaginitis symptoms varies widely from child to child. This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. Patient has this new skin finding, what should you worry about? 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. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. A visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers. 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. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. In 2019, there were over 1.7 million new cases of cancer, with 10,270 cases occurring among children ages 0 to 14 years of age and 70,000 occurring in adolescents and young adults. One way to describe genital area and breasts is to call them private areas and define this as meaning areas that are covered by a bathing suit. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . The most common malignancy in preadolescent girls is a germ cell tumor. Videos - Hopkins Medicine Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. Macleod's Physical Examination - Head, Eyes and Ears Examination - OSCE Guide 2017. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Am J Obstet Gynecol1987;157:950, 6. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. 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. Most such traumas involve straddle injuries. In girls with persistent, purulent, or recurrent vaginal discharge, orthose with a suspicion of sexual abuse, obtain a wet preparation and culturesfor bacterial pathogens, C trachomatis, and N gonorrhoeae. If you put your stethoscope over this, what will you hear? It is recommended that the examination start with the nongenital areas , such as listening to the heart and lungs; an abdominal examination and inspection of the skin should be performed. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. This easily assembled adaptation uses a No. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. Cystic ovarian masses commonly occur in infants, children and adolescents. This chapter considers gynecologic diseases of children from infancy through adolescence. Sometimes doctors do pelvic exams if they think there's a problem. The relative size ratio of cervix to uterus is 2:1 in a child. In preadolescent girls, both benign and malignant ovarian tumors are usually unilateral. The tape is subsequently examined under the microscope. She also explains why it is important to check ferritin levels for iron deficiency and discusses the etiology of abnormal uterine bleeding, with most heavy menstrual bleeding in adolescents and young adults due to ovulatory dysfunction or inherited bleeding disorders. Emphasize that the most important part of the examination is just looking and that there will be conversation during the entire process. Physiologic leukorrheacan be confused with vulvovaginitis. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. The vagina of a child is 4 to 5 cm long and has a neutral pH. 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A hand lens or otoscope often is helpful. This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. It is not diagnostic since few vaginal diseases can be diagnosed visually. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. Observation alone is appropriate for small adhesions. A girl who has nonspecific vaginitis shouldbe counseled to do the following: (1) practice good perineal hygiene; (2)urinate with her knees spread apart; (3) wear white cotton underpants andloose clothing; (4) take sitz baths once or twice a day; (5) avoid irritantssuch as bubble bath and use hypoallergenic soaps; and (6) apply a barrierointment such as A and D, Vaseline, or Desitin to the perineum. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. The vulva and anus. 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. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. 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. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. This conveys an unhurried approach. 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. 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. 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. 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. Your pediatrician will describe each step of the exam. An imperforate hymen appearsas a thin membrane, and will bulge if hydromucocolpos is present. The Pelvic Exam. 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. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. Tricia Huguelet, MD, Chief of Pediatric and Adolescent Gynecology, describes the typical presentation of hymen imperforations in adolescents and young adults, as well as obstructing and non-obstructing mllerian anomalies. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. Pay special attention to anatomic and pathophysiologicdifferences in the child. 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. What Is The Specific Cause of This Patients Clubbing? The source maybe the vulva, vagina, endometrium, and occasionally the urethra. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. 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. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescents hormonal milieu. These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. 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 ( ). If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. 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. Menstrual pain and cramps are very common in women and affect 50% to 90% of female teens. EMANS is Chief, Adolescent Division, Children's Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). She also discusses the preferred diagnostic modality and when to consider surgery. Hymens are often crescent shaped but may be annular or ringlike. Pokorny SF. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. The most common gynecologic condition of children is vulvovaginitis . Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. Genital bleeding should always be assessed thoroughly. Pelvic exam - Mayo Clinic Last updated on April 26, 2013 @3:30 pm Feedback: How useful was the above information? This short 1958 educational film from the American Cancer Society shows how to perform a routine pelvic examination and cytologic test for the detection of cancer of the uterus. Thefinding of genital herpes type 2 is a strong indication of sexual abuse.Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.14Trichomonaswill rarely cause symptoms in the newborn period and spontaneously resolveswith waning of estrogen levels. Chronic Pelvic Pain and Endometriosis: Part 2 - UCSF Health First gynecological exam debunked: What parents need to know Vulvovaginitis: causes and management. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. 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. There will also be an extra sheet you can use to cover yourself. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. Obtaining a history from a child is not an easy process. An infant may be examined on her mothers lap. Female Urethral Catheterization Male Urethral Catheterization Female Genital Exam Male Genital Exam Don't forget to watch the Why Urology video! If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). A tape testmay be useful for suspected pinworm. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Medical Forensic Exam Videos Adult/Adolescent Sexual Assault Medical Forensic Exam This 58 minute video includes: History Taking Discussion of HIV Prophylaxis Full anogenital exam with evidence collection Demonstration of Foley catheter technique Demonstration of toluidine blue dye application Photography Pediatric History Taking This 63 minute video uses unscripted interactions with children . A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. An older child should be asked whom she prefersto have in the room during the examination. Diagnosing and treating PCOS in adolescents. (From Emans SJ. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina. 4:40. Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. Dealing with a foreign body. 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. Whats the diagnosis? Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. Pokorny SF: Configuration of the prepubertal hymen. 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. 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. Childrens Hospital Colorado providers are faculty members of the University of Colorado School of Medicine. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. Emans SJ, Lanfer MR, Goldstein DP: Pediatric and Adolescent Gynecology,4th ed. 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. Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. Adolescents often come for examinations with the preconceived idea that it will be very painful. Pediatrics 1987;79:778, 8. A pelvic exam is where a doctor or nurse practitioner looks at a girl's reproductive organs (both outside and internally).