Pelvic Examination | NEJM The severity of vulvovaginitis symptoms varies widely from child to child. Thus the office visit and the gynecologic physical examination are performed differently in a prepubertal child compared with an adolescent girl or a mature reproductive-age woman. The introduction of any instrument into the vagina of a young child takes skillful patience. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. 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. In this video, Veronica Alaniz, MD, provides guidelines for examining and understanding genital lacerations and hematomas resulting from vulvovaginal trauma, including blunt trauma or straddle injury and penetrating. 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. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. 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). The most common gynecologic condition of children is vulvovaginitis . Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescents hormonal milieu. . The tape is subsequently examined under the microscope. Cystic ovarian masses commonly occur in infants, children and adolescents. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. Providers can counsel patients that they will inform them of each step in the process and then ask the teen if she is ready before performing each step. The child is told to have her abdomen sag into the table. 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. Over the last decade, however, the management of ovarian masses has shifted toward a more conservative approach with the goal of ovarian preservation. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. Tailor your gynecologic examination to the presentingissue. Different positions for performing a gynecologic examination on a child. Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques. 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. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. The prepubertal vagina is neutral or slightly alkaline. A handheld mirror may help in some instances when discussing specifics of genital anatomy. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. An ectopic ureter can present as persistent wetnessor purulent discharge. What will bedside manner look like for new data-driven physicians? Pediatrics 1990;86:428, 9. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding. It is not diagnostic since few vaginal diseases can be diagnosed visually. Vulvovaginitis is the most common gynecologic problem in prepubertal girls. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. These minor accidents result in injury because the genital tissues in children, without estrogen, are very thin and easily traumatized. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. Pediatrics 1980;65:758, 4. 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. A history of trauma--whetheraccidental, intentional (for example, scratching due to pinworm infection)or caused by sexual abuse--also should be elicited. 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. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. 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. 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. 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. Pelvic Exam, The | Advanced Pediatric Associates | Pediatricians in The most common malignancy in preadolescent girls is a germ cell tumor. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. Help me decide. 12.2 ). The child's buttocks will now be heldup in the air and her back and abdomen will fall downward (Figure 4). The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). Nonspecific vulvovaginitis. For example, if a girl complains of . There will also be an extra sheet you can use to cover yourself. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. Pediatrics 1987;79:778, 8. Vulvovaginitis: causes and management. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. For example, if a girl complains of . The evaluation of young girls is age dependent. Chronic Pelvic Pain and Endometriosis: Part 2 - UCSF Health Obtaining a history from a child is not an easy process. 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. 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. Hymens are often crescent shaped but may be annular or ringlike. Obtaining cultures. Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. This is referred to as nonspecific vulvovaginitis. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. 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The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. Pelvic Exams - HealthyChildren.org 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 Your pediatrician will describe each step of the exam. Emphasize setting the stage to make the examination a positive experience for your young patient. Affiliated with the University of Colorado School of Medicine. View a sample video. From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. From AccessMedicine. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. 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. Classifications of hymenalconfiguration include posterior rim (crescent), annular, or redundant (Figures6 and 7).5 Congenital anomalies, including imperforate, microperforate,and septate hymen, also can occur. The history should include the quality of the discharge(color, odor, presence of blood), hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions. 0:38. Pelvic exam - Mayo Clinic Examination of the Female Genitourinary System. 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. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. A helpful technique is to place the childs hand on top of the physicians hand as the abdominal examination is being performed and to give her some choices, such as having a doll, an electronic tablet, or a toy with her. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. 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 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. Children usually are asymptomatic,but they may present with secondary infection. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. 1 A vaginal self-exam is not the same as a vulvar examination. Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. It's also not true that the pelvic exam is a "test" to see if you are a virgin. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. 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 . Often reassurance and sometimes delay until another day are the best approaches. Abraham Verghese Asks: Why Are We Doing This Teaching? In life-threatening emergencies, find the emergency room location nearest you.