The child is told to have her abdomen sag into the table. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. 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. Pelvic Exam; Breast Exam; Self Breast Exam; Bimanual Exam; Pap Smear Hysteroscopy is performed in the operating room under general anesthesia. Children often cannot hold still for long intervals while instruments are being located. After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.6 In premenarchal girls, the vagina is 4 to 5 cm long withthin, red epithelium. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Vulvarskin disorders are common, and often easily recognizable on exam. Urethral prolapse also can present with bleeding. Power your marketing strategy with perfectly branded videos to drive better ROI. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. Girls should have their first gynecological exam between the ages of 13 and 15. In some patients, particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen. A gentle, patient approach is important when examining a prepubertal girl. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. The evaluation of young girls is age dependent. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . Not sure if you need urgent or emergency care? 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. If a child's symptoms are severe,a one- to four-week course of a moderate-potency ointment can be recommended,followed by a lower-potency preparation. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. These data can be used to inform the design of teaching interventions to improve skill in this area. A foreign object and the cervix may be visualized using this technique. 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. 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 ( ). The majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). 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. Yuwoko. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. Your pediatrician will describe each step of the exam. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). 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. 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. 3 simple steps. 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. 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. Urethral lesions alsoshould be considered. However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. The child lies prone and places her buttocks in the air with legs wide apart. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. 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. 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. There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. During a pelvic exam, a doctor evaluates your reproductive organs. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers. 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. An Initiative of the Program for Bedside Medicine, Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. 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. Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass. 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 . A handheld mirror may help in some instances when discussing specifics of genital anatomy. Most such traumas involve straddle injuries. Slang terminology for speculums among teens includes the threatening label the clamp. Teens should be assured that although the examination may include mild discomfort, it should not be painful . Forunusually persistent cases, it is appropriate to prescribe a 10-day trialof antibiotics (amoxicillin, amoxicillin-clavulanate, or a cephalosporin)or occasionally a two- to three-week course of an estrogen cream. Nonspecific vulvovaginitis. Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. 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. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. This can be accomplished without the insertion of any instruments. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. 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. The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse. Menstrual pain and cramps are very common in women and affect 50% to 90% of female teens. 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. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. Noninfectious causes of vulvovaginitis also are common. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. Inspect the child's breasts and palpate themfor signs of puberty. In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. It's also not true that the pelvic exam is a "test" to see if you are a virgin. In addition to your doctor, there will be a nurse or an assistant in the room during . 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. 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. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). This includes feeling a girl's uterus and ovaries to be sure everything's normal. All-New Assessment Videos! The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. Clin Obstet Gynecol 1987;30:643, 7. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. Patient has this new skin finding, what should you worry about? Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. 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. . Below is a collection of all our Stanford 25-generated videos also found throughout the website. Routine gynecologic examinationof infants and children can help prevent future health problems such asvulvovaginitis by giving the clinician the opportunity to educate parentsabout perineal hygiene.1 During the annual genital inspection,the pediatrician also may discover such significant abnormalities as clitoromegaly,signs of early puberty, vulvar dermatoses, or rarely hymenal or vaginaltrauma. 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. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. Sometimes doctors do pelvic exams if they think there's a problem. The child's buttocks will now be heldup in the air and her back and abdomen will fall downward (Figure 4). Dr. An infant may be examined on her mothers lap. 12.4 ). An older child should be asked whom she prefersto have in the room during the examination. Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. Obtaining a history from a child is not an easy process. Teens don't usually get pelvic exams. Can you diagnose the cause of the patients lymphedema? This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses. Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. Obtaining cultures. Whenever possible, addressquestions directly to the child. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). 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 device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. It is important to give the child a sense that she will be in control of the examination process. The vagina will then fill with air, aiding the evaluation. In this. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. 1 A vaginal self-exam is not the same as a vulvar examination. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . From AccessMedicine. Management is dictatedby the diagnosis: antibiotics and hygiene measures for infectious vulvovaginitis,surgical repair of trauma if necessary, biopsy of polyps or suspected tumors,removal of foreign bodies, further investigation for sexual abuse if itis suspected by exam or history or if condylomata are found, sitz bathsand estrogen cream for urethral prolapse, and further investigationinto the etiology of precocious puberty. This is to help girls understand that there is a doctor dedicated to their reproductive health. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation and discharge. This includes the process for diagnosis and considerations for work-up, evaluation and treatment, such as support and counseling. activated charcoal for hiatal hernia,