Pediatric and Adolescent Gynecology

Indications

The American Academy of Pediatrics (AAP) recommends that inspection of the external genitalia be part of every general physical examination. Careful perineal inspection during the first several well-child visits allows early identification of congenital anomalies of the labia and hymen. Anomalies of these external structures are rare but, if present, can be associated with anomalies of the urethra and bladder. Evidence of virilization in the newborn, especially when accompanied by hyperpigmentation, should prompt immediate laboratory investigation for evidence of salt-losing adrenal hyperplasia and warrants urgent endocrinology referral.

The proximal vagina, uterus, cervix, and fallopian tubes are derived from the Mullerian or paramesonephric ducts and develop concurrently with the urinary tract. Thus, patients with renal or urinary tract abnormalities are at greater risk for having associated anomalies of internal genital structures. Ultrasonography is very useful in evaluating neonates for suspected upper genital tract anomalies; these structures are relatively large during the neonatal period because of the influence of maternal hormones and higher levels of gonadotropins. Later in infancy and during early childhood, they are occasionally difficult to detect because of their small size. Hence, failure to visualize internal genital structures in prepubertal patients does not equate with agenesis, and in such cases, magnetic resonance imaging (MRI) can clarify the presence or absence of pelvic organs.

Patients who have specific complaints at acute care visits also warrant inspection of the genitalia in addition to abdominal, inguinal, and (when indicated) rectal examination. These complaints include abdominal pain; dysuria, urinary frequency, urgency, incontinence, or enuresis; constipation or encopresis; perineal pruritus, pain, or other abnormal sensation; vaginal discharge or bleeding before menarche; and suspected or acknowledged sexual abuse. Sexual abuse in the pediatric patient warrants referral to a clinician with the specialized knowledge, skills, and equipment appropriate to this evaluation. Careful documentation of the history is vital, because physical examination is likely to be normal. Any signs of injury that are noted should be fully described in words and photographed whenever possible. On occasion, colposcopic, radiologic, or internal examination is indicated.

Technique

Whether the patient is being seen for a routine checkup or for a specific problem, the gynecologic portion of the assessment should occur only after establishing rapport to avoid frightening the child. Because parents and health care providers communicate their own comfort levels to children both verbally and nonverbally, a discussion of any parental anxieties and the clinician’s self-awareness of his or her own attitudes can facilitate successful examination. The use of pictures and language familiar to the child and family may further enhance cooperation but interspersing anatomically correct vocabulary can also be educational. External inspection of the genitals can take place during routine physicals after the abdominal and inguinal exam. The AAP recommends the exam to be performed in the presence of a parent or guardian. The clinician should explain the exam and its reasoning to the child and caregiver. The clinician can request the help of the child as well. Having the support of the caregiver can reassure children.

Young infants can be assessed easily on an examination table after being positioned by the examiner. Drapes generally are unnecessary for toddlers and preschoolers because they are isolating and often perceived as threatening. However, similar to adolescents, school-age children may find drapes helpful in reducing embarrassment. An older infant, toddler, or preschool child may be more relaxed when examined on the parent’s lap, with the parent assisting by gently holding the child in either the frog-leg or lithotomy position ( Fig. 19.5A and B ). School-age children usually can be examined on the table in the frog-leg, lithotomy, or knee-chest position. Knee-chest positioning can provide excellent visualization of the hymen and the distal vagina ( Fig. 19.6 ), but some patients may feel threatened by being examined from behind. An alternative means of achieving visualization of the distal vagina is with the patient supine and performing the Valsalva maneuver (i.e., asking the child to push down as if they were going to pass a stool). This often produces distention of the distal vagina and hymenal orifice, facilitating visualization and atraumatic collection of specimens.

Use of good focused lighting is essential. In the office setting the otoscope provides excellent focused light and low magnification, which is sufficient for most examinations. Some young children fear it because of prior painful experiences during otoscopy. Given this, the patient should be reassured ahead of time that no speculum will be attached and that they will not be forcibly restrained. Preliminary “examination” of the umbilicus may help allay anxiety.

Once the patient is properly positioned, visualization of the introitus, hymen, and lower portion of the vagina is facilitated by maneuvers that separate the labia. These maneuvers should be explained first, and the child reassured that the examiner is “just going to look.” If the patient desires or is mildly anxious, they may place their hands beneath the examiner’s, or the parent may be enlisted to perform the maneuver. Some patients prefer to separate their labia themselves. The maneuvers include labial traction and separation (see Fig. 19.2 ). When using a handheld light (otoscope), a second set of hands (parent or nurse) may be needed to maximize labial separation and focus the light. Care must be taken to ensure that excess traction is not applied during these maneuvers because it can result in painful tearing of labial adhesions, if present.

If the patient is unusually anxious about the procedure and cannot be reassured, the examination should be deferred to a later date. On occasion, use of relaxation techniques, an oral benzodiazepine, conscious sedation, or anesthesia may be needed for an adequate evaluation. At no time should a frightened, struggling child be physically restrained and forced to undergo examination; the yield is minimal and the experience is physically and emotionally traumatic.

On inspection, the clinician can readily ascertain the presence or absence of pubic hair; note the appearance and configuration of the labia majora, labia minora, clitoris, urethra, hymen, vaginal orifice, and anus; note the color of the mucosa and the presence or absence of rash, discharge, or unusual odor; and often visualize the distal vagina. Vaginoscopy is required only occasionally in the prepubertal child in order to perform a complete evaluation for complaints such as vaginal bleeding with or without evidence of trauma, discharge resistant to routine therapy, a suspected vaginal foreign body, and suspected vaginal tumors. Because of the high potential for inflicting pain, especially if the patient moves suddenly, vaginoscopy generally is best performed under anesthesia or sedation. Some older school-age children may tolerate internal examination by a highly skilled examiner without sedation if preparation is careful. Again, a traumatic experience should be avoided. Useful information can be gathered by use of sonography or MRI. Computed tomography (CT) involves greater radiation exposure and provides poorer resolution of pelvic structures and thus should be used only to provide information not obtainable by other imaging studies.

Specimen Collection

If a prepubertal child with vaginal discharge or perineal or urinary complaints is to be evaluated, it is advisable to ask the family not to bathe the patient or to apply any creams for at least 12 hours before the examination. The patient should always be prepared for the procedure with simple and truthful explanations. In the presence of ulcers, herpes cultures or specimens for a polymerase chain reaction (PCR) test should be obtained from the base of unroofed fresh vesicles or ulcers. Routine bacterial cultures, including those for gonococci, can be collected from any visible discharge on the perineum in the prepubertal child. If specimens must be collected because of a history of vaginal discharge, having the patient perform a Valsalva maneuver may move discharge into the introitus. If this fails, specimens can be collected with little discomfort with a Dacron wire swab premoistened with sterile nonbacteriostatic saline.

It can be helpful to allow the patient to handle a moistened swab and touch themself with it. The swab is inserted gently through the vaginal opening, taking care to avoid contact with the hymen, which is exquisitely sensitive. Dry cotton-tipped swabs should be avoided because of their size and because they tend to abrade the thin vaginal mucosa of the prepubertal child. If collection is likely to be difficult because of pain or anxiety or because the hymenal orifice is very small, application of a topical anesthetic to the perineal and hymenal area beforehand can be beneficial. Although topical lidocaine preparations work within 5 to 10 minutes, they can produce transient discomfort before the onset of anesthetic action, reducing cooperation in some patients. When time permits, use of a newer topical anesthetic cream (e.g., eutectic mixture of local anesthetics [EMLA] or lidocaine [LMX]) is an excellent alternative. Table 19.2 lists the specimens that may be considered in evaluating patients with symptoms of vulvitis, vaginitis, or vaginal discharge. If testing for sexually transmitted infections (STIs) is indicated due to concerns of possible child sexual abuse, please refer to Chapter 6 .

Indications

The practice of routine inspection of the external genitalia at each well-child visit beyond infancy facilitates early diagnosis of any problems that may arise and allows evaluation of physical growth and secondary sex characteristics. This also creates an opportunity to discuss normal anatomy and behaviors, including masturbation; to distinguish acceptable from unacceptable (exploitative or abusive) forms of touching; and to help overcome the reluctance of some parents and children to express concerns about the genitalia. Making assessment and counseling a routine part of well-child care may help reduce anxiety and embarrassment for the child when genital or pelvic examinations are required.

A gynecologic examination should be considered for any patient with a variety of specific complaints and concerns, including those listed in Box 19.1 . This examination should include careful inspection of the external genitalia and regional lymph nodes, and palpation of the uterus and adnexa when indicated. In some cases, assessment of internal pelvic structures may require radiologic imaging. For example, if menarche is delayed or menstrual periods are unusually problematic (e.g., excessive pain or unusually irregular flow patterns), ultrasound evaluation can be useful. In most cases, ultrasound imaging in a pediatric radiology suite is preferable to a point of care study.

The gynecologic examination is an important part of routine health care for sexually active adolescents (see Box 19.1 ) and should be considered at 12-month intervals or with greater frequency if indicated based on community and behavioral risk factors. Use of a speculum is typically not required but is useful in situations that necessitate visual inspection of the vaginal cavity or cervix, including those listed in Box 19.2 . In the absence of the aforementioned indications, a speculum exam could first be considered at 21 years old. At this age, women should undergo their first cervical cytology screening, using liquid-based cytology or traditional Papanicolaou (Pap) smear, according to recommendations from the American College of Obstetricians and Gynecologists ( ). Transmasculine patients who still have a cervix should undergo routine Pap testing but may require additional measures (e.g., lubricant or pretreatment with estrogen cream) to ensure comfort during examination.

Technique

A thorough and directed history precedes the examination. A comprehensive outline is suggested in Table 19.3 . Adequate time should be devoted to interviewing the patient alone, which provides an opportunity to ask questions about voluntary and involuntary sexual activity and to explore other concerns that may be difficult to discuss in the presence of a parent or guardian. A similar opportunity should be given to the parents to express any concerns that they are reluctant to share in their child’s presence.

A young patient’s initial experience with a pelvic examination may greatly affect the ease with which they experience routine gynecologic care and sexual relations throughout adult life. Hence, the examiner’s approach should be sympathetic, unhurried, and sensitive to the modesty of the patient. When patients have had gynecologic examinations in the past, it is helpful to ask them about their prior experience to avoid rekindling any emotional or physical trauma.

Young women should be given the choice of being examined with or without an accompanying person in the room. Some patients, particularly early adolescents, may be conflicted between their modesty and their desire for support from a friend or relative. Suggesting that the support person must stay at the head of the table and using drapes that allow visual (eye) contact between patient and examiner is often the most comfortable compromise. Chaperones should be offered to all patients and their presence is considered standard when the examiner is male, is a trainee, or when there is a history of sexual abuse.

The pelvic examination is done after other components of the physical examination. The patient should empty her bladder beforehand, and a urine specimen can be collected at this time if needed for testing. Raising the head of the examining table 20 to 45 degrees helps relax abdominal muscles and facilitates maintenance of visual contact with the patient. Before beginning, the examiner should carefully explain the various parts of the examination: inspection of the external genitalia, speculum examination of the vagina and cervix (with specimen collection), and bimanual palpation. Use of anatomic drawings and/or models can be helpful and educational. Throughout the procedure, clinicians should explain what they are seeing and provide reassurance and education. This should help the patient relax and can also confirm normal anatomic findings and provide examples of accurate vocabulary for reproductive anatomy and function. A hand mirror held by the patient is often useful for similar reasons.

The patient should be assisted into the lithotomy position at the end of the examination table. Non-latex gloves should be worn for both external and internal examinations. Patient comfort may be increased by identifying and then touching distal areas first and moving proximally (e.g., knees, thighs, groin, labia, introitus). Next, the external genitalia are inspected. Pubic hair distribution should be noted as should the presence of any nits, lice, skin or vulvar lesions, or vaginal discharge on the perineum. The introital opening is examined and palpated if there is swelling in the region of the Bartholin glands. Clitoral size is assessed. The urethral opening is then inspected for erythema or discharge. Any purulent material obtained should be tested for gonorrhea, Chlamydia, and Trichomonas.

If a speculum examination is required, successful examination depends on adequate patient preparation and use of appropriate instruments, including a good light source. For virginal adolescents, the narrow-bladed Huffman speculum (½ × 4¼ inches) is recommended. Although long enough to expose the cervix, its narrow blades are usually inserted easily through the virginal introitus. Most sexually active adolescents can be examined with the straight-sided Pederson speculum (⅞ × 4 inches); however, the Huffman speculum should be considered as an alternative for a first pelvic examination or for particularly anxious patients. The duck-billed Graves speculum (1⅜ × 3¾ inches) is useful in parous patients ( Fig. 19.7 ). Obese patients may require a Graves speculum or a longer Pederson (1 × 4¾ inches) for adequate visualization of the cervix. Metal speculums may be preferred, because they are easier to manipulate and are available in a greater range of lengths and widths; disposable plastic specula with intrinsic lights are now widely available and can be purchased in a range of sizes.

The patient should be shown the speculum and allowed to touch it if they desire. Patients experiencing their first pelvic examination should be reassured that only the blades of the speculum will be inserted. Comparing the size of an open speculum to a finger or tampon often is reassuring. The patient should be told that they will feel “a sense of pressure,” not pain, during speculum insertion and should be reminded to breathe regularly because tensing abdominal or pelvic muscles can produce discomfort and make the examination more difficult to perform. A history of inability to use a tampon suggests an increased possibility of a physical or emotional barrier to a successful speculum exam.

The examiner may then gently insert the gloved index finger into the vagina to assess the size of the introital opening and to locate the cervix. Vaginal muscle tone can be assessed by asking the patient to “tighten their muscles” around the examiner’s finger. Conscious relaxation can be practiced by asking the patient to relax those same muscles and to push their buttocks onto the examining table. Both plastic and metal speculums should be moistened with warm water or water-based lubricant to increase comfort and ease of insertion. With the index finger partially withdrawn but gently pressing on the vaginal floor, the speculum is inserted over the finger into the vagina, taking care to avoid catching pubic hairs or the labia in the mechanism of the speculum. This is done at an oblique angle along the posterior wall to accommodate the vertical introitus and avoid traumatizing the urethra, which lies above the anterior vaginal wall. Another technique that effectively assists insertion involves using the middle and index fingers to stretch the posterior labial folds down and out before inserting the speculum. With the speculum in place, the vaginal walls are inspected for erythema, lesions, and quality and quantity of discharge, and specimens are collected (see the Specimen Collection section, later).

After specimens have been collected the speculum is removed, and the bimanual (vaginal/abdominal) examination is performed. Water-based lubricant is placed on the two gloved fingers to be used before inserting them carefully through the introitus into the vagina. The examiner should note the size, consistency, position, and mobility of the uterus and check for tenderness on cervical or fundal motion. The adnexa should be palpated for evidence of enlargement or excess tenderness.

Once the examination is completed, the patient should be helped out of the lithotomy position, given tissues to wipe away any lubricant or discharge, and allowed privacy to get dressed. At the conclusion of the visit, the examiner can present the results of point-of-care testing (such as microscopic evaluation of wet mount and potassium hydroxide [KOH] preparation). The use of handouts with pictures or drawings can enhance the patient’s understanding of the results. This is also an opportunity to encourage communication between the patient and their parent, as appropriate to the circumstance.

Specimen Collection

Adolescents should be advised not to douche or to use tampons or feminine hygiene products before a gynecologic examination. When testing for Neisseria gonorrhoeae and Chlamydia trachomatis, the newer nucleic acid amplification tests (NAATs) detect minute quantities of pathogen DNA/RNA and thus are highly sensitive and specific; they also offer the advantage that specimens may be collected from a variety of sites (vaginal wall, urine, urethra, cervix). To obtain a vaginal sample for gonococcus (GC) and C. trachomatis NAAT, slide the swab 4 to 5 cm into the vagina and rotate it for greater than 10 seconds, moistening it against the walls of the vagina. In cases of symptomatic gonococcal infection where there are concerns about antibiotic resistance, one must perform a culture with sensitivities, which are not part of NAAT testing, to ensure proper antibiotic selection. (See later for guidance on collecting specimens during a speculum examination.)

The vaginal pH level can be measured by moistening a cotton-tipped swab on the lateral vaginal wall and rolling it on pH paper (with an appropriate range of pH 3.6 to 6.1). Vaginal pH levels are elevated in bacterial vaginosis and tend to be increased with Trichomonas and decreased with candida infections. Vaginal secretions should be obtained with a cotton or Dacron swab and placed in a tube with 1 mL of nonbacteriostatic normal saline for wet mount and KOH examination. The swabs for GC and C. trachomatis NAAT and for wet mount may be obtained by the patient (“self-swab”) if the patient prefers and additional examination is not required.

To review the wet mount, a drop of the saline solution containing vaginal secretions is examined under low (×10) and high (×40) power for distribution of epithelial cells, leukocytes, yeast forms, Trichomonas organisms, sperm, and clue cells. A drop of 10% KOH is added to a second drop of the saline solution. This preparation is immediately “whiff tested” for the presence of the acrid odor associated with amines that is found in bacterial vaginosis and often in patients with trichomoniasis. After this, viewing of the KOH preparation facilitates identification of yeast.

If a speculum examination is required (see Box 19.2 ), the vaginal pH is measured by holding pH paper (described previously) against the lateral vaginal wall, away from pooled secretions. Visible vaginal secretions from the posterior vaginal pool should be obtained with a cotton or Dacron swab for wet mount. Before obtaining samples from the cervix, any surface mucus should be gently removed with cotton swabs. The normal nulliparous cervix usually has a small round os ( Fig. 19.8 ). Any cervical lesions seen, such as cysts, warts, polyps, or vesicles, should be noted. An ectropion (or eversion) of the endocervical columnar epithelium onto the cervical surface is common and normal in adolescents ( Fig. 19.9 ). Ectropion should be distinguished from cervicitis, the latter being suggested by erythema, friability, and/or mucopurulent cervical discharge (see Fig. 19.34 ). If a gonorrhea culture is necessary (to test for antibiotic sensitivities), insert a sterile swab into the endocervical canal, rotate it for at least 10 seconds, and then immediately place it into a selective transport or culture medium. Either medium must be at room temperature before inoculation. Gonorrhea-specific media prevent bacterial overgrowth by other species and allow a longer transport time.

Cervical cytology (Pap) screening using liquid-based cytology to check for cervical dysplasia (a precursor of cervical cancer) is done by rotating a plastic Ayre spatula circumferentially (360 degrees) around the cervical os, including the entire squamocolumnar junction. A sample from the endocervical canal is collected with a Cytobrush (or a cotton swab if the patient is pregnant). Each sample is swished in liquid ThinPrep solution or fixed onto a glass slide according to laboratory protocol. Cervical cytology results can be uninterpretable in the presence of inflammation and bleeding; therefore, it is preferable to defer collection until infections are treated and menstrual bleeding has finished. However, concerns about patient follow-up or urgent clinical needs can justify collection of specimens at less optimal times. A number of strains of human papillomavirus (HPV) have been identified as causative in cervical cancer, as well as genital warts. All adolescents should be encouraged to complete their HPV vaccination series. However, currently available vaccines against HPV do not cover all strains associated with cervical cancer. Therefore, a Pap smear every 3 years is indicated starting at 21 years old. Immunocompromised women under 21 years old with human immunodeficiency virus (HIV), solid organ transplant, hematopoietic stem cell transplant as well as systemic lupus erythematous, inflammatory bowel disease, and rheumatoid arthritis on immunosuppressants should have their first Pap within 1 year of sexual activity onset, and annually for the first three years. The Centers for Disease Control and Prevention (CDC) advises that HPV typing is not indicated in women under the age of 30.