Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty

General approach

Considerable effort should be devoted to gaining the child’s confidence and establishing rapport. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ).

The pediatric gynecologic visit may be unique to both the child and the parent. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . This may create considerable and understandable anxiety in the child and parent. The majority of children’s gynecologic problems are treated by medical , rather than surgical, means .

The most common gynecologic condition of children is vulvovaginitis . Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia.

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. One excellent technique is for the physician to sit, not stand, during the initial encounter. This conveys an unhurried approach. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as children’s posters are present. Interruptions should be avoided. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. 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.

Performance of the gynecologic exam in a child

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 ( ).

Obtaining a history from a child is not an easy process. Children are not skilled historians and will often ramble, introducing many unrelated facts. Much of the history must be obtained from the parents . However, young children can help define their exact symptoms on direct questioning.

In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. 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. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse.

After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . It is important to give the child a sense that she will be in control of the examination process. A helpful technique is to place the child’s hand on top of the physician’s 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. This will give the child a sense of control and divert the child’s attention if she is ticklish or is squirming. Emphasize that the most important part of the examination is just “looking” and there will be conversation during the entire process. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant.

A child’s reaction will depend on her age, emotional maturity, and previous experience with health care providers. She should be allowed to visualize and handle any instruments that will be used. Many young children’s primary contact with providers involves immunizations; children should be assured that this visit does not involve any “shots.” It is also helpful to assure the adult accompanying the child that speculums are not part of the examination.

Occasionally it is best to defer the genital examination until a second visit . This is a difficult decision and is based on the extent of the child’s anxiety in relation to the severity of the clinical symptoms. 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. 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. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. A child should never be restrained for a gynecologic examination . Often reassurance and sometimes delay until another day are the best approaches. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. The most important technique to ensure cooperation is to involve the child as a partner. Ideally children should feel they are part of the examination rather than having an exam “done to them.”

Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. A handheld mirror may help in some instances when discussing specifics of genital anatomy. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. Children often cannot hold still for long intervals while instruments are being located.

The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. 12.1 ). An infant may be examined on her mother’s lap. Pads should be placed in the mother’s lap because examination often is associated with urination. Young children may be examined in the frog leg position, and children as young as 2 to 3 years of age may be examined in the lithotomy position with use of stirrups, although this is generally used for girls aged 4 to 5 years and older.

Once the child is positioned, the vulvar area and introitus should be inspected. Many gynecologic conditions in children may be diagnosed by inspection . The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. 12.2 ). Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. 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.

The second phase of the examination involves evaluation of the vagina . This can be accomplished without the insertion of any instruments. One method is to use the knee-chest position (see Fig. 12.1 , B ). The child lies prone and places her buttocks in the air with legs wide apart. The vagina will then fill with air, aiding the evaluation. The child is told to have her abdomen sag into the table. An assistant pulls upward and outward on the labia majora on one side while the examiner does the same with the nondominant hand on the contralateral labia. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina.

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. This technique is generally successful in cooperative children unless there is a very high crescent-shaped hymen, in which case it is too difficult to shine the light into the small aperture of the vaginal introitus. A foreign object and the cervix may be visualized using this technique. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later).

Normal findings: Hymen and vagina of a prepubertal child

The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. 12.3 ). Hymens are often crescent shaped but may be annular or ringlike. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. There are no reported cases of congenital absence of the hymen. A mounding of hymeneal tissue is often called a bump. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Not every variant of hymen is normal, and transections between 3 and 9 o’clock should raise a suspicion for abuse because these are likely acquired rather than congenital (discussed further in Chapter 9 ).

The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . 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.

Vaginoscopy in a prepubertal child most often requires sedation with a brief inhalation or intravenous anesthetic, but in select circumstances it can also be performed in the office with older, cooperative children. The introduction of any instrument into the vagina of a young child takes skillful patience. The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. 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. The ideal pediatric endoscope is a cystoscope or hysteroscope because the accessory channel facilitates the retrieval of foreign bodies while at the same time allowing a vaginal lavage to be performed. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. A complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children.

The last step in the pelvic examination may be a rectal examination. This is often the most distressing aspect of the examination and may be omitted, depending on the child’s symptoms. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. In this age of reliable access to ultrasonography, the internal genital examination to evaluate the uterus and ovaries can be performed with the assistance of sonography , often sparing the child from a rectal or pelvic examination.

The office visit and examination of the adolescent girl

Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . This period of transition involves important physical and emotional changes. Before puberty, the girl’s reproductive organs are in a resting, dormant state. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescent’s hormonal milieu. Because the pubertal changes are often a cause of concern for adolescent girls and their parents, the gynecologist must offer the adolescent patient an empathetic, kind, knowledgeable, and gentle approach. These interactions between the physician and the adolescent girl allow the physician an opportunity to gain the patient’s trust and educate the pubertal teenager about pelvic anatomy and reproduction.

The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. 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 ( ). Common indications for a pelvic examination in an adolescent are listed in Box 12.1 .

Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. 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. Those in middle or late adolescence (aged 15 to 19 years) may be more accepting of the idea of an examination and more likely to cooperate with the proper counseling and in the appropriate setting.

Adolescents often come for examinations with the preconceived idea that it will be very painful. 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 . 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. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. 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.

Problems in prepubertal children