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. Children usually are asymptomatic,but they may present with secondary infection. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. Ideally children should feel they are part of the examination rather than having an exam done to them.. Hysteroscopy is a procedure to evaluate and manage issues of the uterine cavity and is typically only performed in adolescents when indicated. . 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. A handheld mirror may help in some instances when discussing specifics of genital anatomy. Condylomata acuminataalso can cause bleeding but may be difficult to recognize, because in prepubertalchildren, they often do not have the typical cauliflower-like appearance.Rather, genital warts typically present as exophytic lesions or papuleswith small red punctations over the surface. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. The relative size ratio of cervix to uterus is 2:1 in a child. The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. This includes feeling a girl's uterus and ovaries to be sure everything's normal. However, it is important to do a thorough workup because of the serious sequelae of some of the causes of vaginal bleeding. The child is told to have her abdomen sag into the table. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. 1 A vaginal self-exam is not the same as a vulvar examination. Pay special attention to anatomic and pathophysiologic differences in the child. The presence of sexually transmitted organisms in a child is usually a strong indication that sexual abuse may have taken place, and appropriate referral and follow-up is necessary (see Chapter 9 ). Includes menu so you can select the portion of the video most applicable to you. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. 14 mins, 33 secs. 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. 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. Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. 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. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). You canmodel for parents appropriate ways to discuss gynecologic issues with theirchild, and help parents and children understand the importance of discussingissues related to reproductive healthand sexuality during the prepubertalyears.1. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. Pokorny SF. 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. This patient presents with chest pain. The most important technique to ensure cooperation is to involve the child as a partner. What questions should PNPs consider related to womens health? Below is a collection of all our Stanford 25-generated videos also found throughout the website. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Will the Healing Touch Go Out the Door With the Stethoscope? All children should have a chance for a healthy future. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. Approach to evaluation of premenarcheal child with a gynecologicproblem. However, it is when the pain gets progressively worse and occurs outside the menstrual cycle, that it might be time to consider a pathological cause, such as endometriosis. Non-sexually acquired genital ulcers (NSGUs) in adolescent females are uncommon, painful skin lesions on the mucous membranes of the vulva and vaginal structures, unrelated to sexual activity. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. If you put your stethoscope over this, what will you hear? Using Google Glass to Examine the Hand with Dr. Verghese. In this video, Tricia Huguelet, MD, provides an overview of normal menstrual flow, screening for heavy menstrual flow in teens, and identifying red flags for an underlying bleeding disorder. Adolescents often come for examinations with the preconceived idea that it will be very painful. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. 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. What Stands in the Way of Bedside Teaching? OB/GYN - Physical Examination Resources - University of Iowa 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. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. Employee communication. 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. Having a relationship with a pediatric gynecologist can help girls take . 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. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Whats the diagnosis? 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 vagina will then fill with air, aiding the evaluation. Inspect the child's breasts and palpate themfor signs of puberty. At the 44th National Association of Pediatric Nurse Practitioners Conference, data was presented on how to diagnose and treat polycystic ovarian syndrome in adolescent patients. Before puberty, the girls reproductive organs are in a resting, dormant state. When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. Sarah's Physical Exam with Pelvic Exam - YouTube 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. Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating. The signs of vulvovaginitis are variable and not diagnostic, but they include vulvar erythema, edema, and excoriation. . Stanford ENT Free Oral Screening November 2nd. 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. 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. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. Remember that this procedure can be painful to achild if you use a dry cotton swab or do not perform the examination gently.A better way of obtaining specimens from the prepubertal child is to usea nasopharyngeal Calgiswab moistened with nonbacteriostatic saline. Pokorny SF: Configuration of the prepubertal hymen. Obtaining cultures. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . 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. ObstetGynecol 1971;37:462, 13. View a sample video A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. Gynecologic examination of the prepubertal girl - Contemporary Pediatrics Interruptions should be avoided. 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 ( ). Online Teaching Videos - Department of Urology 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 history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). Pediatric and adolescent gynecology: Gynecologic Examination N gonorrhoeaerarely persists beyond the newborn period without symptoms. 1. This can be accomplished without the insertion of any instruments. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. The color ranges from white or gray to yellow or green. An infant may be examined on her mothers lap. In this video, the Director of the Fertility Preservation and Reproductive Late Effects Program, Leslie Appiah, MD, discusses the prevalence of reproductive late effects and female risk stratification based on age and therapy doses. Chronic Pelvic Pain and Endometriosis: Part 2 - UCSF Health Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle. These exams may be done as part of a yearly check-up for teenagers or young adults, however, you may need them sooner or . These interactions between the physician and the adolescent girl allow the physician an opportunity to gain the patients trust and educate the pubertal teenager about pelvic anatomy and reproduction. Cystic ovarian masses commonly occur in infants, children and adolescents. Abraham-Vergheses-TED-Talk:-Over-one-million-views! When is it best to reassure, and when is it necessary to evaluate? 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. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation.
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