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. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. 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 . She also discusses the preferred diagnostic modality and when to consider surgery. 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. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. 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. There will also be an extra sheet you can use to cover yourself. . The most important technique to ensure cooperation is to involve the child as a partner. The normal prepubertal uterus and ovaries are nonpalpable. Yuwoko. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . Considerable effort should be devoted to gaining the childs confidence and establishing rapport. 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. Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube The normal vagina of a prepubertal child is colonized by an average of nine different species of bacteria: four aerobic and facultative anaerobic species and five obligatory anaerobic species. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. Below is a collection of all our Stanford 25-generated videos also found throughout the website. Urethral prolapse also can present with bleeding. 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. 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. Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. Tricia Huguelet, MD, Chief of Pediatric and Adolescent Gynecology, describes the typical presentation of hymen imperforations in adolescents and young adults, as well as obstructing and non-obstructing mllerian anomalies. The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement. It's also not true that the pelvic exam is a "test" to see if you are a virgin. Pelvic Exams - HealthyChildren.org The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. When Do Teens Need a Gynecologist? > News > Yale Medicine Children are not skilled historians and will often ramble, introducing many unrelated facts. Sometimes doctors do pelvic exams if they think there's a problem. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Pelvic Exam; Breast Exam; Self Breast Exam; Bimanual Exam; Pap Smear The surgical therapy of an ovarian neoplasm in a child should have two goals: the appropriate surgical removal of the neoplasm and the preservation of future fertility. Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus. Tell the child that the examination willnot hurt, and if you are going to use instruments, that these tools areall specially designed for little girls.1Let the child look atand touch the instruments to be used, such as an otoscope or a hand lens.When talking with parents, it is important to carefully explain that thechild's hymen will not be altered in any way by the examination, becausemany parents do not fully understand the anatomy of the vagina and hymen.Basic diagrams of the anatomy may be helpful. A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. Pelvic Exams (for Teens) - Humana - Kentucky These are the organs related to your monthly menstrual cycles, to sexual activity, and to pregnancy and childbirth. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Join Childrens Hospital Colorado pediatric experts for a virtual Were passionate about providing answers, treatment and care for the full range of female reproductive health concerns, from infancy through adolescence and into adulthood. 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. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. An infant may be examined on her mothers lap. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. First gynecological exam debunked: What parents need to know Hysteroscopy is performed in the operating room under general anesthesia. Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. How to Perform a Vaginal Self-Exam - Verywell Health You might have a pelvic exam as part of your regular checkup. Symptoms of vulvovaginitis can occur if an adhesionis extensive enough to cause pooling of urine above the agglutinated tissue.If that is the case, a child may have symptoms of urethritis or a historyof urinary tract infections. Intestinal parasitic invasion with pruritus. Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics(Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies). Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. A history of trauma--whetheraccidental, intentional (for example, scratching due to pinworm infection)or caused by sexual abuse--also should be elicited. 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. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle. Menstrual bleeding in adolescents can be chaotic. HPV is also verticallytransmitted and lesions may appear in the first few years of life. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. 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. Videos - Hopkins Medicine The classic symptom of pinworms is nocturnal vulvar and perianal itching. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole. Pokorny SF: Configuration of the prepubertal hymen. Many young childrens 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. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. A discharge that is both bloody and purulent is likely not from vulvovaginitis but from a foreign body (see Vaginoscopy for Prepubertal Bleeding without Signs of Puberty later in this chapter), although patients infected with some pathogens, particularly Shigella boydii, often present with a bloody or blood-tinged discharge . Will the Healing Touch Go Out the Door With the Stethoscope? 5 Minute Pelvic Exam Video | The Brookside Associates It is not diagnostic since few vaginal diseases can be diagnosed visually. 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. You can also ask the child to cough in order todistract her and cause her hymen to open. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). This period of transition involves important physical and emotional changes. There is no significant geographic barrier between the vagina and anus. These minor accidents result in injury because the genital tissues in children, without estrogen, are very thin and easily traumatized. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. Before puberty, the girls reproductive organs are in a resting, dormant state. 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. During the exam, your doctor will check your vagina, uterus, and ovaries. 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. A gentle, patient approach is important when examininga prepubertal girl. For example, if a girl complains of . This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Capraro VJ: Gynecologic examination in children and adolescents.Pediatr Clin North Am 1972;19:511, 12. Sometimes doctors do pelvic exams if they think there's a problem. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. Different positions for performing a gynecologic examination on a child. This chapter considers gynecologic diseases of children from infancy through adolescence. 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. In the office setting, the examination should be limited to external inspection only; speculum exams should not be performed in pediatric patients. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. Includes menu so you can select the portion of the video most applicable to you. Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases. Making the examination a positive experience, ifpossible, therefore is critical.2. The atrophymay distort the anatomy of the labia and clitoris. A foreign object and the cervix may be visualized using this technique. The pathophysiology of the majority of instances of vulvovaginitis in children involves a primary irritation of the vulva, which may be accompanied by secondary involvement of the lower one-third of the vagina. 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 ). Employee communication. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors. Pediatric and adolescent gynecology: Gynecologic Examination Emphasize setting the stage to make the examination a positive experience for your young patient. This conveys an unhurried approach. Over the last decade, however, the management of ovarian masses has shifted toward a more conservative approach with the goal of ovarian preservation. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine. 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). A pelvic exam is where a doctor or nurse practitioner looks at a girl's reproductive organs (both outside and internally). 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. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing. 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. The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. Using a hand mirror can be usefulto promote education, distract a child, and allow her to participate moreactivelyin the examination. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. Exam Videos - IAFN - forensic nurses 25:50. W Webcam. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. Abraham-Vergheses-TED-Talk:-Over-one-million-views! 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. It is important to give the child a sense that she will be in control of the examination process. Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. Many gynecologic conditions in children can be diagnosed by inspection alone. Group A streptococciand Shigella are the most common causes. Having a relationship with a pediatric gynecologist can help girls take . 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. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. A nurse retrieves the patient from the office and takes her to an exam room. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. The typical location is the anterior vaginalwall near the cervix. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. Genital Exam - Male (Pre- or Early Puberty) - Nationwide Children's From AccessMedicine. Pokorny SF. PDF Genital Examination of Young Girls - Royal Children's Hospital 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. 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. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation (discomfort/pruritus) or discharge ( Table 12.1 ) ( ). Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. Support Lucile Packard Children's Hospital Stanford and child and maternal health. Small follicular cysts in preadolescent girls are usually self-limiting. Visualizing the hymen. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. Adult pinworms maybe visible at night. 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. 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. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. Caring pediatric nurses are available 24/7 to help answer your questions. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . Pelvic Exam, The | Advanced Pediatric Associates | Pediatricians in Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. The medical history should be guided by the presenting complaint anddifferential diagnosis. . 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. Hymens are often crescent shaped but may be annular or ringlike. The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. Pediatric Gynecology Videos | Children's Hospital Colorado An ectopic ureter can present as persistent wetnessor purulent discharge. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. The child lies prone and places her buttocks in the air with legs wide apart. The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. Pay special attention to anatomic and pathophysiologicdifferences in the child. Gynecologic Examination for Adolescents in the Pediatric Office Setting Addressing the Youth Mental Health Crisis, Department of Pediatric and Adolescent Gynecology, Fertility Preservation and Reproductive Late Effects Program, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome, Insurance, billing and payment information.