Pediatric and Adolescent Gynecology PDF

**OUTLINE** I. **Gynecologic Visit & Physical Exam of a Prepubertal Child** II. **Gynecologic Visit & Physical Exam of an Adolescent** III. **Common Gyne Problems in the Prepubertal Child** IV. **The Ovary and Adnexa** V. **References** +-----------------------+-----------------------+------...

**OUTLINE** I. **Gynecologic Visit & Physical Exam of a Prepubertal Child** II. **Gynecologic Visit & Physical Exam of an Adolescent** III. **Common Gyne Problems in the Prepubertal Child** IV. **The Ovary and Adnexa** V. **References** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ GYNECOLOGIC VISIT & PHYSICAL EXAM OF A PREPUBERTAL CHILD {#gynecologic-visit-physical-exam-of-a-prepubertal-child.TransOutline} ======================================================== APPROACH TO PHYSICAL EXAM {#approach-to-physical-exam.TransSubtopic1} ------------------------- Pediatric and Adolescent Gynecology encompasses **ages 19-years-old and below** 🖊️Approach to PE is different. Because we have to make sure the patient is comfortable. They should feel that they are participating in the examination. A gentle approach is warranted 🖊️Physicians should have more patience. Because an adult woman will be more readily agreeable to having a physical exam done, especially, in the genital area. More often than not, we will encounter children who do not want to be examined, especially in the genital area. 🖊️We should avoid loud shouting voice and never force the child to open her legs.If we encounter a child that doesn't want to get an examination, we can always postpone the PE to another meeting. Unless, there is an emergency, like bleeding or accident, then we have to push for sedation. The good part about this, is that instrumentation is rarely ever needed during examination of a child. ⭐**Important: Remind the child that only the doctor or caregiver can touch the areas you examine.** Should we complete genital examination on an adolescent patient? Only if pregnant or need to in relation to the case 🖊️You can also take this opportunity to teach them about "good touch" and "bad touch". ⭐Examine other body parts before proceeding to the genital examination. You may give: Toys to play with or have toys in the surroundings. A mirror, so they can see what you are doing. No need to put a drape, but you may give a kiddie gown Proceed with the genital examination ⭐ **You can accomplish a lot just by inspection.** What are the techniques we employ when we examine the child? You can ask the patient to sit on her mother before doing a supine-frog leg position. You can proceed with labial separation Or labial traction technique where you grip the labia anteriorly and downwards May be a bit uncomfortable so you have to ask permission first and say that they will feel just a tiny pinch 🖊️You can ask for the patient's arm, pinch a part of it, and tell them that this is more or less what you will be feeling down there. 🖊️Ask the patient to cough to help visualize the hymen Next, you can do a knee chest position to visualize the vaginal canal, where the child lies prone and places the buttocks in the air. This may take practice, because a lot of children have a difficult time following instructions.  What to expect in a prepubertal child? Anatomy is the same, but since the child is not yet "estrogenized", we expect: Thinner labial fat pad Very thin hymen 🖊️Usual Configuration and most common hymen: Crescentic and Annular No hair Easily seen during the PE of the child as opposed to an estrogenized hymen which would usually becomes a redundant configuration 🖊️Redundant configuration of the hymen in a child, means that there is a problem **Figure 3. Types of Hymen** There are other variations of hymen aside from annular and crescentic. Sometime we catch them in the clinics. You can see an imperforate hymen, cribriform, or aseptate hymen. We must keep in mind that this may cause problems once the child reaches puberty  🖊️Often times, we see hymenal mounds or bumps, but these are not problematic. You must be familiar *(Source: Dr. Santos' lecture)* 🖊️**If you see transections in the hymen. Especially, in the 3 o'clock and 9 o'clock positions, we must be suspicious of sexual abuse because these are not normal in a prepubertal hymen.** OTHER THINGS TO NOTE {#other-things-to-note.TransSub-subtopic2} -------------------- Vaginal epithelium is reddish, thin. pH is always neutral or slightly alkaline, never acidic. Length of vagina is 4-6 cm Rectal examination: Always warranted? The answer is **NO**! Indications: Unexplained vaginal bleeding Abdominal pain Suspicion of a foreign body Suspicion of a pelvic or vaginal mass GYNECOLOGIC VISIT & PHYSICAL EXAM OF AN ADOLESCENT {#gynecologic-visit-physical-exam-of-an-adolescent.TransOutline} ================================================== APPROACH TO PHYSICAL EXAMINATION {#approach-to-physical-examination.TransSubtopic1} -------------------------------- Different approach as compared to pediatric age group. You still have 2 patients, the caregiver, and the adolescent. BUT! Often, they would prefer more privacy compared to the prepubertal patient that prefers to be with their parents. ☤ A common technique that we employ in the clinic is that we **interview the parent and the adolescent patient together** **first** and then **inform the parent that we will have to** **interview the adolescent by themselves and explain the** **concept of confidentiality**, where information will not be shared unless it relates to the safety of the patient and those around them then we are obliged to inform the parents COMMON REASONS FOR CONSULT IN ADOLESCENT {#common-reasons-for-consult-in-adolescent.TransSubtopic1} ---------------------------------------- Amenorrhea -- primary and secondary Primary Amenorrhea Ex. At 15-years-old with breast budding 2 years ago and still has no menses. Pelvic pain Delayed puberty Abnormal bleeding Abnormal discharge No vaginal opening Abdominal enlargement #### Should we do a complete genital examination on an adolescent patient? {#should-we-do-a-complete-genital-examination-on-an-adolescent-patient.TransSub-subtopic3} ☤ Do we have done a full pelvic exam including internal examination? No this is not necessary we should do a ☤ ★ **So we do not do an internal examination especially if** COMMON GYNE PROBLEMS IN THE PREPUBERTAL CHILD {#common-gyne-problems-in-the-prepubertal-child.TransOutline} ============================================= VULVOVAGINITIS {#vulvovaginitis.TransSubtopic1} -------------- Patient is brought for perineal pruritus, pain, or discharge. Blood is not a usual presentation of nonspecific vulvovaginitis Most common cause of vaginitis: **Nonspecific Vulvovaginitis** #### Why are children predisposed to have vulvovaginitis? {#why-are-children-predisposed-to-have-vulvovaginitis.TransSub-subtopic3} Neutral pH -- excellent medium for bacterial growth No estrogen yet Thin labial fat pads No pubic hair Proximity to anus ★ **HYGIENE** ☤ Most common culprit unfortunately. SPECIFIC VULVOVAGINITIS {#specific-vulvovaginitis.TransSubtopic1} ----------------------- Group A/B Beta hemolytic Streptococci Hemophilus influenza ☤ We often see this in patients who Shigella boydii ☤ Often associated with blood. Pinworms Yeast indentions -- uncommon in prepuberal child ☤ Unless they are immunocompromised, because ☤ Usually discharge is clear, yellowish, and non-foul smelling If the discharge is bloody, purulent, or foul smelling, suspect: Foreign body Vulvar skin disease Ectopic ureter Sometimes Sexual abuse ★ **Treatment** ★ **Success is based mostly on change in hygiene** ☤ so we recommend that parents use **mild soaps.** ☤ A common culprit is that parents often use harsh soaps in genital area which causes irritation Avoid tight fitting garments. ☤ Which promotes maceration especially after they urinate, and they don't wipe so the moist environment causes maceration and irritation. Education on front to back washing ☤ Also important because we catch a lot of patients who do back to front washing. Advise warm sitz bath. ☤ Where the child will sit on a basin for 10 minutes at least twice a day for 1-2 weeks Very rarely have we found the need for antibiotics after hygiene has been instructed. Advisable to collect a sample of the discharge before starting antibiotics. LABIAL ADHESIONS {#labial-adhesions.TransSubtopic1} ---------------- Occurs when denuded epithelium causes the labia minora to fuse together, giving the appearance of an absent vaginal opening. The translucent vertical line is pathognomonic of labial adhesions, and it's called the **median raphe.** Common between the ages 2-6 Extremely rare for a complete fusion to occur ☤ wherein the fusion will even cover the urethral opening.  **Figure 6**. Labial Adhesion. The fusion is almost complete **Treatment:** Observation and assurance to the parents. If treatment is needed, **estrogen cream** ☤ twice a day for 2 weeks then once a day since the pathophysiology would be because of low estrogen but we should explain the side effects which could be breast budding and vaginal bleeding, but we should assure parents that this is reversible after treatment. ☤ Some international guidelines would also recommend observation and assurance meaning not to do anything but more often the parents would really request for treatment for these patients especially if they are starting to become symptomatic ★ **Avoid pulling part the labia manually** ☤ This would cause much pain to the patient and after that they would not allow anyone to put anymore creams or medications which would cause problems because the labia would then fuse again. PHYSIOLOGIC DISCHARGE OF PUBERTY {#physiologic-discharge-of-puberty.TransSubtopic1} -------------------------------- Sometimes in the early stages of puberty, children develop a **yellowish to grayish non-foul-smelling discharge.** ☤ when they are starting breast budding around 8 or 9 years old Caused by **desquamation of prepubertal vaginal epithelium** ☤ it looks like a pasty material in the underwear ★ **Rarely causes symptoms** ☤ you should just assure parents that this would resolve on its own. URETHRAL PROLAPSE {#urethral-prolapse.TransSubtopic1} ----------------- Sometimes in the early stages of puberty, children develop a **yellowish to grayish non-foul-smelling discharge.** A common occurrence due to the **protruding urethral mucosa** ★ Common symptom -- **bleeding** which is mistaken to come from the vagina ☤ but when you do PE, you will see the bleeding is coming from urethra. Often preceded by increase in intraabdominal pressure ☤such as persistent coughing, obese, intraabdominal mass Pathognomonic sign: **donut-like shape from urethral opening** **Treatment:** ★Topical estrogen cream ☤ very effective Very rarely is surgery required LICHEN SCLEROSUS {#lichen-sclerosus.TransSubtopic1} ---------------- Skin condition common in 2 age groups: prepubertal girls and postmenopausal women Said to be associated with autoimmune phenomena. ★ Pathognomonic sign: **Figure of eight formation involving the labial and perianal area**. Skin is lichenified and hypopigmented. Biopsy is not often needed. **Treatment:** High potency steroids which may take as long as 4-6 week PREPUBERTAL BLEEDING WITHOUT SECONDARY SEXUAL CHARACTERISTICS {#prepubertal-bleeding-without-secondary-sexual-characteristics.TransSubtopic1} ------------------------------------------------------------- Thelarche (breast budding) Growth Spurt Pubarche Menarche Things to remember: **Thelarche 8 years old** **Menarche 12 years old** ★ Hence, if you have **a child who has secondary characteristics before 8 years old, this warrants an investigation.** Differential Diagnosis of Bleeding Without Secondary Characteristics Foreign body Vulvar excoriations Lichen sclerosus Shigella vaginitis Trauma Tumors -- Rhabdomyosarcoma FOREIGN BODIES {#foreign-bodies.TransSubtopic1} -------------- MD should be suspicious if the vaginal discharge is persistent, foul smelling or bloody. ACCIDENTAL TRAUMA {#accidental-trauma.TransSubtopic1} ----------------- ★ **Most are straddle injuries.** When the soft tissue of the perineum falls onto a hard surface. Injuries may be penetrating or non-penetrating ☤ It is the duty of the examining physician to see if these cases are admissible or not Hymen is not commonly affected. Superficial lacerations need no treatment. Vulvar hematomas may occur. ☤ So a decision point if these hematomas have to evacuated should be done at the ER.  **Figure 10. Accidental Trauma** SEXUAL ABUSE {#sexual-abuse.TransSubtopic1} ------------ ★ **Reporting** ☤ Unfortunately it is a reality, so who is mandated to report sexual abuse?  Educational institutions, Health care providers and concerned citizens are all mandated reporters who if a child is suspected to be abused anyone can report. Hymen is not usually injured in accidental trauma. ☤ If there is hymenal transection one must consider sexual abuse Physical evidence is present in less than 5%. The child's testimony can be used as evidence. ☤If these cases are brought to court. GENITAL WARTS {#genital-warts.TransSubtopic1} ------------- - Before the age of 3, most likely from maternal to child transmission - If more than 3 years old, consider abuse. - ★ **Treatment options:** - **Observation, TCA** (Trichloro acetic acid), **Imiquimod cream, cautery of warts** - ☤ Some cases do resolve on their own that's why observation is a treatment option. TCA's and imiquimod cream are very painful so it would bring much discomfort for the child. Cautery can also be done but post-op pain is also a problem.  THE OVARY AND ADNEXIA {#the-ovary-and-adnexia.TransOutline} ===================== PRENATAL OVARIAN CYSTS {#prenatal-ovarian-cysts.TransSubtopic1} ---------------------- Stressful for the mother Seen on ultrasound. Have to decide whether a CS is warranted. ☤ Unless mass is very big Ovarian malignancy is extremely rare in this group. NEONATAL OVARIAN CYSTS {#neonatal-ovarian-cysts.TransSubtopic1} ---------------------- Observation is warranted. ☤ We do not immediately proceed to surgery if a neonatal ovarian cyst is seen in an ultrasound Malignancy is not a consideration. Serial ultrasound every 4-6 weeks ☤ Because most of these cases resolve on their own OVARIAN CYSTS IN CHILDREN AND ADOLESCENTS {#ovarian-cysts-in-children-and-adolescents.TransSubtopic1} ----------------------------------------- Management is expectant unless the mass is very large If mass is large or patient is symptomatic, then that is the decision point for bringing the patient into the operating room ☤ Meaning there is extreme or severe abdominal pain or the patient keeps on vomiting. An ultrasound of a baby Description automatically generated **Figure 12. Ovarian cysts in children and adolescents** OVARIAN TUMORS IN CHILDREN AND ADOLESCENTS {#ovarian-tumors-in-children-and-adolescents.TransSubtopic1} ------------------------------------------ ★ **Look at the ultrasound.** **☤ Most important** Solid and cystic components? Large? Enlarging abdomen? ☤ Not only due to the mass but possibly due to ascites Pain? Request for tumor markers ☤ There are many cells in the ovary where ovarian tumors arise from you have sex cord stromal cells, germ cells, and surface-epithelial cells. Surface epithelial tumors usually occur in adult women. In children, germ cell tumors which may or may not be malignant.  But if we are suspecting a malignancy or the tumor doesn't look good on the ultrasound it's just cystic then we proceed with an operation.  **Figure 13. Ovarian cysts in children and adolescents** OVARIAN TORSION {#ovarian-torsion.TransSubtopic1} --------------- Whatever the mass, prone to torsion ☤ May it be cystic, solid, small, or big it can still be prone to torsion. Longer ligaments More commonly on the right side ☤ Because sigmoid colon on the left prevents torsion ★ **Commonly mistaken as appendicitis.** Issue of removing the whole ovary ☤ Based on experience and studies have shown, that once we untwist the torsed ovary usually blood flow returns and there is no need to remove the whole ovary. Because we advocate for fertility preservation III. **REFERENCES** - William's OB - Batch 2025 Trans - Dr. Santos' lecture video