However, young children can help define their exact symptoms on direct questioning. Your job will be easier if you adopt a relaxedand unhurried approach, which can help prevent anxiety in a child. ObstetGynecol 1971;37:462, 13. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. Intestinal parasitic invasion with pruritus. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. 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. Over the last decade, however, the management of ovarian masses has shifted toward a more conservative approach with the goal of ovarian preservation. Urethral lesions alsoshould be considered. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. In the office setting, the examination should be limited to external inspection only; speculum exams should not be performed in pediatric patients. Menstrual pain and cramps are very common in women and affect 50% to 90% of female teens. It is not diagnostic since few vaginal diseases can be diagnosed visually. Thisarticle focuses on setting the stage so that the examination is a positiveexperience for the patient and her family, describes specific techniquesand strategies for performing an appropriate and non-traumatic examination,and reviews diagnosis of disorders commonly found in prepubertal children. Opening questions can include inquiriesabout the family structure and recent changes, school, friends (such aswhether she has a best friend), and the types of activities she enjoys.It is important to assess who cares for the child and to uncover--both fromthe parent and from the child--information about any history of sexual abuseor current concerns in that regard. Learn more about patient ratings and reviews. Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds. Newborns will exhibit maternal estrogen effects:the labia majora, labia minora, and clitoris will be relatively large, theepithelium a dull pink color, and the hymen often thick and redundant. This short 1958 educational film from the American Cancer Society shows how to perform a routine pelvic examination and cytologic test for the detection of cancer of the uterus. Last updated on April 26, 2013 @3:30 pm Feedback: How useful was the above information? 12.4 ). Topics for the pediatric nurse practitioner to be aware of. The tape is subsequently examined under the microscope. 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Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. 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. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. In addition to your doctor, there will be a nurse or an assistant in the room during . Leukorrhea may be present. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. 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. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. Diagnose this skin lesion with newest Stanford 25 video and topic. The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. The typical location is the anterior vaginalwall near the cervix. Stanford Medicine 25 Launches New Website, Medical Errors and Adverse Events from a Missed or Inadequate Physical Exam, Announcing the Stanford 25 Skills Symposium, Thyroid Nodule Overview - The Thyroid Exam. The signs of vulvovaginitis are variable and not diagnostic, but they include vulvar erythema, edema, and excoriation. The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. 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. The classic symptom of pinworms is nocturnal vulvar and perianal itching. The work-up for vaginal bleeding includes a careful inspection of thevulva and vagina, wet preparation and bacterial cultures, and cultures forsexually transmitted infections if indicated. What will bedside manner look like for new data-driven physicians? View a sample video This period of transition involves important physical and emotional changes. An infant may be examined on her mothers lap. For example, if a girl complains of . A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Occasionally it is best to defer the genital examination until a second visit . A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. A foreign object and the cervix may be visualized using this technique. Urethral prolapse, a mucosal inversion at the urethral meatus, may beasymptomatic but it also can become inflamed and cause dysuria, perinealdiscomfort, and bleeding. It's also not true that the pelvic exam is a "test" to see if you are a virgin. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. Buyers also reviews treatment options, including menstrual suppression, with a focus on key counseling points to help patients and families decide which method is best for them. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. The evaluation of young girls is age dependent. Children's Hospital Colorado partners with NRC Health to gather star ratings and reviews from patients, residents and family survey data. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). 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. If vaginalcultures are not needed, lidocaine jelly can be used to decrease the child'sdiscomfort. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Vaginalagenesis is characterized by thick vestibular tissue, and often there isa dimple surrounded by a vulvar depression where the hymen should be.6, Acquired hymenal abnormalities usually are caused by sexual abuse andrarely by accidental trauma. In addition, she reviews the potential for ovarian torsion, including signs and symptoms, evaluation and management. 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. The genital examination of the infant through adolescence.Curr Opin Obstet Gynecol 1993;5:753, 11. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. The child is told to have her abdomen sag into the table. Gynecologic Examination with Pap Smear. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. Because of compassion and empathy, the gynecologist may underestimate the extent of the anatomic injuries. The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. 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. The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. A parent or caretaker is usually present during the examination of ayoung child, and most children are comfortable with the parent sitting closeby or holding their hand. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. This may create considerable and understandable anxiety in the child and parent. She reviews the services that the Program provides, such as inpatient and outpatient consults, fertility preservation services and reproductive healthcare, and how to request consultation. Videos : Exams. . Pelvic pain is common in adolescent girls. Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . McCann J, Wells R, Simon M, et al: Genital findings in prepubertalgirls selected for nonabuse: A descriptive study. Emphasize setting the stage to make the examination a positive experience for your young patient. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The color ranges from white or gray to yellow or green. Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Affiliated with the University of Colorado School of Medicine. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . Forpersistent cases, prescribe a one- to three-month course of a low-potencytopical steroid preparation, such as hydrocortisone 1% or 2.5%, followedby careful hygiene and use of emollients. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. 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. 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. That's why we conduct research to advance care techniques that can be used for our patients and kids anywhere. However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. W Webcam. There are no reported cases of congenital absence of the hymen. Gidwani GP. The significance of the diameter of the hymenalorifice is controversial; a large orifice may be consistent with a historyof sexual abuse, but it is not an absolute criterion.7,8. The vulva and anus. From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. 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. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Am J Obstet Gynecol 1987;156:581. Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. Pokorny SF: Configuration of the prepubertal hymen. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. The majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). 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. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 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 ( ). In determining the diagnosis, it may be helpfulto inquire about persistently wet underwear, recurrent fevers, unexplainedUTI, and abdominal or lower back pain. 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 . 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. There is no significant geographic barrier between the vagina and anus. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. Because the child lacks the labial fat pads and pubic hair of the adult, when a child squats, the lower one-third of the vagina is unprotected and open. In girls with persistent, purulent, or recurrent vaginal discharge, orthose with a suspicion of sexual abuse, obtain a wet preparation and culturesfor bacterial pathogens, C trachomatis, and N gonorrhoeae. Historically, these masses were surgically removed, often involving removal of the entire ovary.
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