The differential diagnosis of persistent or recurrent vulvovaginitis not responsive to treatment should include considerations of a foreign body, primary vulvar skin disease (allergic or contact dermatitis), ectopic ureter, and child abuse. This results from the anatomic proximity of the rectum and vagina coupled with the fact that, after toilet training, most youngsters are unsupervised when they defecate. The child is told to have her abdomen sag into the table. Dr. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. A nurse retrieves the patient from the office and takes her to an exam room. 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). How To do a Pediatric Physical Exam Zachys 1.48K subscribers Subscribe 2.8K Share 1.1M views 7 years ago Today Nurse Lindsey demonstrates how to give a proper pediatric physical exam. Urethral prolapse also can present with bleeding. When is it best to reassure, and when is it necessary to evaluate? Presence or absence of Doppler flow in the ovary on ultrasound is not diagnostic of ovarian torsion, and the decision to pursue surgical intervention should be based on the level of clinical suspicion. Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. 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. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. The pediatric gynecologic visit may be unique to both the child and the parent. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. Usually, it is related to menstrual cramps, though many other conditions can cause it, including endometriosis, a painful disease in which uterine tissue grows outside the uterus. Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds. A child should never be restrained for a gynecologic examination . Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. Because of compassion and empathy, the gynecologist may underestimate the extent of the anatomic injuries. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Small follicular cysts in preadolescent girls are usually self-limiting. The American Academy of Pediatrics (AAP) promotes the inclusion of the pelvic examination in the primary care setting within the medical home. Before puberty, the girls reproductive organs are in a resting, dormant state. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. Teens don't usually get pelvic exams. You may need a pelvic exam sooner if you are experiencing problems with your period or have other symptoms, including: Pain in your lower abdomen or pelvic area. Urethritis can be caused by an infectiousagent, irritation, or trauma. The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. A gentle, patient approach is important when examininga prepubertal girl. 14 mins, 33 secs. Lichen sclerosis also can present as vulvar discomfort or pruritus.It is characterized by atrophy of the vulvar skin, which may distort theanatomy of the labia and clitoris, producing ecchymoses and "bloodblisters.". Pediatrics 1990;86:428, 9. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. Philadelphia, PA, Raven-Lippincott, 1998, 2. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . Your questions should address the onset of symptoms; the type,frequency and timing of discharge; associated bleeding, pain, or pruritus;foreign body insertion; perineal hygiene; recent infections in the patientor her family (such as streptococcal pharyngitis or pinworms); recent antibiotictherapy; masturbation; and a history of sexual abuse. Historically, these masses were surgically removed, often involving removal of the entire ovary. 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. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. 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. Includes menu so you can select the portion of the video most applicable to you. The vagina will then fill with air, aiding the evaluation. After your examination is complete, congratulate the child for her cooperationand bravery. 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. First gynecological exam is about establishing care and a relationship not a pelvic exam. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. For example, if a girl complains of . Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. She also explains why it is important to check ferritin levels for iron deficiency and discusses the etiology of abnormal uterine bleeding, with most heavy menstrual bleeding in adolescents and young adults due to ovulatory dysfunction or inherited bleeding disorders. Pay special attention to anatomic and pathophysiologicdifferences in the child. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. This will give the child a sense of control and divert the childs attention if she is ticklish or is squirming. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. Female Pelvic Exam. Gynecological examination of the prepubertal girl can be challenging. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. (From Emans SJ. 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. When indicated, both vaginoscopy and hysteroscopy procedures can be performed by a pediatric and adolescent gynecologist at Childrens Hospital Colorado. Before the exam, you will need to undress and put on a gown. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. Sources of accidental trauma areusually straddle injuries. 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. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. 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. Polycystic ovary syndrome (PCOS) is one of the most common metabolic conditions affecting at least 10% of women of reproductive age. The source maybe the vulva, vagina, endometrium, and occasionally the urethra. Below is a collection of all our Stanford 25-generated videos also found throughout the website. The quantity of discharge can vary greatly, from minimal to copious. 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 ). The extent of labial adhesions and associated symptoms are variable (seefigure "B"). A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. For girls olderthan 2 years, the knee-chest position also permits excellent visualizationof the vagina and cervix without instrumentation.3 If necessary,an experienced examiner or pediatric gynecologist may use a small vaginoscope,cystoscope, hysteroscope, or flexible fiberoptic scope with water insufflationof the vagina to improve visualization. These procedures are usually performed under anesthesia. 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. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. It is important to give the child a sense that she will be in control of the examination process. Vulvovaginitis also may be associated with aspecific infectious agent. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. Prep for OSCEs! 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. Nonspecific vulvovaginitis. Instructing patients to use nonmedicated, nonscented wipes rather than toilet paper may prevent the self-inoculation of the vagina with small pieces of toilet paper, which can initiate a chronic discharge. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). 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 . Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. 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. She should be allowed to visualize and handle any instruments that will be used. The evaluation of young girls is age dependent. Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . 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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. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. HPV is also verticallytransmitted and lesions may appear in the first few years of life. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. Leukorrhea may be present. Once the child is positioned, the vulvar area and introitus should be inspected. 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 ( ). 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. Change gloves, lubricate the rectum, and then gently . Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. 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. Treatment is the same as for labialadhesions. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. 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. If thechild is anxious, you may need to leave the room and return when she feelsready to be examined; in some cases, the procedure may have to be postponedfor several days. Interruptions should be avoided. In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases. During a pelvic exam, a doctor evaluates your reproductive organs. Caring pediatric nurses are available 24/7 to help answer your questions. An infant may be examined on her mothers lap. 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