Urethritis can be caused by an infectiousagent, irritation, or trauma. The vulva and anus. 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. 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. Finally, issues of privacy and confidentiality are essential considerationswhen examining older children. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. PCOS occurs due to a complex interaction of genetic and environmental factors can affect the menstrual cycle, hair growth, skin, weight and the ability to have children. This can be accomplished without the insertion of any instruments. Management is dictatedby the diagnosis: antibiotics and hygiene measures for infectious vulvovaginitis,surgical repair of trauma if necessary, biopsy of polyps or suspected tumors,removal of foreign bodies, further investigation for sexual abuse if itis suspected by exam or history or if condylomata are found, sitz bathsand estrogen cream for urethral prolapse, and further investigationinto the etiology of precocious puberty. 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. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. The outer catheter serves as an insulator, and the inner catheter is used to instill a small amount of saline and aspirate into the vaginal fluid. 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 . 0:38. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Interruptions should be avoided. Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect. Watch the gynecology medical education videos below for protocols and research from our experts to help improve the care of your patients. Observation alone is appropriate for small adhesions. Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. 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. Philadelphia, PA, Raven-Lippincott, 1998, 2. In addition to your doctor, there will be a nurse or an assistant in the room during . 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. Introduction to the Basic Pelvic Exam. Abraham-Vergheses-TED-Talk:-Over-one-million-views! 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 . In this. Videos : Exams. Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers. Children are not skilled historians and will often ramble, introducing many unrelated facts. The history should include the quality of the discharge(color, odor, presence of blood), hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions. Cystic ovarian masses commonly occur in infants, children and adolescents. The most important technique to ensure cooperation is to involve the child as a partner. 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. The history shouldassess the child's growth and development; signs of puberty such as breastdevelopment, axillary hair, pubic hair, growth spurt, and leukorrhea; genitaltrauma; vaginal discharge; and a history of foreign body insertion. 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. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Group A streptococciand Shigella are the most common causes. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. 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. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 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. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. Yuwoko. What Stands in the Way of Bedside Teaching? 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. A foreign object and the cervix may be visualized using this technique. PDF Genital Examination of Young Girls - Royal Children's Hospital The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. These are the organs related to your monthly menstrual cycles, to sexual activity, and to pregnancy and childbirth. 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. Pelvic Exam, The | Advanced Pediatric Associates | Pediatricians in This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. 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. . 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. You can use this section to discover where and how this . The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. An interesting illustration of the physical exam. These data can be used to inform the design of teaching interventions to improve skill in this area. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation and discharge. W Webcam. Over the last decade, however, the management of ovarian masses has shifted toward a more conservative approach with the goal of ovarian preservation. . The extent of labial adhesions and associated symptoms are variable (seefigure "B"). 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. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. Because of compassion and empathy, the gynecologist may underestimate the extent of the anatomic injuries. The Pelvic Exam - Stanford Medicine 25 - YouTube The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. Most such traumas involve straddle injuries. There are many narrow-diameter endoscopes that will suffice, including the Kelly air cystoscope, contact hysteroscopes, pediatric cystoscopes, small-diameter laparoscopes, plastic vaginoscopes, handheld disposable hysteroscopes (e.g., Endosee Handheld Hysteroscopy System, CooperSurgical Inc., Trumbull, CT), and special smaller, narrower speculums designed by Huffman and Pederson. Pay special attention to anatomic and pathophysiologicdifferences in the child. Small follicular cysts in preadolescent girls are usually self-limiting. Inspect the child's breasts and palpate themfor signs of puberty. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. Despite widespread belief, mycotic (yeast) vaginal infections are not common in prepubertal children because the alkaline pH of the vagina does not support fungal growth. Stanford 25 YouTube Channel Abdominal Examination Examination of the Spleen (Stanford Medicine 25) Percussion of the Spleen (Stanford Medicine 25) Diagnosis Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) with Carnett's Sign - Abdominal Pain Ankle Brachial Index Ankle Brachial Index (ABI) Test: How to Perform Venous Testing Bedside Ultrasound Recurrent vulvovaginitis, persistent bleeding, suspicion of a foreign body or neoplasm, and congenital anomalies may be indications to perform a vaginoscopy and examine the inside of the vagina. 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. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. If extensive labial adhesions are present, you maynot be able to adequately examine the hymen and vagina and will need toreexamine the child after she has successfully completed treatment withlocal hygiene measures and topical estrogen (see Sidebar, "Common gynecologicfindings in the prepubertal girl"). 5 Minute Pelvic Exam Video | The Brookside Associates 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. Whats the diagnosis? OB/GYN - Physical Examination Resources - University of Iowa The severity of vulvovaginitis symptoms varies widely from child to child. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. 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. 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. A handheld mirror may help in some instances when discussing specifics of genital anatomy. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. 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 ( ). Many adolescent girls do not want their mother, guardian, or other observers in the examining room, and in many adolescent gynecology visits, a full pelvic examination is unnecessary ( ). After you have established a rapport with the child and taken her history,you should explain the gynecologic examination to both the child and herparent. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. Pokorny SF. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. So this is the scariest picture weve got! Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. From AccessMedicine. Sometimes doctors do pelvic exams if they think there's a problem. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Sources of accidental trauma areusually straddle injuries. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. If you cannot fully visualize the hymen, ask thechild to cough or take a deep breath, or pull the labia gently forward anddown or laterally yourself so that you can see the hymen and the anteriorvagina. 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 child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. A gentle, patient approach is important when examininga prepubertal girl. These procedures are usually performed under anesthesia. Female Urethral Catheterization Male Urethral Catheterization Female Genital Exam Male Genital Exam Don't forget to watch the Why Urology video! Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Genital bleeding should always be assessed thoroughly. 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. Gidwani GP. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. 0:31. Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. However, it is important to do a thorough workup because of the serious sequelae of some of the causes of vaginal bleeding. There is no significant geographic barrier between the vagina and anus. 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. Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). 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. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus.It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact. Dealing with a foreign body. Gynecological examination of the prepubertal girl can be challenging. This easily assembled adaptation uses a No. Adolescents often come for examinations with the preconceived idea that it will be very painful. A successful gynecologic examination of a child demands that the physician employ an exam pace that conveys both gentleness and patience with the time spent, without seeming to be hurried or rushed. Many dermatologic disorders, suchas atopic dermatitis, seborrhea, and psoriasis, can manifest as vulvitisor vulvovaginitis. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. Once the child is positioned, the vulvar area and introitus should be inspected. 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. The color ranges from white or gray to yellow or green. Affecting approximately one in every 4,500 newborn girls, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome can be challenging to treat both medically and psychologically, due to the potential loss of fertility. See a listing of all our Childrens Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more. A mounding of hymeneal tissue is often called a bump. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. 25:50. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. This includes feeling a girl's uterus and ovaries to be sure everything's normal. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. 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. Many gynecologic conditions in children may be diagnosed by inspection . 12.4 ). Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. Pelvic Exam The pelvic exam is a vital part of every woman's preventative care and is also important towards making a number of diagnoses when presenting with abdominal or pelvic complaints. This is an important step toward reinforcing the child's sense ofcontrol over the examination. 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. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs. Power your marketing strategy with perfectly branded videos to drive better ROI. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. 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. Gynecologic Examination for Adolescents in the Pediatric Office Setting The film opens with a woman sitting in an office of a physician. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. Viscous lidocaine and warmsaline for irrigation through an IV set-up may be helpful when examininga child who has an acute straddle injury and bleeding. A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal abuse. In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. 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. You might have a pelvic exam as part of your regular checkup. 12.1 ). For example, if a girl complains of . Contemporary Pediatrics Resident Writer Program, Food Insecurity and the Dangers of Infant Formula Dilution, Getting into the Roots of Childhood Atopic Dermatitis, Opt-Out Chlamydia Screening in Adolescent Care, The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, Choose article sectionPrinciples of gynecologic assessmentTaking the historyBeginning the examinationExamining the external genitaliaExamining the vaginaConcluding the examinationSIDEBAR: Common gynecologic findings in the prepubertal girlVulvovaginitisVaginal bleedingLabial adhesions, | Obstetrics-Gynecology & Women's Health, | Contemporary Pediatrics Resident Writer Program, | Food Insecurity and the Dangers of Infant Formula Dilution, | Getting into the Roots of Childhood Atopic Dermatitis, | Opt-Out Chlamydia Screening in Adolescent Care, | The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, | Update in Pediatric COVID-19 Vaccines. It can also present as a chronic colonization (diaper rash) in patients using diapers. A child should never be restrained for a gynecologic examination . It's also not true that the pelvic exam is a "test" to see if you are a virgin. This period of transition involves important physical and emotional changes. Dr. Appiah also reviews the expert consensus position statements that provide guidance on how providers should care for this population, including informing patients about options for fertility preservation and future reproduction prior to treatment. HPV is also verticallytransmitted and lesions may appear in the first few years of life. Female Pelvic Exam. The second phase of the examination involves evaluation of the vagina . Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage .