pediatric pelvic exam video
Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. 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. Ideally children should feel they are part of the examination rather than having an exam done to them.. After your examination is complete, congratulate the child for her cooperationand bravery. 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. Host virtual events and webinars to increase engagement and generate leads. Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse. In severe cases, clobetasol (Temovate)may be useful, applied twice daily for two weeks and then gradually taperedover the next several weeks, but this requires expertise and careful supervisionwith frequent follow-up. Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. Specific vulvovaginitis. In some patients, particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. If a child's symptoms are severe,a one- to four-week course of a moderate-potency ointment can be recommended,followed by a lower-potency preparation. 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. In preadolescent girls, both benign and malignant ovarian tumors are usually unilateral. Adolescents often come for examinations with the preconceived idea that it will be very painful. During a pelvic exam, a doctor evaluates your reproductive organs. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. 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. 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. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. 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. 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 ) ( ). If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. She should be allowed to visualize and handle any instruments that will be used. Support teaching, research, and patient care. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. Pay special attention to anatomic and pathophysiologic differences in the child. Hymens are often crescent shaped but may be annular or ringlike. The color ranges from white or gray to yellow or green. 1 A vaginal self-exam is not the same as a vulvar examination. After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.6 In premenarchal girls, the vagina is 4 to 5 cm long withthin, red epithelium. 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. Vaginal foreign bodiesare a common cause of bleeding, but children often are reluctant to admitto foreign body insertion. 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. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. 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. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. 25:50. 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 normal prepubertal uterus and ovaries are nonpalpable on rectal examination. Support Lucile Packard Children's Hospital Stanford and child and maternal health. 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 exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. 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. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Occasionally, an adhesion will require separation, which canbe done either in the office or under anesthesia. Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. 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. The most important technique to ensure cooperation is to involve the child as a partner. Change gloves, lubricate the rectum, and then gently . They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. Affiliated with the University of Colorado School of Medicine. If the issue is "vaginal" bleeding, the differential diagnosisincludes condyloma acuminatum, urethral prolapse, vascular lesions, precociouspuberty, hormonal medications, and (rarely) sarcoma botryoides, in additionto vulvovaginitis, foreign body, and lichen sclerosus. 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. Female Pelvic Exam. You can use this section to discover where and how this . Pokorny SF: Configuration of the prepubertal hymen. Capraro VJ: Gynecologic examination in children and adolescents.Pediatr Clin North Am 1972;19:511, 12. 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. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . 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In life-threatening emergencies, find the emergency room location nearest you. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. Treatment is the same as for labialadhesions. 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. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics(Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies). Pelvic Exam; Breast Exam; Self Breast Exam; Bimanual Exam; Pap Smear Vulvovaginitis in children may also be caused by a variety specific pathogens such as group A or group B b-hemolytic streptococci, Haemophilus influenzae, and Shigella boydii ; Neisseria gonorrhoeae, Trichomonas vaginalis, and Chlamydia trachomatis may also be responsible in cases associated with abuse but are significantly less common. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as childrens posters are present. However, it is important to do a thorough workup because of the serious sequelae of some of the causes of vaginal bleeding. The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. In this. Pelvic pain is common in adolescent girls. 12.3 ). A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. Diagnosing and treating PCOS in adolescents. The child is told to have her abdomen sag into the table. Children often cannot hold still for long intervals while instruments are being located. 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. Hysteroscopy is performed in the operating room under general anesthesia. 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. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. Positive identification of gonorrhea or chlamydia in a child with premenarcheal vulvovaginitis is considered diagnostic of sexual abuse. From AccessMedicine. An imperforate hymen appearsas a thin membrane, and will bulge if hydromucocolpos is present. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. Learn how we're addressing community health needs, We're a nonprofit that is supported by donors. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Gynecologic Examination with Pap Smear. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . So this is the scariest picture weve got! 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 ( ). Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. They may be discovered by means of a flashlight or by dabbing of the vulvar skin with clear cellophane adhesive tape, ideally before the child has arisen in the morning. It is not diagnostic since few vaginal diseases can be diagnosed visually. If vaginalcultures are not needed, lidocaine jelly can be used to decrease the child'sdiscomfort. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). Emphasize setting the stage to make the examinationa positive experience for your young patient. Cystic ovarian masses commonly occur in infants, children and adolescents. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. Stanford ENT Free Oral Screening November 2nd. 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. The history is critical in terms of making a diagnosis, but it also providestime for you to establish rapport with the patient and elicit her understandingof her symptoms and expectationsof the visit. Routine biopsy of the normal-appearing contralateral ovary should be avoided. In: Emans SJ, Laufer MR, Goldstein DP, eds. For example, if a girl complains of . 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. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. In this video, Chief of Pediatric and Adolescent Gynecology, Tricia Huguelet, MD, discusses the epidemiology, clinical features and management of ovarian cysts that may occur during the fetal and neonatal periods, and on through adolescence. 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. Prepubertal vulvovaginopathies. From Pierce AM, Hart CA. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. The usual cause of genital trauma during childhood is an accidental fall. There will also be an extra sheet you can use to cover yourself. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. The classic symptom of pinworms is nocturnal vulvar and perianal itching. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. 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Cleveland Clinic reexamines syphilis testing strategies after rise in cases. Am J Obstet Gynecol 1987;156:581. 0:31. Will the Healing Touch Go Out the Door With the Stethoscope? Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. Obstet Gynecol Clin NorthAm 1992;19:39, 10. All children should have a chance for a healthy future. Vulvovaginitis also may be associated with aspecific infectious agent. There is no significant geographic barrier between the vagina and anus. Physicians may elect to treat the primary symptoms of vulvovaginitis for 2 to 3 weeks, realizing that on rare occasions they could be missing something more serious. The entire exam takes about only 5 minutes. Often reassurance and sometimes delay until another day are the best approaches. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen. If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. Making the examination a positive experience, ifpossible, therefore is critical.2. 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. Office evaluation of the child and adolescent. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. 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. cryptococcal meningitis isolation precautions, how is motor movement dependent on sensory input, signs he's in denial about his feelings,
