The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. 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. There will also be an extra sheet you can use to cover yourself. Diagnosing and treating PCOS in adolescents. This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. Different positions for performing a gynecologic examination on a child. The color ranges from white or gray to yellow or green. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. 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. In the office setting, the examination should be limited to external inspection only; speculum exams should not be performed in pediatric patients. After your examination is complete, congratulate the child for her cooperationand bravery. These exams may be done as part of a yearly check-up for teenagers or young adults, however, you may need them sooner or . A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. 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. Prepubescent Female Genital Examination Images: Evidence - PubMed 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. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents. Leukorrhea may be present. If the issue is vaginal discomfort, pruritus, ordischarge, the differential diagnosis includes nonspecific or infectiousvulvovaginitis, vulvar skin disease, lichen sclerosis, and presence of aforeign body. An ectopic ureter can present as persistent wetnessor purulent discharge. 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. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. 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. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. A mounding of hymeneal tissue is often called a bump. A tape testmay be useful for suspected pinworm. 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. From AccessMedicine. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. 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. Pokorny SF: Configuration of the prepubertal hymen. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. When a child has vaginal discharge or bleeding andthe source (such as a foreign body) is not obvious, obtain samples for cultureand saline preparation. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. The exam can be done even if you have never had sexual intercourse, because the opening to your vagina is large enough to allow for the exam. There is no significant geographic barrier between the vagina and anus. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. 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. An older child should be asked whom she prefersto have in the room during the examination. 12.1 , B ). "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. 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. 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. Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. In 2019, there were over 1.7 million new cases of cancer, with 10,270 cases occurring among children ages 0 to 14 years of age and 70,000 occurring in adolescents and young adults. 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. Young children may be examined in the frog leg position, and children as young as 2 to 3 years of age may be examined in the lithotomy position with use of stirrups, although this is generally used for girls aged 4 to 5 years and older. This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. 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"). The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. Because the pubertal changes are often a cause of concern for adolescent girls and their parents, the gynecologist must offer the adolescent patient an empathetic, kind, knowledgeable, and gentle approach. This is an important step toward reinforcing the child's sense ofcontrol over the examination. 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. When indicated, both vaginoscopy and hysteroscopy procedures can be performed by a pediatric and adolescent gynecologist at Childrens Hospital Colorado. Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing. A complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children. The typical location is the anterior vaginalwall near the cervix. Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. Video Gallery | Stanford Medicine 25 | Stanford Medicine An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. The signs of vulvovaginitis are variable and not diagnostic, but they include vulvar erythema, edema, and excoriation. Inspect the child's breasts and palpate themfor signs of puberty. Related collections for "Pelvic Exam Variations" on Vimeo At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . Change gloves, lubricate the rectum, and then gently . Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube 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. 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. 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. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. A gentle, patient approach is important when examining a prepubertal girl. 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. Group A streptococciand Shigella are the most common causes. Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . A nurse retrieves the patient from the office and takes her to an exam room. 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. 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). (From Emans SJ. A helpful technique is to place the childs hand on top of the physicians hand as the abdominal examination is being performed and to give her some choices, such as having a doll, an electronic tablet, or a toy with her. If patients are going to be treated with antibiotics, one should attempt to collect a sample of the vulvovaginal discharge for culture before initiation of the antibiotics . Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. 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. Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques. Support teaching, research, and patient care. 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. Nonspecific vulvovaginitis. With a five-year survival rate of 84%, there are 100,000 annual survivors of reproductive age. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. ObstetGynecol 1971;37:462, 13. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later). Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. Can you diagnose the cause of the patients lymphedema? It's also not true that the pelvic exam is a "test" to see if you are a virgin. 4:40. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. Vaginal bleeding is also associated with vulvovaginitis. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. A gentle, patient approach is important when examininga prepubertal girl. Pelvic pain is common in adolescent girls. Heavy menstrual bleeding is common in adolescents, with about 15% to 40% of teens experiencing heavy bleeding, but many teens dont recognize that their bleeding is abnormal. Or your doctor might recommend a pelvic exam if you have symptoms such as unusual vaginal discharge or pelvic pain. Learn Peds Genitourinary 04 Genital Exam Intro from UBC Learn Pediatrics on Vimeo. A patient presents with foot pain and these chronic findings? During a pelvic exam, a doctor evaluates your reproductive organs. This chapter considers gynecologic diseases of children from infancy through adolescence. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. This video demonstrates how to perform a comprehensive pelvic examination, including an examination of the external genitalia, a Papanicolaou test to screen for cervical dysplasia, a bimanual exami. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. If the bleeding is unexplainedor you suspect a foreign body or tumor and the vagina cannot be fully visualized,an exam under anesthesia by a gynecologist is necessary. 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. Female Pelvic Exam. You can use this section to discover where and how this . Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. 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. Macleod's Physical Examination - Head, Eyes and Ears Examination - OSCE Guide 2017. The importance of patient/family preference along with individualization based on medical history and treatment goals is reviewed. Teens don't usually get pelvic exams. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. This includes the process for diagnosis and considerations for work-up, evaluation and treatment, such as support and counseling. 5 Minute Pelvic Exam Video. This may create considerable and understandable anxiety in the child and parent. One excellent technique is for the physician to sit, not stand, during the initial encounter. Capraro VJ: Gynecologic examination in children and adolescents.Pediatr Clin North Am 1972;19:511, 12. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. This patient presents with chest pain. A pelvic exam is where a doctor or nurse practitioner looks at a girl's reproductive organs (both outside and internally). In this video, the Director of the Fertility Preservation and Reproductive Late Effects Program, Leslie Appiah, MD, discusses the prevalence of reproductive late effects and female risk stratification based on age and therapy doses. Some healthcare professionals listed on our website have medical privileges to practice at Childrens Hospital Colorado, but they are community providers. 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. Heavy menstrual bleeding frequently interferes with a patients physical, social and emotional health and negatively impacts their quality of life. It is important to give the child a sense that she will be in control of the examination process. When is it best to reassure, and when is it necessary to evaluate? After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. New onset of Trichomonas vaginitis in theprepubertal child is associated with sexual abuse. She also discusses the preferred diagnostic modality and when to consider surgery. For example, if a girl complains of . 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. The second phase of the examination involves evaluation of the vagina . When Do Teens Need a Gynecologist? > News > Yale Medicine PDF Genital Examination of Young Girls - Royal Children's Hospital Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . In life-threatening emergencies, find the emergency room location nearest you. Not sure if you need urgent or emergency care? There are no reported cases of congenital absence of the hymen. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. 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. 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 . Support Lucile Packard Children's Hospital Stanford and child and maternal health. In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. 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. View a sample video Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Most such traumas involve straddle injuries. The Pelvic Exam - Stanford Medicine 25 - YouTube The vagina will then fill with air, aiding the evaluation. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. Your First Pelvic Exam - Texas Children's Hospital So this is the scariest picture weve got! The major factor in childhood vulvovaginitis is poor perineal hygiene. Gynecologic Examination for Adolescents in the Pediatric Office Setting The most common gynecologic condition of children is vulvovaginitis . 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. Vulvarskin disorders are common, and often easily recognizable on exam. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.Referral should be made to a gynecologist with experience in pediatric gynecology. 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. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). 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. 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. If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. Host virtual events and webinars to increase engagement and generate leads. A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Occasionally it is best to defer the genital examination until a second visit . Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. Introduction to the Basic Pelvic Exam. 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. 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. 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. What questions should PNPs consider related to womens health? 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 ( ).