Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. Whats the diagnosis? Introduction to the Basic Pelvic Exam. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. Support Lucile Packard Children's Hospital Stanford and child and maternal health. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. 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. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. 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 device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). Abraham-Vergheses-TED-Talk:-Over-one-million-views! Once the child is positioned, the vulvar area and introitus should be inspected. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. Visualizing the hymen. Pediatric Gynecology Videos | Children's Hospital Colorado The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. Prep for OSCEs! . Not sure if you need urgent or emergency care? 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"). Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. 12.3 ). However, many infants are infected with Chlamydia trachomatis during birth and remain infected for up to 2 to 3 years in the absence of specific antibiotic therapy. This period of transition involves important physical and emotional changes. What Stands in the Way of Bedside Teaching? The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases. 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. Affiliated with the University of Colorado School of Medicine. Can you guess the cause of the patients bleed? Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . 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. She also discusses the preferred diagnostic modality and when to consider surgery. 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. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Pediatrics 1987;79:778, 8. So this is the scariest picture weve got! Acute genital bleeding in girls is most caused by accidental trauma, such as straddling a bicycle or falling on playground equipment. In a microperforate hymen, it may be difficult to identify an opening.To establish its presence, try squirting a small amount of warm water orsaline with a syringe or angiocath, placing the girl in the knee-chest position,or probing with a small urethral catheter, feeding tube, or nasopharyngealCalgiswab moistened with saline or vaginal lubricant (Figure 8). If you identify and remove a foreign body, recommend that the child takesitz baths for two weeks. DR. KAHN is Assistant in Medicine, Children's Hospital, Boston, and Instructor in Pediatrics, Harvard Medical School, Boston, MA.DR. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. 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. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. Your patient gets this rash, whats the diagnosis? 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. Ideally children should feel they are part of the examination rather than having an exam done to them.. Obtaining a history from a child is not an easy process. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. Vulvovaginitis is the most common gynecologic problem in prepubertal girls. Pediatricians are uniquely qualified to perform an appropriate clinicalassessment because of their expertise in examining young children and knowledgeof many anatomic and pathophysiologic conditions specific to children. Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. 3 simple steps. Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls. The quantity of discharge can vary greatly, from minimal to copious. 4:40. Online Teaching Videos - Department of Urology Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. 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. Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. These are the organs related to your monthly menstrual cycles, to sexual activity, and to pregnancy and childbirth. During the exam You may be asked to help your child lower his pants and possibly have him put on a hospital gown. 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.