COMMON PEDIATRIC

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COMMON PEDIATRIC ADOLESCENT GYNECOLOGICAL
COMPLAINTS

• District 1 ACOG Medical Student Education Module
  2008

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Gynecological care begins in the delivery room as
part of the newborn examination with palpation of
the breast buds and examination of the external
genitalia
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Newborn Anatomy

• 1st few weeks of life, residual maternal sex
  hormones may have physiologic effects on newborn
• Breast budding in majority of term female infants
  and there may be marked breast enlargement or
  even nipple discharge but no treatment is
  required
• Labia majora are bulbous
• Labia minora are thick protruding
• Clitoris is relatively large (normal is 0.6cm2 or
  less)
• Vaginal epithelium dull pink initially and then
  as maternal residual estrogen levels decline,
  genitalia take on their juvenile appearance with
  small labial fat pads and the vaginal epithelium
  (1-3 cells thick) becomes bright red

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Newborn Anatomy

• Vaginal discharge is common, usually composed of
  cervical mucus exfoliated vaginal cells
• Vaginal bleeding is also common as the estrogen
  levels fall and the stimulated endometrial lining
  sheds. Generally stops in 7-10 days.
• Hymen has varied configuration size of opening.
  Initially turgid
• Vagina is approximately 4 cm long
• Uterus is enlarged (4 cm) with no axial flexion
• Ratio b/w Cx corpus is 31
• Columnar epithelium protrudes through os
• Ovaries are abdominal organs into early childhood

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Early Chilhood Anatomy

• Little estrogen stimulation
• Labia majora flatten, labia minora and hymen
  become thin
• Vagina has atrophic mucosa and is very
  susceptible to trauma infection
• Cx is flush with vaginal vault as vaginal
  fornices do not develop until puberty
• Uterus regresses in size until about age 6
• Ovaries begin to enlarge descend
• By age 7-10 years, genitalia start to show signs
  of estrogen stimulation with thickening of the
  mons pubis, labia majora, hymen, vaginal
  mucosa.
• The labia minora become rounded the vagina
  elongates to 8cm
• Uterus starts to grow and rapid endometrial
  proliferation occurs as menarche becomes imminent
• ovarian follicles increases

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History Physical Exam

• Give child an opportunity to speak with you alone
  when appropriate
• Give child as much control as possible over
  situation get them involved in the exam if
  possible
• Be mindful of abuse and be aware of appropriate
  steps in suspicious cases
• Never restrain a child (general anesthetic may be
  required)
• Have parents sit on table with child
• Use frog leg and knee/chest positions in younger
  children
• Inspect hymen carefully for signs of breaks or
  trauma as minor external injuries may hide
  serious vaginal lesions
• Inspect anal region but do vaginal/rectal exams
  only when needed (imaging often better option)

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Instruments

• May need instruments to visualize the upper 1/3-
  1/2 of the vagina
• Office vaginoscope can be tried (0.5 cm in
  infancy/childhood 0.8 cm in premenarcheal
  girls)
• Water cystoscope allows some distention of vagina
  cleans debris
• Can use urethroscope/laparoscope
• Topical lidocaine to anesthetize vulva
• General Anesthesia if exam not easy
• Huffman-Graves Pedersen specula should be used
  for adolescents
• Saline soaked swabs are used for vaginal samples
  in children because this is adequate given
  immature lining
• Speculum exam with Cx cultures may be necessary
  in adolescent

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Genital Ambiguity

• 1/14 000 newborns
• Needs immediate identification and response as
  life threatening salt wasting congenital adrenal
  hyperplasia may be cause
• Ambiguity can result from masculinization of a
  female child, exogenous hormone ingestion,
  maternal or fetal overproduction of androgens,
  incomplete virilization of a male infant,
  hormonal insensitivity, gonadal dysgenesis, or
  chromosomal abnormalities
• Assessment should include lytes,
  17-hydroxyprogesterone, cortisol, karyotype, and
  any other relevant blood work
• Careful genital exam and pelvic u/s to detail
  internal anatomy
• Multidisciplinary approach essential

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Clitoral Abnormalities

• Normal clitoris 1-1.5 cm long and 0.5 cm wide
• Abnormalities uncommon
• Clitoromegally usually associated with ??
  androgen exposure (often assoc with labial
  fusion)
• Clitoral splitting is rare and caused by a
  midline fusion defect
• Bifid clitoris usually assoc with bladder
  extrophy
• Extrophy rare (1/30 000 births)
• 40 assoc with some genital tract abn

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Imperforate Hymen

• Represents a persistent portion of the urogenital
  membrane
• One of most common obstructive lesions in the
  female genital tract
• Incidence 1/1000 live born ?
• Generally sporadic anomaly
• Often not diagnosed until puberty with c/o
  cyclical abd pain 1O amenorrhea
• Classic is bluish bulge at introitus
• Mucocolpos or hematocolpos may cause pain,
  difficulty voiding/defecating
• Variations include imperforate, microperforate,
  septate, and cribriform hymens
• Requires surgical resection if clinical
  significance evident

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Transverse Vaginal Septum

• Results from faulty fusion or defective
  canalization of the urogenital sinus mullerian
  ducts
• 1/75,000 women
• 46 upper, 40 mid, 14 lower vagina
• Septa in the upper vagina more likely to be
  patent
• Complete septum has similar signs Sx as an
  imperforate hymen except without the bulge at the
  introitus
• Membrane excised with surrounding ring of
  subepithelial tissue may then require an end to
  end reanastomosis of upper and lower vaginal
  mucosa (depending on the thickness of the septum)

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Longitudinal Vaginal Septum

• Duplication of vagina very rare often
  associated with duplication of vulva, bladder,
  uterus
• More commonly, longitudinal septa form when the
  distal ends of the mullerian ducts fail to fuse
  properly
• Surgical excision not required unless symptomatic
  or worries re SVD

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Vaginal Agenesis

• Incidence 1/5000
• Most common cause is Mayer-Rokitansky-Kuster-Hause
  r Syndrome (46XX)
• Not inherited but is an accident of development
• External genitalia normal with variable levels of
  uterine development, although often cervical
  uterine agenesis are present
• May be urinary tract, spinal, middle ear, other
  mesodermal structural abnormalities
• 75 with MRKH have complete vaginal agenesis and
  25 have a short vaginal pouch

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Vaginal Agenesis

• Typically normal female karyotypes with normal
  ovaries and ovarian function
• Normal secondary sexual characteristics
• Often present with 1O amenorrhea
• Creation of a vagina should be delayed until pt
  wishes to be sexually active
• Vaginal dilators or surgical creation
• Complete androgen insensitivity may also present
  as vaginal agenesis and must be correctly
  identified 2O risk of gonadoblastoma (4-5 risk)
• Chromosomal analysis is definitive

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Uterine Abnormalities

• Result from agenesis of the mullerian duct or a
  defect in fusion or canalization
• Most are asymptomatic are only picked up
  incidentally or when they interfere with
  reproduction
• Bicornuate uterus (37), arcuate uterus (15),
  incomplete septum (13), uterine didelphys (11),
  complete septum (9), unicornuate uterus (4)
• Mullerian anomalies occur in 1-3 ?

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Unicornuate Uterus

• Single horned uterus with corresponding fallopian
  tube round ligament
• Results from agenesis of 1 mullerian duct with
  absence of structures on 1 side
• If other hemiuterus present, a small rudimentary
  horn is created
• If this horn does not communicate with other
  cavity or vagina, may develop dysmenorrhea and
  hematometra
• Higher risk preterm labor, infertility,
  endometriosis, malpresentation

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Uterine Didelphys

• Failure of fusion of the mullerian duct may
  result in 2 separate uterine bodies
• Generally good reproductive outcomes
• Vaginal septae may require resection if causing
  difficulty with intercourse, vaginal delivery, or
  pain from obstructed menstruation

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Bicornuate Uterus

• Results from partial fusion of the mullerian
  ducts which leads to varying degrees of
  separation of the uterine horns
• Reproductive function is generally good

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Septate Uterus

• Results from failure of canalization or resoption
  of the midline septa between the 2 mullerian
  ducts
• Higher risk of miscarriage with increasing length
  of septa
• Hysteroscopic resection may need to be considered

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Vulvovaginitis

• Most common gyne complaint of children
• Children are susceptible to pruritus vaginal
  discharge from irritation/infection as the vulva
  is thin without labial fat pads and pubic hair,
  closer to the anus, unestrogenized vagina is
  atrophic, pH is excellent for bacterial growth,
  perineal hygiene is suboptimal
• Itch/scratch cycle and subsequent inflammation
  bleeding

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Vulvovaginitis

• Sand boxes, wet clothes, etc contribute
• May have large extension onto thighs
• Note of other derm conditions/lesions and whether
  there are signs of abuse
• Wet mount may show numerous leuks
• Cultures evaluation of vaginal secretions as
  appropriate
• Most cases resolve with better hygiene
  avoidance of irritants

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Foreign Bodies

• Very common in children
• Often present with vulvovaginitis, pain, foul
  smelling purulent/bloody d/c
• Often fragments of toilet paper but may be toys
  etc which child may not remember or admit to
• Foreign bodies in the lower 1/3 vagina can often
  be flushed out with warm saline irrigation
• Vaginoscopy in many cases appropriate

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Labial Agglutination

• Common in prepubertal children
• Etiology unknown but likely secondary to low
  estrogen levels
• Skin covering labia is thin and local irritation
  may denude the labia causing adherence in the
  midline and reepithelialization
• Must distinguish from vaginal atresia
• Most children are asymptomatic but may have
  urinary Sx recurrent infections
• Tx if symptomatic is estrogen cream bid for 7-10
  days
• Surgical separation may be necessary in some
  cases
• Recurrence common

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Trauma

• Straddle injuries most common cause of genitalia
  trauma in young girls
• Seasonal peak in spring with bikes
• Contusions generally require no tx
• Hematomas are generally controlled with pressure
  an ice pack although an enlarging hematoma may
  need incision ligation of bleeders
• May need to pack vagina
• Catheter if hematoma blocking urethra
• Pelvic X-ray Abx as appropriate
• Must rule out more severe injury (eg above
  hymenal ring)

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Abuse

• May victims are not seen immediately
• Suspect
• Know who to call be sure of evidence collection
• Tx all injuries, good perineal care, screen for
  STDs tx as needed
• Pregnancy test if appropriate
• Counselling support

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Neoplasms

• Uncommon but about 50 genital tumors found in
  children are premalignant or malignant
• Benign tumors of the vulva/vagina include
  teratomas, hemangiomas, simple cysts of the
  hymen, granulomas, condylomata acuminata,
• Only large, suspicious, or symptomatic lesions
  require surgical removal
• Embryonal vaginal carcinomas most commonly seen 3y
• Tumors arise in the submucosal tissues spread
  rapidly beneath an intact vaginal epithelium so
  that the mucosa bulges into a series of polypoid
  growths (botryoid sarcoma)

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Neoplasms

• Ovarian tumors most common genital tumor (1
  total)
• Most common neoplasm in girls is the dermoid
• 70 germ cell
• Abdominal pain mass most common sx
• Tumors present abdominally