Paediatric Gynaecology

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Paediatric Gynaecology

• Tarek Motan
• Division of Reproductive Endocrinology
  Infertility
• Adolescent Paediatric Gynaecology
• University of Alberta
• 25 September 2009

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Objectives

• To discuss the following common conditions
• Prepubertal girls
• Vaginal discharges
• Perineal trauma
• Adolescents
• Pelvic pain
• Abnormal Bleeding

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Vaginal Discharge

• Common prepubertal gynaecologic complaint
• Lack of oestrogenic affect on vaginal mucosa
  increases susceptibility to infection
• Thin mucosa with alkaline pH

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Vaginal Discharge

• Non Infectious
• Vulvovaginitis
• Foreign body
• Systemic disorders
• Tumours
• Anomalies

• Infectious
• Grp A Strep
• Shigella
• Pinworms
• Gonococcus
• Chlamydia
• Trichomonas
• Bacterial vaginosis

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Vaginal Discharge

• Bloody
• Grp A Strep
• Shigella
• Foreign body
• Trauma
• Scratching
• Condyloma

• Green
• Staphylococcus
• Streptococcus
• Haemophilus
• Gonococcus
• Foreign body

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History

• Onset, duration, colour, odour
• Associated symptoms
• Fever, pruritis, dysuria, anal sx
• Improvement / worsening?
• Bleeding?
• Hygiene measures
• Diapers, toilet trained, cleansing routine
• Signs of puberty
• Treatments tried

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Examination

• Systematic genital exam
• Frog-leg (butterfly) position
• Seated on parent
• Knee chest position
• Child can spread own labia
• Cough or deep breath
• May need an EUA
• Specifics to note
• Dermatological conditions
• Psoriasis, eczema
• Evidence of abuse
• Bruising, trauma

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Examination

• Swab discharge
• Prefer dacron male urethral swab
• Avoid touching post hymen
• Request
• Aerobic culture
• Gonorrhoea chlamydia culture
• Consider wet mount

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Vulvovaginitis

• Vulvovaginal inflam most common cause of
  discharge
• Erythema, discomfort, itching, discharge
  dysuria
• Non specific (75)
• Specific (25)
• Respiratory pathogens
• Enteric
• STIs
• Pinworms
• Foreign body
• Systemic illness
• Dermatologic disorders

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Vulvovaginitis - Therapy

• Vulvar hygiene
• Front-to-back wiping with warm water after a
  bowel movement
• Avoid deodorant soaps, bubble baths, or lotions
• Keep vulvar area clean and dry
• White cotton underwear or if in diapers, change
  soon after each urination or bowel movement
• Use unscented toilet paper
• Wash hands prior to following use of toilet
• Mild bath soap (e.g., Dove, Neutrogena, Basis,
  Cetaphil)
• Remove wet bathing suits soon after exiting pool
  area
• Sitz baths in lukewarm water with 2 tablespoons
  of baking soda or colloidal oatmeal

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Vulvovaginitis - Therapy

• Re-evaluate in 2 weeks
• Review hygiene measures
• If no improvement
• Exclude pinworms consider empiric treatment
• Review results of culture
• Amoxicillin for 10 days
• Cephalexin for 10 days
• Topical antibacterial cream
• Oestrogen cream bid for 2w
• Hydrocortisone cream bid until improved
• Consider EUA to rule out foreign body

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Vulvovaginitis

• Infectious causes
• Presents with vaginitis rather than vulvitis
• Candida is rare in prepubertal age group
• Respiratory organisms
• Grp A Strep most common, Haemophilus, Staph
• Itch, discharge, dysuria, pain, beefy red
  appearance
• Treatment is systemic antibiotics hand washing
• Enteric organisms
• Shigella
• Mucopurulent bloody discharge, foul odour
• Diagnosed on culture treated with cotrimoxazole
• Pinworms (helminth)
• Itch irritation, discharge in vagina infected
• Diagnosed with tape test treated with
  mebendazole

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Foreign Body

• Daily, malodourous dark brown discharge
• May also have pain or bleeding
• Discharge is unresponsive to treatment
• Toilet paper, safety pins, parts of toys
• May be visible on examination
• Vaginal irrigation with saline or EUA

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Perineal Trauma

• Accidental injuries
• Straddle
• Aetiology - playground equipment, bicycle bar
• Prominent surface, rarely hymen or vagina,
  usually anterior
• Penetrating
• Aetiology - falls on to pointed object, fence
  post, bed post
• Hymeneal injuries may occur
• If upper vagina is penetrated may extend to
  peritoneum
• Non-penetrating
• Crush or associated with pelvic fracture
• Associated with multiple trauma, i.e. MVA
• Urethral injuries
• Insufflation injuries

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Perineal Trauma

• History
• Consistent history
• Consider rule out abuse
• Ability to urinate or catheterise
• Time since injury
• Physical exam
• Anterior injury common
• Usually between 3 9 oclock
• Hymenal/vaginal injury rare
• Peri-urethral injury
• Visualise entire laceration

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Perineal Trauma - Therapy

• Straddle injury
• Superficial / haemostatic - observe
• Repair under conscious sedation or EUA
• Ability to urinate need for catheter
• Compression, ice packs analgesia
• Haematoma
• Observe size expansion
• Expectant vs. evacuation with ligation
• of vessels
• Catheterise, ice packs analgesia

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Perineal Trauma - Therapy

• Vulvar Injury
• Prophylactic pre-op antibiotics
• Assess extent of laceration
• Assure urethral / urinary tract intact
• Anatomic repair
• Fine absorbable suture
• ? Post-op oestrogen cream

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Adolescent Pelvic Pain

• Primary dysmenorrhoea
• Secondary dysmenorrhoea
• Painful menstruation in the presence of pelvic
  pathology
• Endometriosis
• Congenital obstructive Mullerian anomalies
• Cervical stenosis
• Pelvic inflammatory disease
• Pelvic adhesions
• Ovarian cysts

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Primary Dysmenorrhoea

• Definition
• Recurrent, crampy lower abdominal pain during
  menstruation in absence of pelvic pathology
• pain 1 - 4 hours prior to menses lasts 24 - 48
  hours
• Prevalence in adolescents
• Very common (20 - 90)
• Only 15 adolescent females seek care
• National Health Examination Survey
• 12 to 17 year old girls
• 50 of 2699 girls reported dysmenorrhoea
• 25 of all excessive school absences due to
  pelvic pain or dysmenorrhoea

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Primary Dysmenorrhoea

• Pathogenesis
• Prolonged uterine contractions
• Decreased uterine blood flow to myometrium
• Increased with ovulation
• PGF2 alpha, PGE2, Leukotrienes
• Therapeutic Options
• NSAIDs first line treatment, unless
  contraindicated
• OCPs improve symptoms
• Contraceptive advantages may make first line
  choice

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Primary Dysmenorrhoea

• NSAID treatment
• Ibuprofen 200 600 mg q6h
• Naproxen sodium 550 mg initially
• Followed by 275 in 8 hours
• Mefenamic acid 500 mg initially
• followed by 250 mg q6h
• Take at onset cramps or menses
• Take for 2 3 days (not to exceed 1 week)
• Take with food

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Primary Dysmenorrhoea

• Oral Contraceptive Pills
• No randomized placebo-controlled trials
• Improvement of dysmenorrhoea over time
• But few adolescents enrolled in studies
• Consideration should be given to extended use
  OCPs
• Depot MPA or Levonorgestrel IUS is effective
• Both can be considered as treatment options

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Primary Dysmenorrhoea

• Non Medicinal Therapeutic Options
• High frequency TENS
• Better than placebo
• Less effective than Ibuprofen
• Equivalent to naproxen
• Acupuncture
• 1 study benefit vs. placebo limited evidence
• Topical heat therapy
• Equivalent ibuprofen
• Better than placebo
• Faster relief in combination with ibuprofen
• Spinal manipulation - No evidence
• Exercise - Cochrane review pending

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Adolescent Endometriosis

• Benign gynaecologic disorder
• Characterized by growth of endometrial cells
  (glands and stroma) in an ectopic location
• Most commonly found on pelvic structures and
  peritoneum
• Bladder, rectum, vulva, vagina, cervix
• Also found less commonly in extra-pelvic
  locations Umbilicus, abdominal surgical scars,
  lungs

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Adolescent Endometriosis

• Most common cause of secondary dysmenorrhoea
• Most common finding in chronic pelvic pain
• Adolescents unresponsive to NSAIDs OCPs
• Up to 73 diagnosed on laparoscopy
• Delay to diagnosis
• 4.2 MDs consulted before diagnosis
• 4.1 years from onset to diagnosis
• Thelarche developmental threshold

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Adolescent Endometriosis

• Symptoms
• Acyclic and cyclic pain 62.5
• Acyclic pain 28.1
• Cyclic pain 9.4
• Gastrointestinal pain 34.3
• Urinary Tract symptoms 5 12.5
• Irregular menses/abnormal bleeding 36

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Adolescent Endometriosis

• Medical Management
• NSAIDS therapy
• Use upper end of dose range
• Ibuprofen 600mg every 6 hours
• OCPs or vaginal ring monthly or extended
• Create pseudopregancy
• Continuous progestin treatment
• DMPA
• GnRH agonists
• Usually withheld until 16 years to allow full
  growth development
• Needs addback oestrogen

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Adolescent Endometriosis

• Surgical Management
• Consider laparoscopy within 3 - 6 mths if pain
  persists
• May proceed prior to 3 mths if interfering with
  school or social activities
• Resection or ablation are equally effective
• Laser, scissors, harmonic scalpel, electrocautery
• 24 patient RCT for chronic pain with stage I or
  II
• No difference in pain over 6 months

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Abnormal Bleeding

• 50 of all adolescent gynae visits
• Minimal to profuse bleeding
• 80 manageable in clinic
• Hospitalisation mainly for hypovolaemia
• 80 due to anovulatory bleeding
• Normal menstrual pattern
• Ovulatory cycle length ranges 28 7d
• Flow 4 2 days while excessive gt 8 - 10d
• Blood loss 40 20 ml while excessive gt
  80ml/cycle

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Aetiology of Abnormal Bleeding

• Endocrine
• Hypothyroidism
• Hyperprolactinaemia
• Vulva/vagina
• Vaginitis
• Trauma
• Infection
• Malignancies
• Sarcoma botryoides
• Clear-cell adenocarcinoma
• Cervix
• Cervicitis
• Condyloma
• Polyps
• Malignancies
• Sarcoma botryoides

• Uterus
• Pregnancy
• Endometritis
• Hyperplasia
• Malignancy
• Polyps
• Leiomyomata
• Ovaries
• Immature hypothalamic-pituitary axis
• Polycystic ovarian disease
• Oestrogen-producing tumours
• Other
• Exercise
• Dieting/anorexia nervosa

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Abnormal Bleeding

• Exclude pregnancy related conditions (ectopics,
  etc)
• Dx ?-hCG endovaginal ultrasound
• Immature H-P-O axis
• Ovulatory by 1y - 18, 5y - 80, 6y - 100 post
  menarche
• LH FSH for follicles development but not for
  ovulation
• Endometrium outgrows blood supply sheds
  irregularly
• Therapy
• Mild bleeding - reassurance Fe
• Hb 90 - 120 OCPs Fe for 3-6m
• Hb lt 90 if stable OCPs Fe for 6-12m
• Severe hosp, transfusion, D C, OCPs 3/2/1 a
  further 28d

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Abnormal Bleeding

• Endocrine abnormalities
• Hyperprolactinaemia
• Prolactinomas, stalk lesions, meds,
  hypothyroidism
• Affects H-P-O function, CL dysfunction
• Rx dopamine agonists regulate menses in 4m
• Hypothyroidism
• ? TRH affects PRL dopamine action
• Rx thyroid replacement

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Abnormal Bleeding

• Blood dyscrasia
• Affects 5 - 19 of adolescents hospitalised with
  menorrhagia
• ITP, von Willebrands disease, leukaemia,
  platelet dysfunction
• Dx CBC, PTT, INR, bleeding time, vWFAg,
  ristocetin cofactor
• Müllerian anomalies
• Incidence 13000 births
• Dx U/S MRI
• Rx formal surgical correction

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Abnormal Bleeding

• Infections
• Cervicitis
• Chlamydia or gonorrhoea
• Non-infectious causes if swabs negative
• Vaginitis
• Trichomonas, Candidiasis, bacterial vaginosis
• Endometritis
• Acute chronic forms
• Menometrorrhagia, mucopurulent PVD, uterine
  tenderness
• Dx endometrial biopsy, ? ESR, ? WCC
• Treatment is aerobic anaerobic antibiotics

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Abnormal Bleeding

• Condyloma accuminata
• 15 of adolescents HPV ve (types 6 11)
• Rx cryotherapy, podophyllin, TCA, CO2 laser,
  imiquimod
• Recurrence chemical - 27-65, laser - 35,
  imiquimod - 20
• Uterine fibroids polyps
• Low incidence in adolescents
• Haemangiomas
• Dx physical exam MRI
• Rx laser, sclerosing, embolisation,
  cauterisation, steroids

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Questions Please