What questions should PNPs consider related to womens health? The source maybe the vulva, vagina, endometrium, and occasionally the urethra. These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus. That's why we conduct research to advance care techniques that can be used for our patients and kids anywhere. Past medical history should include information about congenital anomalies,systemic disorders with dermatologic manifestations, and growth and development.Congenital anomalies, and particularly renal anomalies, may be associatedwith gynecologic anatomic abnormalities. Tricia Huguelet, MD, Chief of Pediatric and Adolescent Gynecology, describes the typical presentation of hymen imperforations in adolescents and young adults, as well as obstructing and non-obstructing mllerian anomalies. Treatment is the same as for labialadhesions. Sometimes doctors do pelvic exams if they think there's a problem. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. 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. Much of the history must be obtained from the parents . Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. 0:38. Once the child is positioned, the vulvar area and introitus should be inspected. Stanford 25 Skills Symposium 2016 Announced! 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. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. You might have a pelvic exam as part of your regular checkup. Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). Instructing patients to use nonmedicated, nonscented wipes rather than toilet paper may prevent the self-inoculation of the vagina with small pieces of toilet paper, which can initiate a chronic discharge. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. The importance of patient/family preference along with individualization based on medical history and treatment goals is reviewed. When is it best to reassure, and when is it necessary to evaluate? The Pelvic Exam. Asking the child whether anyone hasever touched her in a way that made her feel uncomfortable often is helpfulin drawing out this information. Although rare, it isimportant to recognize sarcoma botryoides, or embryonal rhabdomyosarcoma.Such a tumor can present as a lower abdominal mass or as vaginal bleedingor passage of part of the tumor. 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. Vulvovaginitis also may be associated with aspecific infectious agent. A visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help. Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Gynecologic Examination with Pap Smear. 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 . A patient presents with foot pain and these chronic findings? The work-up for vaginal bleeding includes a careful inspection of thevulva and vagina, wet preparation and bacterial cultures, and cultures forsexually transmitted infections if indicated. What is it? A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. Inspect the child's breasts and palpate themfor signs of puberty. Learn about our mission and more, or search for opportunities to join our team. Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. 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. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. A handheld mirror may help in some instances when discussing specifics of genital anatomy. This chapter considers gynecologic diseases of children from infancy through adolescence. Join Childrens Hospital Colorado pediatric experts for a virtual Were passionate about providing answers, treatment and care for the full range of female reproductive health concerns, from infancy through adolescence and into adulthood. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. This is often the most distressing aspect of the examination and may be omitted, depending on the childs symptoms. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. This is a difficult decision and is based on the extent of the childs anxiety in relation to the severity of the clinical symptoms. Forpersistent cases, prescribe a one- to three-month course of a low-potencytopical steroid preparation, such as hydrocortisone 1% or 2.5%, followedby careful hygiene and use of emollients. The genital examination of the infant through adolescence.Curr Opin Obstet Gynecol 1993;5:753, 11. 12.4 ). 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. After viewing, providers will be better able to counsel patients and their families on treatment methods as well as provide them with updated resources on this topic. 12.1 ). In this video, adolescent gynecologist Eliza Buyers, MD, reviews options for menstrual suppression, how they work, and various considerations for teens with complex medical issues. W Webcam. Watch the video to learn how Dr. Scott teams up with specialists from urinary and gastrointestinal medicine to develop a holistic approach to identifying and managing chronic pelvic pain in adolescent girls. Diagnose this skin lesion with newest Stanford 25 video and topic. This easily assembled adaptation uses a No. An ectopic ureter can present as persistent wetnessor purulent discharge. Introduction to the Basic Pelvic Exam. Can you diagnose the cause of the patients lymphedema? Children usually are asymptomatic,but they may present with secondary infection. Childrens Hospital Colorado providers are faculty members of the University of Colorado School of Medicine. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. 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. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Loose-fitting cotton undergarments should be worn. A vaginal self-examination is a way to look at your vulva and vagina to better understand your body and to spot problems that may need medical attention. Specific vulvovaginitis. 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. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. There is nothing specific about the symptoms or signs of childhood vulvovaginitis. Obtaining a history from a child is not an easy process. Patient has this new skin finding, what should you worry about? In this video, Stephen Scott, MD, MPH, emphasizes the fact that pain originates from nerve signaling and uses this understanding to help him identify the source of pain and its cause. 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. A child should never be restrained for a gynecologic examination . Dr. Appiah also reviews the expert consensus position statements that provide guidance on how providers should care for this population, including informing patients about options for fertility preservation and future reproduction prior to treatment. Pediatrics 1987;79:778, 8. Non-sexually acquired genital ulcers (NSGUs) in adolescent females are uncommon, painful skin lesions on the mucous membranes of the vulva and vaginal structures, unrelated to sexual activity. 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. Urethral prolapse also can present with bleeding. It is not diagnostic since few vaginal diseases can be diagnosed visually. Afterthe newborn period, the average size of a normal clitoral glans in a premenarchalchild is 3 mm in length and 3 mm in transverse diameter.4 Inprepubertal girls, the vaginal mucosa and perihymenal tissue will be moreatrophic and appear thin and red. The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. Your doctor checks your vulva, vagina, cervix . An Emphasis on the Bedside May Prevent Physician Burnout, Artificial Intelligence as a Partner in Patient Care, Physical Exam Can Sort Out - And Treat - Common Type of Vertigo, Bedside Medicine Training Benefits New and Established Physicians, Benefits of Bringing Doctors Back to the Bedside, UMKC Case Highlights the Importance of Thorough Physical Exam, Register Now for the 4th Annual Bedside Teaching Symposium, Using Art to Teach the Human Side of Medicine, Journal Dedicates Entire Issue to Enduring Value of Bedside Medicine, The Basics vs. Technology Debate: When They Work Together Everyone Wins, Abraham Verghese Shares Story of the EHRs Negative Consequences With Broader Audience, The 4th Annual Stanford 25 Bedside Teaching Symposium, Compassion, Patience and Bedside Manner Improve Patient Satisfaction, Technology Doesnt Have to Be the Antithesis of Humanity, AI to Complement Not Compete With Physicians Diagnostic Skills, The Tradition of Daily Bedside Clinical Care, How Technology May Lead to Greater Human Connection at the Bedside, As Prices Drop, Point-of-Care Ultrasound May Spark Evolution of Physical Exam, Empathy and the Physical Exam Remain Essential Components of Medicine, AI is Doing More to Help Keep Doctors at the Bedside, Medical Students Recognize Importance of Bedside Manner, Announcing the 2017 Stanford 25 Skills Symposium, Dr. Abraham Verghese Interviews Dr. Jerome Kassirer on New Book, conversation-about-bedside-medicine-gains-momentum. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection. Explain to the child that the most important part of the examinationis "looking," and that it is important for her to communicatewith you during the examination. Tailor your gynecologic examination to the presentingissue. McCann J, Wells R, Simon M, et al: Genital findings in prepubertalgirls selected for nonabuse: A descriptive study. The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years. If the child'ssymptoms of vulvovaginitis persist, you should review your diagnosis. Emans SJ, Goldstein DP: The gynecologic examination of the prepubertalchild withvulvovaginitis: Use of the knee-chest position. 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. Promoting the Culture of Bedside Medicine, Promoting Inclusive Care at the Patient Bedside, The Significance of Small Gestures at the Patient Bedside, Through a Patients Eyes: Physicians Reflect on Personal Illness, Physical Exams and Clinical Observations Related to Cardiovascular Health, Combat Physician Burnout with the Joy of Bedside Medicine, Physical Exam Techniques to Support and Promote Womens Health, How Physicians Go Above and Beyond to Promote Patient Healing, How to Address Monumental Patient Conversations, The Importance of Cultural Competence in Bedside Medicine, How Physicians Can Help Promote Early Detection of Prostate Cancer, 7th Time's a Charm: The 2022 Stanford 25 Skills Symposium, Communication Strategies to Help Physicians Lead Meaningful Patient Conversations, Bringing Tidings of Comfort and Joy to the Patient Bedside, Registration is Now Open for the 2021 Stanford Medicine 25 Skills Symposium, Medscape Article Highlights Need for Physical Exam Training & Assessment, The Resurgence of Bedside Teaching During the Pandemic, The Presence 5 for Racial Justice: Promoting Anti-Racism in Clinical Interactions, Dr. Vergheses Rules for the Bedside Exam, Bringing Human Connection to the Forefront of Medicine in a Technological Era, Five Practices to Strengthen the Physician-Patient Relationship, Telehealth Tips to Preserve Key Aspects of Patient Care, How AI Can Improve the EHR and Bedside Medicine, Bedside Teaching is a Powerful Learning Tool in the ICU, Thoughtful Implementation of Machine Learning Can Help Physicians Improve Patient Care, Register Now for the 5th Annual Stanford 25 Skills Symposium, Cultivating The Golden Minute at the Bedside, Four Physicians Describe the Synergy Between Technology and Bedside Medicine, Artificial Intelligence and the Gift of Physician Time, Compassion: A Powerful Tool for Improving Patient Outcomes, The Physical Exam Remains an Effective Tool for Physicians, Learning from the Bedside at the 5th Annual Stanford 25 Bedside Teaching Symposium, Physicians Can Protect the Human Connection in Medicine, A Diagnosis of Nelson's Syndrome and Why You Won't See it Anymore. ObstetGynecol 1971;37:462, 13. Many gynecologic conditions in children may be diagnosed by inspection . Cultures from the vagina indicate normal rectal flora or Escherichia coli. There is no significant geographic barrier between the vagina and anus. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. This can be accomplished without the insertion of any instruments. 0:31. An interesting illustration of the physical exam. Emphasize that the most important part of the examination is just looking and that there will be conversation during the entire process. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies. 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 . Intestinal parasitic invasion with pruritus. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. 12.3 ). Physiologically the childs vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adults. 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. 14 mins, 33 secs. Making the examination a positive experience, ifpossible, therefore is critical.2. 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. In this video, Veronica Alaniz, MD, provides guidelines for examining and understanding genital lacerations and hematomas resulting from vulvovaginal trauma, including blunt trauma or straddle injury and penetrating. The most common malignancy in preadolescent girls is a germ cell tumor. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. 5 Minute Pelvic Exam Video. Stanford 25 YouTube Channel Abdominal Examination Examination of the Spleen (Stanford Medicine 25) Percussion of the Spleen (Stanford Medicine 25) Diagnosis Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) with Carnett's Sign - Abdominal Pain Ankle Brachial Index Ankle Brachial Index (ABI) Test: How to Perform Venous Testing Bedside Ultrasound Endocrinologic issues, such asneonatal bleeding due to maternal estrogen withdrawal, precocious puberty,exogenous hormone preparations, and hypothyroidism should be ruled out.Dermatoses such as lichen sclerosus can cause bleeding. View a sample video. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. The pelvic exam doesn't change whether you are a virgin. Pokorny has described another method for collecting fluid from a childs vagina using a catheter within a catheter ( ). Ideally children should feel they are part of the examination rather than having an exam done to them.. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. 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. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. The atrophymay distort the anatomy of the labia and clitoris. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later). Philadelphia, PA, Raven-Lippincott, 1998, 2. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit. A nurse retrieves the patient from the office and takes her to an exam room. An older child should be asked whom she prefersto have in the room during the examination. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. 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. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. They schedule and bill separately for their services, and are not employees of the Hospital. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . In this video, Veronica Alaniz, MD, MPH, talks about the types of Mllerian agenesis associated with MRKH. When alone withan examiner, a child may disclose abuse or other concerns, and allowingher to be interviewed or examined alone may give her a greater sense ofcontrol and responsibility for her own health. Condylomata acuminataalso can cause bleeding but may be difficult to recognize, because in prepubertalchildren, they often do not have the typical cauliflower-like appearance.Rather, genital warts typically present as exophytic lesions or papuleswith small red punctations over the surface. Obstet Gynecol Clin NorthAm 1992;19:39, 10. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ). These exams may be done as part of a yearly check-up for teenagers or young adults, however, you may need them sooner or . Pediatrics 1980;65:758, 4. A carefulhistory is important; a history of hormonal medications or signs of precociouspuberty may suggest the cause of the bleeding. For non-life-threatening medical needs when your pediatrician is unavailable, visit one of our urgent care locations. For a small childwho is fearful of the exam, it may be best to have the mother sit on thetable in a semireclined position (feet in or out of stirrups) with the child'slegs straddling her thighs (Figure 3).