Atlas Of Pediatric And Adolescent Gynecology

[Timothee Cazares]

Chapter 1 An Introduction to Pediatric and Adolescent Gynecology Practice

Adam Balen , Lesley Breech , Sarah M. Creighton , and Lih-Mei Liao

Introduction

Pediatric and adolescent gynecology (PAG) is now a recognized subspecialty that encompasses a spectrum of conditions affecting gynecological health from birth through to adulthood. Serious and life-threatening diseases may be relatively rare, but problems such as atypical development of the genital tract are highly complex. The development of specialist centers is important for appropriate and timely referral. For conditions that affect fertility, sexuality, health, and well-being, multidisciplinary care is the gold standard. In addition, for conditions requiring lifelong care, the development of methodical transition from pediatric to adolescent and adult services is necessary. Collaborative clinical networks not only promote quality and consistency in care delivery, they also improve professional learning and raise the standard of research.

The subspecialized area of pediatric and adolescent gynecology is an integral part of gynecologic care. In most instances it is the first gynecologic encounter that a female will experience. It is of the utmost importance that this be a positive experience in an effort to set the stage for all future gynecologic care. This chapter addresses the history and physical examination process and basic tenets of the more common gynecologic problems identified in the pediatric patient. The importance of an adequate examination cannot be overemphasized. The clinician should remain cognizant of both the psychological effects and the physical problem at hand. For instance, with precocious puberty, an understanding of the psychological effects the patient and parents experience is intrinsic to the evaluation process. The problem may prove to be life threatening, such as congenital adrenal hyperplasia, and the importance of the obstetrician/gynecologist identifying this and providing appropriate management is paramount.

For the vast majority of patients, evaluation can be accomplished without sedation, except for the rare circumstance when it is needed for an adequate evaluation. In general, parents and patients should be reassured that an "internal" exam is frequently not required. However, if the child requires some degree of sedation, pediatric conscious sedation may be used when trained personnel are available or with an examination under anesthesia. As the pediatric patient approaches puberty, the option of having an examination without the parent present should be offered. The physical presence of an assistant (i.e., medical assistant or nurse) must be emphasized.

The breast examination in the neonate frequently reveals evidence of maternal estrogen effect in that palpable breast tissue is noted. In addition, a milky discharge can be expressed. This discharge usually abates within several days postpartum. Massaging of the breast tissue is discouraged because it can lead to abscess formation, especially with staphylococcal organisms.

Thelarche on average begins at around 9 years of age in white girls and slightly earlier in African American girls. The median age of onset is 9.8 years.1 Asymmetric breast development is not uncommon, especially in the early stages of breast formation (Fig. 1). Tanner staging of breasts is encouraged (Fig. 2).

Inspection for any skin lesions is the initial approach to evaluation of the abdomen. Assessment of bowel sounds is followed by palpation for masses. The ovaries in the prepubertal child are located at the pelvic brim; thus, enlargement of an adnexum presents as an intra-abdominal mass.2 Ultrasonography is a useful complement to the examination process to identify reproductive tract abnormalities.

Forceful manipulation of the labia is discouraged, and any pain or discomfort merits re-evaluation of the technique being used for evaluation. The hymenal diameter, configuration, and symmetry are important. Documentation of the size and configuration of the clitoris and any urethral abnormalities should occur.

Recurrent vaginal discharge and bleeding are the most common historical complaints voiced by the parent or guardian, but a clinician must remain open to an extensive differential. A wet preparation is useful in assessing vaginal discharge.

A speculum is rarely if ever necessary in assessing the pediatric patient. If a foreign body is suspected, irrigation of the vaginal area with body-temperature saline frequently lavages out the foreign body. The most common foreign body is rolled toilet paper, and this is easily amenable to irrigation (Fig. 4).

Special aspects of the prepubertal female's examination Inform the child that the genital examination is sanctioned.

Involve the child by giving them a hand-held mirror and magnification device.

Be open to different types of positioning for the exam. Consider the child with the feet in the stirrups, with the feet on the examiner's lap, or sitting on the parent's lap, with the child's legs droped over the parent's thighs.

Attempt both the supine and knee-chest positions.

Be knowledgeable about the various visualization methods to see the vestibule.

There is only a limited need to use instruments.

At what age should a virginal adolescent have her first pelvic examination? This topic has been addressed by many authorities in the field. Current recommendation is to perform a speculuum exam with Pap smear 3 years after coitarche or age 21 for a virginal patient. Evaluations for sexually transmitted infections (STI), however should be routine in any sexually active young woman regardless of coitarche. Options for STI testing may include urine, vaginal or cervical specimens. In a sexually active patient, if a Pap smear is not indicated, the clinician will decide whether visualization of the external genitalia, vagina or cervix are indicated. Bear in mind that a patient may not be "sexually active" but may have been the victim of childhood sexual abuse. In these patients, a Pap smear may be warranted if the event was 3 years or greater. Counseling sessions with adolescent patients may allow the clinician to address preventive health aspects, sexuality and establish rapport in a nonthreatening manner.

Most of the secondary sex characteristics that develop during puberty are due to the effects of ovarian estrogen (Fig. 8). The mons pubis becomes full and midline abdominal hair forms. The labia majora and the labia minora thicken, becoming softer and more rounded. The clitoris enlarges slightly, and the urethra becomes more prominent. The hymen also thickens as its central opening enlarges. The vaginal mucosa also thickens and softens. Vaginal secretions increase, making the mucosa moist. It also takes on a pink appearance, and pH levels decrease. Perineal and pelvic tissues become more elastic and the ovaries move into the pelvis. In the months preceding menarche, increasing estrogen levels stimulate physiologic leukorrhea, a white discharge containing mature epithelial cells, which often becomes a concern to patients and their parents. They should be reassured that this is a normal part of development and does not signify infection.

As androgens increase, facial acne and body odor develop. The first physical sign of puberty is breast development, followed by pubic hair development, a maximal rate of linear growth, and then menarche (see Fig. 2).

Physical examination shows a thin lucent vertical line within the central area of the labia. Inquiry should be made about any urinary tract signs and symptoms because urinary tract infections can be associated with labial adhesions. The differential diagnosis includes lichen sclerosus, child sexual abuse, and less common causes, such as childhood cicatricial pemphigoid.

On physical examination, gentle traction should be applied to the labia, but this should be accomplished in a manner that is not traumatic to the child (Fig. 9). Any discomfort should lead to cessation of efforts to separate the labia.

Vulvitis is defined as inflammation of the labia majora, labia minora, clitoris, and introitus; vaginitis is inflammation of the vaginal mucosa. Pediatric vulvovaginitis, involving the vulvar and vaginal tissues, is a very common diagnosis made by the primary care provider, who often refers the patient to a specialist when initial treatment is unsuccessful. Thus, it is important to understand the pathophysiology, know the various etiologies as they relate to the clinical presentation, and establish a methodologic approach to the evaluation of vulvovaginitis.

Pediatric vulvovaginitis typically presents as vaginal itching with associated excoriation, vaginal discharge that may be malodorous, generalized vulvar, vaginal, or perianal discomfort, or pain or dysuria.22, 23 Parents may also report staining, odor, or color on the child's underwear. The history is very important in narrowing the etiology and directing treatment. Parents should be asked about the onset, timing, and duration of symptoms, previous home therapies and medications used (including prescription and over-the-counter oral and topical therapies), and prior laboratory tests or evaluative procedures. The possibility of sexual abuse should be assessed, along with a detailed review of the developmental, behavioral, and psychosocial history. The child's past medical or surgical history should be evaluated for other skin infections, dermatoses, or allergies. Family history of chronic illness, allergies, and contact sensitivities should also be assessed. A list of possible acute or chronic irritant exposures such as bubble baths, cleaning agents and techniques (e.g. use of washcloths), lotions, powders, fabric softeners, and hair products that may have leaked into the bathwater should be investigated.24

Based on the history, physical examination, and laboratory evaluation, the causes of pediatric vulvovaginitis are most easily classified into noninfectious (or nonspecific) and infectious (or specific) groups, with the latter subclassified into nonsexually and sexually transmitted infections19, 20 (Table 3).

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