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The history should include the quality of the discharge(color, odor, presence of blood), hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions. 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Children usually are asymptomatic,but they may present with secondary infection. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. Abraham Verghese Asks: Why Are We Doing This Teaching? Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques. 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. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. 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. Inspect the child's breasts and palpate themfor signs of puberty. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. You may need a pelvic exam sooner if you are experiencing problems with your period or have other symptoms, including: Pain in your lower abdomen or pelvic area. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. 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. Adolescent Gynecology Exam - Children's One method is to use the knee-chest position (see Fig. Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. In addition to your doctor, there will be a nurse or an assistant in the room during . An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. Many young childrens primary contact with providers involves immunizations; children should be assured that this visit does not involve any shots. It is also helpful to assure the adult accompanying the child that speculums are not part of the examination. The relative size ratio of cervix to uterus is 2:1 in a child. If you need to visualize the vagina and cervix and the child is olderthan 2 years, the knee-chest position may be useful. The pediatric gynecologic visit may be unique to both the child and the parent. The film opens with a woman sitting in an office of a physician. This is an important step toward reinforcing the child's sense ofcontrol over the examination. This includes feeling a girl's uterus and ovaries to be sure everything's normal. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. Options covered in the video include: the levonorgestrel IUD, norethindrone acetate, the subdermal implant, combined hormonal contraception and depot medroxyprogesterone acetate. Your First Pelvic Exam - Texas Children's Hospital However, if the reason for the visit is urgent, such assignificant vaginal bleeding, and a child is uncooperative, you may haveto perform the exam under anesthesia. The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. Gynecologic examination of the prepubertal girl - Contemporary Pediatrics Pokorny SF. From AccessMedicine. Pediatric and adolescent gynecology: Gynecologic Examination These procedures are usually performed under anesthesia. This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. 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. A patient presents with foot pain and these chronic findings? Emans SJ, Goldstein DP: The gynecologic examination of the prepubertalchild withvulvovaginitis: Use of the knee-chest position. She also discusses the preferred diagnostic modality and when to consider surgery. What questions should PNPs consider related to womens health? The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. In this age of reliable access to ultrasonography, the internal genital examination to evaluate the uterus and ovaries can be performed with the assistance of sonography , often sparing the child from a rectal or pelvic examination. Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.These conditions usually resolve within ten to fourteen days. One excellent technique is for the physician to sit, not stand, during the initial encounter. 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. Adolescents often come for examinations with the preconceived idea that it will be very painful. 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. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. An ectopic ureter emptying into the vagina may only intermittently release a small amount of urine; thus this rare congenital anomaly should be considered in the differential diagnosis in young children. How To do a Pediatric Physical Exam - YouTube If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.12 Another method ofobtaining samples, used by Pokorny and Stormer, consists of a catheter-in-a-cathetertechnique.13 The proximal end of an IV butterfly catheter isinserted into the distal end of a size 12 bladder catheter, and a 1-mL tuberculinsyringe with 0.5 to 1.0 mL of sterile saline is attached to the hub of thebutterfly tubing. In severe cases, clobetasol (Temovate)may be useful, applied twice daily for two weeks and then gradually taperedover the next several weeks, but this requires expertise and careful supervisionwith frequent follow-up. Learn Peds Genitourinary 04 Genital Exam Intro from UBC Learn Pediatrics on Vimeo. 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. Your patient gets this rash, whats the diagnosis? Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. Online Teaching Videos - Department of Urology Genital Exam | Learn Pediatrics - University of British Columbia In addition, she reviews the potential for ovarian torsion, including signs and symptoms, evaluation and management. Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. A childs reaction will depend on her age, emotional maturity, and previous experience with health care providers. Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. Affiliated with the University of Colorado School of Medicine. Managing vulvovaginitis. 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. Pediatrics 1990;86:428, 9. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. 0:31. It is important to give the child a sense that she will be in control of the examination process. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal abuse. An Initiative of the Program for Bedside Medicine, Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. There are many narrow-diameter endoscopes that will suffice, including the Kelly air cystoscope, contact hysteroscopes, pediatric cystoscopes, small-diameter laparoscopes, plastic vaginoscopes, handheld disposable hysteroscopes (e.g., Endosee Handheld Hysteroscopy System, CooperSurgical Inc., Trumbull, CT), and special smaller, narrower speculums designed by Huffman and Pederson. Young children may be examined in the frog leg position, and children as young as 2 to 3 years of age may be examined in the lithotomy position with use of stirrups, although this is generally used for girls aged 4 to 5 years and older. Thus the office visit and the gynecologic physical examination are performed differently in a prepubertal child compared with an adolescent girl or a mature reproductive-age woman. Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis.The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis. Am J Obstet Gynecol 1987;156:581. Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin.If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits. One way to describe genital area and breasts is to call them private areas and define this as meaning areas that are covered by a bathing suit. The outer catheter serves as an insulator, and the inner catheter is used to instill a small amount of saline and aspirate into the vaginal fluid. Examination of the Female Genitourinary System. 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. First gynecological exam debunked: What parents need to know 12.1 ). Teens don't usually get pelvic exams. With puberty , the prepubertal vagina becomes acidic under the influence of bacilli dependent on a glycogenated estrogen-dependent vagina. Clin Obstet Gynecol 1987;30:643, 7. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. Will the Healing Touch Go Out the Door With the Stethoscope? 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. 1 A vaginal self-exam is not the same as a vulvar examination. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. When is it best to reassure, and when is it necessary to evaluate? The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . Topics for the pediatric nurse practitioner to be aware of. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. The child should be instructed to void with her knees spread wide apart (even while facing the toilet to improve urine draining) and taught to wipe from front to back after defecation. Observation alone is appropriate for small adhesions. An interesting illustration of the physical exam. Help me decide. (From Emans SJ. It may appear as a brightly erythematous, annular,periurethral mass (see figure "A"). The Stanford Medicine 25 program for bedside medicine at the Stanford School of Medicine aims to promote the culture of bedside medicine to make current and . The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle. The vagina of a child is 4 to 5 cm long and has a neutral pH. Stanford Medicine 25 Launches New Website, Medical Errors and Adverse Events from a Missed or Inadequate Physical Exam, Announcing the Stanford 25 Skills Symposium, Thyroid Nodule Overview - The Thyroid Exam. Pediatric Gynecology Videos | Children's Hospital Colorado If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. From AccessMedicine. Nonspecific vulvovaginitis. In this video, Chief of Pediatric and Adolescent Gynecology, Tricia Huguelet, MD, discusses the epidemiology, clinical features and management of ovarian cysts that may occur during the fetal and neonatal periods, and on through adolescence. Female Urethral Catheterization Male Urethral Catheterization Female Genital Exam Male Genital Exam Don't forget to watch the Why Urology video! The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue. Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. Usually, it is related to menstrual cramps, though many other conditions can cause it, including endometriosis, a painful disease in which uterine tissue grows outside the uterus. 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. Finally, trauma, either accidental or due to sexualabuse, may cause significant bleeding. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 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). The extent of labial adhesions and associated symptoms are variable (seefigure "B"). Diagnose this skin lesion with newest Stanford 25 video and topic. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. The child is told to have her abdomen sag into the table. An infant may be examined on her mothers lap. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. Of these survivors, 75% will experience at least one adverse effect, termed late effects of cancer therapy. 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The major factor in childhood vulvovaginitis is poor perineal hygiene. Management is dictatedby the diagnosis: antibiotics and hygiene measures for infectious vulvovaginitis,surgical repair of trauma if necessary, biopsy of polyps or suspected tumors,removal of foreign bodies, further investigation for sexual abuse if itis suspected by exam or history or if condylomata are found, sitz bathsand estrogen cream for urethral prolapse, and further investigationinto the etiology of precocious puberty. Emphasize setting the stage to make the examination a positive experience for your young patient. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. Adult pinworms maybe visible at night. Palpate the abdomen for masses and the inguinal areasfor a hernia or gonad. 11 mins, 28 secs. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina. Historically, these masses were surgically removed, often involving removal of the entire ovary. HPV is also verticallytransmitted and lesions may appear in the first few years of life. 5 Minute Pelvic Exam Video | The Brookside Associates Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. For non-life-threatening medical needs when your pediatrician is unavailable, visit one of our urgent care locations. After your examination is complete, congratulate the child for her cooperationand bravery. Children are not skilled historians and will often ramble, introducing many unrelated facts. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation (discomfort/pruritus) or discharge ( Table 12.1 ) ( ). Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. The atrophymay distort the anatomy of the labia and clitoris. The typical location is the anterior vaginalwall near the cervix. Specific vulvovaginitis. The most common gynecologic condition of children is vulvovaginitis . Many gynecologic conditions in children can be diagnosed by inspection alone. The severity of vulvovaginitis symptoms varies widely from child to child. Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). 1958 MEDICAL TRAINING FILM ROUTINE PELVIC EXAMINATION - Archive When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. Childrens clothing is often tight fitting and nonabsorbent, which keeps the vulvar skin irritated, warm, moist, and at risk for vulvovaginitis. . Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. Often reassurance and sometimes delay until another day are the best approaches. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). When this intervention fails, there should be greater suspicion of bacterial colonization; in this case a reasonable approach is the use of broad-spectrum oral antibiotics such as amoxicillin or trimethoprim/sulfamethoxazole given for 10 to 14 days. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided.