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Pediatric Gynecology

Pediatric Gynecology. By: Ma. Katherine Lipana , MD Associate Professior Reproductive Endocrinology and Infertility Sepcialist Department of Obstetrics and Gynecology. Evaluation of Pediatric P atient. Age dependent Problem oriented

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Pediatric Gynecology

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  1. Pediatric Gynecology By: Ma. Katherine Lipana, MD Associate Professior Reproductive Endocrinology and Infertility Sepcialist Department of Obstetrics and Gynecology

  2. Evaluation of Pediatric Patient • Age dependent • Problem oriented • Gaining the child’s confidence and establishing rapportis important Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  3. Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 most frequent gynecologic disease of children Vulvitis – primary presenting problem

  4. Components of a Complete Pediatric Examination Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • history • inspection with visualization of the vulva, vagina, and cervix • Frog leg position • Dorsal lithotomy – generally for 4-5 years old • Knee-chest position • If indicated, a rectal examination • genital tract bleeding • pelvic pain • suspicion of a foreign body • pelvic mass

  5. Components of a Complete Pediatric Examination Ratio of cervix to uterus: 2 to 1 in a (in contrast to the opposite ratio in an adult) Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • history • inspection with visualization of the vulva, vagina, and cervix • Frog leg position • Dorsal lithotomy – generally for 4-5 years old • Knee-chest position • If indicated, a rectal examination • genital tract bleeding • pelvic pain • suspicion of a foreign body • pelvic mass

  6. Normal Findings Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  7. Hymen of Pre-Pubertal Female • often crescent-shaped, may be annular or ring-like in configuration • Congenital absence of the hymen – none is reported • Bump - a mounding of hymeneal tissue; a normal variant - often attached to longitudinal ridges within the vagina Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  8. Hymen of Pre-Pubertal Female • Newborns • estrogenized, resulting in a thick elastic redundancy • Older girls • unestrogenized, thin non-elastic hymens Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  9. Vagina of Pre-Pubertal Female Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • Epithelium appears redder and thinner • Length - 4 to 6 cm long • Secretions - have a neutral or slightly alkaline pH • Indications for vaginoscopy: • Recurrent vulvovaginitis • Persistent bleeding • Suspicion of a foreign body or neoplasm • Congenital anomalies

  10. PROBLEMS IN PREPUBERTAL CHILDREN Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  11. VULVOVAGINITIS Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 most common gynecologic problem in the prepubertal female 80% to 90% of outpatient visits of children

  12. Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  13. Vaginal Secretions Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  14. Vaginal Secretions Breast budding – a reliable sign that the vaginal pH is shifting to an acidic environment. Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  15. Pathophysiology of Vulvovaginitisin Children Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  16. Reasons for Predisposition of Child to Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 Child’s vulva and vagina are exposed to bacterial contamination from the rectum more frequently than are the adult’s. Child lacks the labial fat pads and pubic hair of the adultthat when a child squats, the lower one third of the vagina is unprotected and open. There is no significant geographic barrier between the vagina and anus. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection.

  17. Reasons for Predisposition of Child to Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 The labia minora are thin and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection.

  18. Reasons for Predisposition of Child to Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 The normal vagina of a pre-pubertal child is colonized by different species of bacteria.

  19. Etiologic Factors of PremenarchealVulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  20. Etiologic Factors of PremenarchealVulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  21. Etiologic Factors of PremenarchealVulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  22. Etiologic Factors of PremenarchealVulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  23. Differential diagnosis of persistent or recurrent vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 foreign body primary vulvar skin disease ectopic ureter child abuse pinworms irritant/nonspecific vulvitis

  24. Treatment of Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • Improvement of local perinealhygiene • vulvar skin should be kept clean, dry, and cool, and irritants should be avoided • for acute weeping lesions - wet compresses of Burrow’s solution • child should be instructed to void with her knees spread wide apart and taught to wipe from front to back after defecation • loose-fitting cotton undergarments should be worn

  25. Treatment of Vulvovaginitis Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 Irritants should be avoided Use of bland creams (zinc oxide or cod liver oil creams) and low potency steroid creams Antibiotics – as necessary

  26. LABIAL ADHESIONS • labia minora have adhered or agglutinated together at the midline • often partial and only involve the upper or lower aspects of the labia • common in preschool children(20% will have some degree of labial adhesions on routine examination) Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  27. LABIAL ADHESIONS • most common in young girls between 2 and 6 years of age • estrogen reaches a nadir during this time, predisposing the nonestrogenized labia to denudation Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  28. LABIAL ADHESIONS • Symptoms: • voiding difficulties • recurrent vulvovaginitis, • discomfort • bleeding • No treatment is absolutely necessary unless the child is symptomatic. Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  29. Treatment of Labial Adhesions Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • Topical estrogen cream - dabbed onto the labia 2x/day at the site of fusion • Results in spontaneous separationinapproximately 2 to 8 weeks

  30. PHYSIOLOGIC DISCHARGE OF PUBERTY Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 discharge is typically described as having a gray-white coloration, but may appear slightly yellow but is not purulent represents desquamation of the vaginal epithelium

  31. PHYSIOLOGIC DISCHARGE OF PUBERTY Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  32. Treatment of Physiologic Discharge of Puberty Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 Reassurance Sitz bath Frequent changing of underwear

  33. URETHRAL PROLAPSE Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 Prepubertal bleeding - most common presentation Preceeded by sharp increase in abdominal pressure, such as coughing

  34. URETHRAL PROLAPSE • On PE: the distal aspect of urethral mucosa may be pro- lapsed along the entire 360 degrees of the urethra • Trearment • Often unnecessary • Estrogen cream Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  35. LICHEN SCLEROSUS Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 most commonly seen in postmenopausal women and prepubertal children cause is unclear, although there is some evidence that it may be associated with autoimmune phenomena Histologically: thinning of the vulvar epithelium with loss of the rete pegs.

  36. LICHEN SCLEROSUS • Appears as whitish plaque in an hourglass or figure of 8 formation involving the genital and perianal area and rarely involve the whole labia majora • Symptoms: • pruritus and vulvar discomfort – most common • prepubertal bleeding, constipation, and dysuria • Rarely is biopsy warranted • Treatment: Topical Clobetasol Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  37. DIFFERENTIALS FOR VAGINAL BLEEDING WITHOUT ANY BREAST DEVELOPMENT Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  38. FOREIGN BODIES Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 4% of pediatric gynecologic outpatient visits found in girls between 3 and 9 years of age most common: small wads of toilet paper classic symptom: foul, bloody vaginal discharge; can also be purulent discharge

  39. McCUNE ALBRIGHT SYNDROME • are somatic mutation that oc- curs during embryogenesis in neural crest cells • mutation affects G protein receptors • classic triad: cafe-au-lait spots, abnormal bone lesions, and precocious puberty • Rarely presents as vaginal bleeding Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  40. SARCOMA BOTYROIDES OF THE VAGINA • Rare • Before age 6 Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  41. VULVAR TRAUMA Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • Straddle injury - one of the most common causes of genital trauma in a child • results in unilateral and superficial injury and very rarely involves the hymen • General anesthesia is usually required for diagnosis and treatment of extensive lacerations

  42. VULVAR HEMATOMA • lack of the mature reproductive woman’s fat pad in the vulvar area predisposes a young child to bleeding from trauma • Surgical exploration is rarely warranted Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  43. SEXUAL ABUSE Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 General examination – including skin bruises and lacerations If the incident happened within 72 hours – all clothing and undergarments are collected Motile sperms – can only be seen w/in 8 hours (Non-motile sperms - 24 hours) due to absence of cervical mucus in pre-pubertal females Hymenal lacerations that extend to the junction of the hymen between 3 o’clock and 9 o’clock is indicative of abuse

  44. GENITAL WARTS • If noted prior to 3 years of age – most likely due to maternal fetal transmission • If the child is 3 years and above – most likely due to sexual abuse Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012

  45. ADNEXAL MASSES IN ADOLESCENTS Lentz et al, Comprehensive Gynecology 6th edition, Elsevier 2012 • Most ovarian masses in this age group are functional ovarian cysts. • Matrurecystic teratoma – most common benign ovarian tumor • Malignancies are most often of germ cell origin, but can also be sex cord tumors • Dysgerminoma - most common malignant germ cell tumor • Most common clinical presentation – lower abdominal pain • Most often unilateral

  46. Thank you!

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