Pediatric GYN issues

Pediatric GYN issues

Overview • Normal Development • Precocious puberty • Vulvovaginitis • Approach to Gyn exam • FB irrigation

Normal Puberty • Puberty begins 8-14 years of age • Begins with breast development (thelarche) • Followed by appearance of pubic hair (pubarche) • Menarche occurs about 2 years after breast

Tanner Stages

Sex Hormone Review

Precocious Puberty • Secondary sexual development before age 8 • Types • Gonadotropin dependent PP (central) • Early Maturation of the hypothalamic-pituitary-gonadotropin axis • Development of breast and pubic hair • Isosexual • Gonadotropin Independent PP (peripheral • Excess secretion of sex hormones (estrogen and androgens) from gonads or adrenals • Can by Isosexual or Contrasexual • Incomplete PP • Premature Thelarche • Usually normal variant, should be monitored to see if progresses to complete PP

Precocious Puberty • Evaluation • With decreasing age at presentation, extent of evaluation should increase • Is puberty progressing in normal sequence but earlier? • Are secondary characteristics virilizing or feminizing? • History—CNS trauma, seizures, HA, abd pain, exposure to estrogens/androgens; age parents/siblings went through puberty • Exam • Height, weight, height velocity (cm/yr) • Tanner Staging • Neuro Exam • Bone Age

Precocious Puberty • Further Evaluation • Basal LH • If level >5 then GDPP; if low or intermediate, should be measured after GnRH stimulation • In GIPP, FSH and LH levels are low and will not increase with GnRH stimulation • If GDPP then need MRI brain • If GIPP then more testing—testosterone, estradiol, LH, FSH, afternoon cortisol, DHEA, DHEAS, 17-hydroxyprogesterone, abdominal u/s • SEND TO ENDOCRINOLOGY

Vulvovaginitis • Symptoms • Vaginal Discharge, Erythema, Soreness, Pruritis, Dysuria, bleeding • Differential Diagnosis • Infection • Congenital • Trauma • Dermatologic • Urinary/Bowel • Other (Idiopathic, foregin body, polyp)

Infections causing Vulvovaginitis • Pinworms • Usually occurs at night, often assoc with anal itching. Remember scotch tape test • Respiratory Flora—Group A strep, S. aureus, H. Flu, S. pneumonia—get culture if purulent/persistent • Enteric Flora—Shigella, Yersenia • Candida-colonization in 3-4%, common in children with recent antibiotics, immunosuppressd, diapers OFTEN OVERDIAGNOSED

Infections causing vulvovaginitis • STDs • Gonorrhea—usually presents with green/mucoid discharge—culture discharge • Chlamydia—transmission can occur at birth, after 12 mo--sexual abuse likely • Trichomonas—can occur in newborns, outside newborn period—sexual abuse likely • CondylomaAcuminata—if <2-3 likely maternal-child transmission; indirect transmission via fomites is possible; biopsy can confirm diagnosis, HPV DNA typing can help with surveillance plan

Infections causing Vulvovaginitis • Systemic Illness • Measles, chickenpox, scarlet fever, Mononucleosis, Crohn’s, Kawasaki • Symptoms include vesicles, discharge, ulcers, fistula and inflammation

Vulvar Ulcers • Apthous ulcers typically seen 10-15 y/o—1 or more ulcer with purulent base, raised edges, often systemic symptoms and very painful

Congenital • Estrogen from mom at birth can cause discharge and bleeding—normal, no aggressive wiping, first few days after birth • Hemangiomas—usually involute between 2-5 years old; if very large and have bleeding manage with vascular surgeon • Labial Adhesions—can result from poor hygiene • Can be asymptomatic, may cause pulling sensation diffiuclty urinating, recurrent UTI and vaginal infections • Treatment is estrogen cream BID until resolves

Trauma • Can cause significant bleeding • History must correlate with exam findings • May need sutures

Trauma • Assess ability to urinate • Large hematomas can develop but rarely need surgical evacuation • Treat with ice, foley if needed and pain medications

Urinary Tract • R/o UTI • Ectopic ureter • Chronic vulvar irritation and wetness • Can see on u/s, may need MRI, VCUG, CT • Treatment is surgical • Urethral prolapse • Distal end can prolapse • Bleeding, dysuria, difficulty urinating • Responds to tx with estrogen

Dermatologic • Lichen Sclerosis • Itching, discomfort, discharge, bleeding • Whitened onion-like skin circumscribing vulvar and perianal areas • May see punctate hemorrhages • Biopsy rarely needed • Treat with high potency corticosteroids for 2 weeks then reasses, tx usually 6-12 wks, need to taper • Important to treat to prevent long-term sexual dysfunction

Dermatologic • Tissue is hypoestrogenic and therefore more susceptible to local irritation • Ask about bubble baths, soaps, shampoos, tight jeans, leotards • Ask about masturbatory activity • Ask about hygiene—self toileting, frequency of bathing, how long they stay in bath, swimming

Dermatologic • Wear breathable clothing • No leotards, tights, leggings (jeggings) • Wear nightgown, skirts, cotton underwear—no fabric softners for underwear • Daily bath—soak in clean water 10-15 min and use soap right before taking child out, minimal soap on genital area, dry well—hair dryer on cool setting • NO BUBBLE BATHS • Wiping front to back (sit backward on toilet) younger than 5 years old need assistance • Don’t sit in wet swimming suits • Apply cool compress, consider wet wipes instead of toilet paper

Pediatric GYN issues