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I. INTRODUCTION
There are a number of problem areas in gynecology in which the diagnosis and treatment of the pediatric patient differs significantly from similar care for the adult
H. PREPUBERTAL VAGINITIS
A. Symptoms
B. Predisposing factors
1. Atrophic vaginal mucosa
2. High vaginal pH
3. Poor hygiene
4. Closed damp area
C. Differential diagnosis
1. Primary vaginal infection
a. Bacteria: most common mixed bowl flora
b. Monilia: rare
(1) Chronic antibiotics
(2) Immunosuppression
(3) Long-term corticosteroids
c. Trichomonas may suggest sexual abuse
d. Gonorrhea and chlamydia suggest sexual abuse
e. Pinworm associated with gastrointestinal (GI) infestation
2. Foreign body: surprisingly common
a. May be nonpalpable and radiolucent
b. Does not represent sexual abuse in vast majority of cases Advanced in Pediatric Gynecology, sexually transmitted diseases, STD
3. Fistula: rare
a. Rectovaginal Advanced in Pediatric Gynecology, sexually transmitted diseases, STD
b. Vesicovaginal Advanced in Pediatric Gynecology, sexually transmitted diseases, STD
4. Tumor
a. Vulvar: condyloma
b. Vaginal
(1) Condyloma
(2) Clear cell carcinoma (Ca) (3) Sarcoma botryoides c. Cervical: pediatric gynecology, sexually transmitted diseases, STD mesonephric Ca d. Uterine: none
D. Clinical approach
1. Careful external exam a. Normal anatomy? b. Odor? pediatric gynecology, sexually transmitted diseases, STD
c. Inflammation? d. Dermatologic or rectal problem? pediatric gynecology, sexually transmitted diseases, STD
2. Internal exam
a. Positions
(1) Frog leg
(2) Knee-chest
O) Simm's
b. Instruments
(1) Huffman vaginoscope
(2) Nasal speculum
(3) Small glass test tube (4) McCarthy endoscope (5) Robertson urethroscope
c. Lab tests
(1) NaCI and KOH wet preps
(2) Cultures for sexually transmitted diseases
(3) Cytology
E. Diagnosis
F. Treatment
1. Mode
a. Systemic: poor choice
b. Local
(1) External: symptomatic
(2) Internal: method of choice
2. Agents
3. Technique: creams delivered inside vagina with suitable applicator
HI. ABNORMAL VAGINAL BLEEDING
A. Prepubertal
1. Medical emergency: immediate investigation indicated
2. Differential diagnosis
a. Vaginitis: most common b. Foreign body c. Trauma d. Urinary tract/GI tract e. Hormone activity
(1) Endogenous: ovarian tumor
(2) Exogenous: household medication
f. Tumor
(1) Vulvovaginal
(a) Benign: most common
i. Condyloma
ii. Granuloma
iii. Ulcer
(b) Malignant
i. Clear cell Ca
ii. Invading local tumor
iii. Sarcoma botryoides
iv. Mesonephric duct adenoma
(2) Cervical: none
(3) Uterine: none
(4) Ovarian: any
B. Menarchal (adolescent dysfunctiona) bleeding
1. Timely investigation
2. Ranges of normaicy
a. Menarche: 9-17 years
b. Menstrual cycle length
(1) Lasts 21-45 clays
(2) Suggests ovulation
3. Etiology: immature feedback systems
a. Anovulation with breakthrough
b. Oligo--ovulation
4. Investigation
a. Full history and examination
b. Blood count
c. Menstrual calendar
d. Basal body temperature graph
e. Gonadotropins and/or medical: work-up only with specific indication
f. Dilation and curettage (D&C) rarely indicated
a. Tincture of time
b. Hematinlcs
c. Progestins
d. Oral contraceptives: only to allow recovery of blood count
e. Estrogens: only to stop an acute bleed
f. D&C: not useful for what is essentially a hormonal problem
g. Reassm-ance
1. Low frustration tolerance
2. Denial of pregnancy risk
3. Lack of acceptance or unreal perception of contraception risks
4. Fear of discovery
5. Moral statement of contraception 6. Episodic nature of activity 7. High fertility
C. The options: same options as for adults but different risk/benefit ratios
D. The risks
1.Highest risk of death associated with absence of method
2.Little difference between methods
3.All small compared to risk of death in auto (1/30,000)
E. Requirements of success
1.Education
3.Enthusiasm
4.Reevaluation
A. Asymmetry
1. Very common
2. Usually self-limited
3. Occasionally iatrogenlc
a. Surgery
b. Radiation
4. Definitive treatment should await full maturity
1.Soft masses common and usually transient
a. Cysts
b. Stimulated glandular tissue
2.Hard masses require removal only when large
a. Never malignant
b. Small defect in a growing breast becomes large defect c. Fibroadenoma: most common
C. Juvenile mammary hypertrophy
1.Unilateral or bilateral
2.May regress spontaneously
3.Diffuse change in entire breast
VI. SEXUAL ABUSE EVALUATION
A. Objective evidence of old/new trauma
1. Scars
2. Posterior vaginal opening shape
4. Condylomata and other infectious sexually transmitted diseases
B. Be careful not to overread
C. Absence of findings does not mean absence of sexual abuse
D. Rectal injury
E. Photo or video record for forensic use or consultation