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Janice Bernal-Lacuna,MD, FPOGS, FPSREI

Objectives

Infancy to Puberty
Vulvovaginitis
Adhesive vulvitis
Accidental genital trauma
Ovarian tumors
Precocious puberty

Gynecologic examination
of a child
Slow pace, gentleness and patience
Ambiance
Rapport
Reassurance
Parental presence

Components
History
Abdominal exam
Inspection with visualization of the

vagina and cervix


Appropriate cultures of the vagina
Rectal exam if with bleeding or
abdominal or pelvic pain

PE
Hymen crescentic, redundant,

imperforate
Vaginal epithelium red, thin
Vaginal canal 4-6cm long
Secretions neutral pH

Inspection and
visualization
Younger child can be examined on

her mothers lap


For older child, knee chest position or
supine with knees apart
Cultures using saline saturated
cotton tip applicator, plastic
medicine dropper
Narrow endoscopes

Rectal exam
May be omitted
Non palpable uterus
2:1 ratio, cervix:uterus
Indications
Bleeding
Pelvic pain
Foreign body
Pelvic mass

Vulvovaginitis
Most common gyne problem in

premenarcheal
80% to 90% of opd visits
Introital irritation
Discharge

75% non-specific etiology (GI flora)


N. gonorrhea, T. vaginalis, Chlamydia,
HSV, Shigella
Mycotic or bacterial vaginosis

Vulvovaginitis vulvar
irritation
Topical allergy
Skin or respiratory infection
Foreign body
UTI
Vulvar skin disease
Ectopic ureter
Pinworm infection
Sexual abuse

Susceptibility to
vulvovaginitis
Lack of labial fat pads and pubic hair
Epithelium lacks estrogen
pH is neutral
Vagina lacks glycogen, lactobacilli

and anitbodies
Poor perineal hygiene

Treatment
Hygiene clean, dry and cool
Weeping lesions hot sitz bath

containing 2 tbsp of baking soda


Wipe front to back
Loose cotton garments
Avoid bubble baths harsh soaps if allergic
Calamine lotion or cornstarch powder on
the vulva
Topical creams and antibiotics for 2
weeks

Foreign body
Between 3 to 9 yo
Toilet paper, toys, crayons, sand
Vaginal discharge
Remove by forceps, irrigation

Vaginal bleeding

Foreign body
Neoplasia
Precocious puberty
Urethral prolapse
Trauma
Sexual assault
Vulvovaginitis
Lichen sclerosis
Condyloma accuminata
Blood dyscrasia
Exposure to estrogen

Vaginal bleeding
Shigella
Group A beta-hemolytic

streptococcus
7-10 days after a sore throat

Adhesive vulvitis
Self-limiting consequence of chronic

vulvitis
Labia minora agglutinates and fuses
Mistaken for congenital absence of vagina
Common between 3 to 6 yo
No symptoms except for difficulty in
voiding if fusion involves the urethra
No treatment necessary
Estrogen cream 2x daily

Accidental genital
trauma
Fall, straddle injury
Sexual abuse
Hematoma or laceration
General anesthesia may be needed to
investigate the extent of the injury
If non-expanding: observation, serial
examination, ice pack then hot sitz
If retroperitoneal hematoma or internal
organ injury is suspected, laparoscopy
or laparotomy may be indicated
Tetanus toxoid injection

Ovarian Tumors
Abdominal pain
Abdominal enlargement increasing

abdominal girth
Ultrasound, abdominal CT, MRI
CA 125, AFP, hCG, inhibin, CEA, LDH,
estradiol and testosterone

Ovarian tumors
Unilateral
Benign or malignant
Germ cell tumor most common in

preadolescents
Immature teratomas surgery alone is

curative regardless of grade


Dysgerminoma most common malignant
Benign teratoma most common benign
Functional luteal cysts

Ovarian tumors
Goal of surgery: removal of

neoplasia and preservation of future


fertility

Precocious puberty
Appearance of signs of secondary sexual

maturation at an age more than 2.5


standard deviations below the mean for
the population to which the child belongs
Breast development and pubic hair
appearance before age 7 for Caucasian
and age 6 for African American girls
Usually with short stature limited
growth spurt because of accelerated
bone maturation and premature closure
of the distal epiphyseal growth centers

Premature Thelarche
Breast development
Neonatal may be normal up to 6

months
1 4 yo
2 4 cm breast bud
Unilateral or bilateral
Benign self-limiting
No treatment

Premature Pubarche
Isolated development of pubic hair
Premature adrenarche axillary hair
No clitoromegaly, bone age is not

advanced
Increased DHEA and DHEA-S by the
adrenals
Not progressive
No treatment, observation

GnRH-Dependent Precocious
Puberty
Idiopathic development 70% of

cases
Abnormal EEGs CNS
Premature maturation of the HPO axis
May develop ovarian follicular cysts
As early as 3-4 years old
Emotional problems shy and
withdrawn

GnRH-Dependent Precocious
Puberty
Headaches
Visual disturbance
Seizures with inappropriate laughter

(gelastic seizures)

GnRH-Dependent Precocious
Puberty
CNS lesions near hypothalamus near 3rd

ventricle
Tuberculosis, encephalitis, trauma,
hamartomas, teratomas, secondary
hydrocephalus, neurofibromatosis,
granulomas, craniopharyngiomas, cranial
irradiation,
Space occupying masses are most difficult
to treat
Poorly understood why it produces
precocious puberty

GnRH-independent precocious
puberty
Most common estrogen-secreting

ovarian tumor
Granulosa cell tumors - > 8cm

Thecomas, luteomas, teratomas,

Sertoli-Leydig cells,
choriocarcinomas, and benign
follicular cysts rare cause
Produce hCG or estrogen

McCune-Albright syndrome
Polyostotic fibrous dysplasia
Triad: caf-au-lait spots, fibrous

dysplasia, cysts of skull and long


bones
Facial asymmetry
40% has isosexual precocious
puberty

Adrenocortical neoplasms
Isosexual or heterosexual
Congenital adrenal hyperplasia
If treated during neonatal period, normal

puberty
If untreated, girl will develop
heterosexual puberty because of
androgens
If treated late in childhood, isosexual
development may follow initial treatment
of adrenal disease

Hypothyroidism
Usually associated with delayed

pubertal development
Rare: may cause precocious puberty
Bone age is retarded (specific)
Hashimotos thyroiditis
Low thyroid hormones negative
feedback increase TSH
increase gonadotrophins

Iatrogenic
Estrogen cream, pills
Regresses after discontinuation

Diagnosis
History and PE
Rule-out life threatening neoplasms

of the ovary, adrenals or CNS


Delineate speed of maturation
Tanner stage

Laboratory exams
Brain CT or MRI
EEGs
Ultrasound
Bone aging by hand-wrist x-rays every 6
months (if 95% advanced: ovarian
estrogen)
Hormonal assays including thyroid function
GnRH stimulation test LH increases if true
precocious puberty, LH does not increase if
incomplete (peripheral sources)

Management of Precocious
Puberty
Extirpation of tumors (ovarian,

hamartomas)
Continuous chronic GnRH analogue
administration (agonists) most
effective between 4-6yo
Down regulation of GnRH receptors

Minimal benefit with growth hormones


Testolactone (aromatase inhibitor)

McCune Albright
Counseling