7. Examination
Should engage the child in a distracting conversation
In toddlers examine when as if changing diaper on parents lap
Position:
Hips are flexed and abducted, Dr’s hands placed on each thigh
Technique:
Labial separation
Labial traction
Gently grasps the labia minora with
thumb & forefinger & pull forward &
out to better visualize entire introitus
8. Preschool & school age
(3-6 yrs)
H-P-G axis becomes suppressed, hormonal effect on genital structures
recede
Labia becomes flatter, clitoris less prominent, hymen becomes thinner &
recedes to give a cresent appearance
Normally:
Some maintain thickened redundant configuration
Single or multiple hymenal tags
9. Examination
Gain trust of PARENT, if parent is uneasy, child will be uncomfortable
Position: frog leg position either on table or on parent’s lap
Technique:
Labial separation or traction
Prone knee-chest position
Better visualize vaginal vault because of concern
for a foreign body
10. Older school age & pre-teen
(7-12)
Labia minora become a separate layer & join at the posterior commissure
years after onset of menarche
Vestibular mucosa thickens & gains cobble stone app
Hymen thickens & develops fimbriations
PHYSIOLOGICAL leucorrhea precedes menses by 3-6 months
12. Examination
Actively engage the child, explain anatomy & procedure with pics
Ask father or other male relatives to leave examination room
Avoid embarrassment by using drapes instead of taking off all cloths
Position:
Frog leg position
Lithotomy position
13. Normal Anatomical Variants
Pigmentation variations NOT to be confused with bruises
Peri-urethral band with labial traction
Deep notches or absent areas of hymen in superior ½ of hymen
An external hymenal ridge & a midline avascular area on the fossa
navicularis (linea alba)
Diaper rash mash lead to labial fusion starting at posterior introitus,
varying from few mm or so extensive that entire introitus is obscured
External hymenal ridge (arrow) & sleevelike hymen
15. Vulvovaginitis
VV is the most common gynecological problem in PP girls
Infection
Bacterial
GABHSC (18%)
S.Flexenari (20%)
Pinworm
Dermatological
Irritant
Atopic dermatitis
Contact dermatitisTrauma
Lead to pruritis,
scratching &
bleeding
16. Vulvovaginitis
1. Bacterial
Group A β-hemolytic
streptococci
Shigella Fexinari
Spread Oral-digital to genital area
(auto-inoculation)
GIT to genital region
History Upper RTI Diarrhea is absent in most
patients
Symptoms Vaginal discharge (92 %)
Itching (45%)
Redness (30%)
Dysuria (19%)
Pain (8%)
Bleeding (5%)
Mucopurulent, malodorous,
bloody discharge
18. Vulvovaginitis
2. Dermatological
Irritant as shampoo, bubble bath, tight clothing
Acute or chronic dermatitis lead to pruritis, scratching, break down of
skin & bleeding
19. Urethral prolapse
Definition: Protrusion of the urethral mucosa through the meatus
forming a hemorrhagic donut shaped mass
Incidence:
Average age is 5 years, common is black girls
Initial diagnosis correct in only 21 % of girls
Occurs following an episode of increase IAP
Management:
Small & urination not obstructed: Sitz bath, topical Estrogen cream for 4-6
weeks, ABs if infections occur (Recurrence 67%)
Large, necrotic, or urination is obstructed: surgical resection
20. Urethral prolapse
The mother of 3 year old girl is concerned because she saw blood in her
underpants, The patient complains of no pain.
Examination shows the following
Note the complete circular eversion of the distal urethral mucosa
Intraoperatively, prolapsed mucosa is excised in quadrants, and the 2
layers of smooth muscle are apposed together.
21. Lichen sclerosus
A destructive inflammatory condition causing pruritis
Ivory colored plaques that bruise easily
Rx local steroids
22. Foreign body
Purulent , foul, bloody discharge
Does not respond to ABs
Commonly toilet paper
Vaginal irrigation or EUA Vaginoscopy for removal
Investigations: WBC is urine & NEGATIVE urine culture
25. Precocious puberty
Definition: appearance of 2ry sexual characters before 8 years of age or
menarche before 10 yrs
Central Peripheral Isolated premature
menarche
Physiologically normal
pubertal dev occurring at
an early age
Dt inappropriate sex H.
secretion or exposure to
exogenous sex steroids
Excessive sensitivity of the
target tissue to low levels
of sex steroids
GnRH dependent GnRH independent
1. Idiopathic 80-90%
2. CNS TR
3. CNS dysfunction
1. Functioning ovarian
tumors or cysts
2. Adrenal tumors, CAH 3.
Chr 1ry hypothyroidism
4. McCune-Albright synd
1. Spontaneous regression
of ovarian cysts
2. Hypothyroidism
3. McCune Albright Synd
Rx of CPP: Rx of cause & GnRH
analogues
26. Trauma
Accidental injuries:
Blunt trauma: (straddle injury…> hematoma)
Managed conservatively with ice packs
If it continues to expand…> evacuation & ligation of bleeding vessels
Penetrating injury:
Hymenal injury alone:
If no active bleeding; conservative management
Active bleeding: indicates involvement of the vagina…> Exploration & repair
under GA to exclude injury to the upper vagina
If vaginal vault is involved…> Laparotomy
Bladder & bowel integrity must be confirmed
Sexual abuse
30. Sarcoma botryoides
Aggressive malignant tumor affecting either vagina, uterus, bladder or
urethra
Incidence: Most common in children 90% < 5Y
Classically presents with polypoid mass protruding through vagina
May present with vaginal bleeding, foul smelling discharge , abdominal
pain
Rx:
Chemotherapy followed by
Surgical resection preserving bladder & rectum
Post-op radiotherapy
35. Evaluation of prepubertal girl
with vaginal bleeding
Hx (duration, quantity, UT symptoms, recent UTI
Physical examination
General: Growth & signs of puberty
Abdominal palpation: masses
Genital examination
Investigations:
Thryroid Fx test
FSH, LH
US/MRI
Bone age
Vaginoscope under GA
36. Conclusion
Vaginal bleeding in premenarchal girls is a rare condition
But it’s an alarming clinical presentation & always a cause of concern for
parents & medical staff
Serious medical or sociological problems can underlay this symptom in
young girls
It requires careful medical evaluation to exclude serious underlying
causes
37. Conclusion
Local lesions of the genital tract are the MCC of vaginal bleeding during
the prepubertal period
Precocious puberty is the 2nd MCC of premenarcheal vaginal bleeding
Although rare, malignant neoplasms of the genital tract must be
considered
Vaginoscopy using the hystroscope is very helpful in the evaluation of
young girls with vaginal bleeding
Prompt and correct diagnosis will lead to successful management
genital examination that requires either physical or psychological force cannot result in accurate examination findings and may lead to fear on the part ofthe patient and her parent
Multiple hymenal tags are evident during examination by using saline or water to float the hymenal tissue
Vaginal epithelium shows ovoid epithelial cells
Labia minora appears as an extension of clitoral hood & extends only 1/3 of length of labia majora
Must discuss examination in details to the PARENT to avoid cultural & religious views
Vagina elongates & become 8 cm long, vaginal swab is polygonal eopithelial cells
Nl lactobacilli & acidic secretions
Add
Such bands oftissue extend from the urethra, creating a false pocket on either side. The pockets can be confused with the actual urethra, which usually appears as a small midline dimple. Sometimes the urethra is dilated, which may present another unexpected configuration. Urethral dilatation is a simple variant and is not a sign of trauma or disease. Perihymenal bands may extend from the hymen to the vestibular wall.
Normal as the hymen changes from circumferential to a crescentic configuration
Discuss Rx if u want
