PEDIATRIC GYNECOLOGY AND
GYNECOLOGICAL DISORDERS IN
CHILDREN AND ADOLESCENTS
Rukset Attar, MD, PhD
Obstetrics and Gynecology
Department
Pediatric & Adolescent Gynecology
Gynecologic care begins in the delivery room, with
inspection of the external genitalia during routine
newborn examination.
Evaluation of the external genitalia continues through
routine well-child examinations, permitting early
detection of infections, labial adhesions, congenital
anomalies, and even genital tumors.
A complete gynecologic examination is indicated when a
child has symptoms or signs of a genital disorder
Common Gynecologic Disorders
Newborn Infants
During the first few weeks of life, residual maternal sex
hormones may produce physiologic effects on the
newborn
Breast budding occurs in nearly all female infants born at term.
In some cases, breast enlargement is marked, and there may be
fluid discharge from the nipples - No treatment is indicated.
The labia majora are bulbous, and the labia minora are thick and
protruding
Vaginal bleeding may occur
Vaginal discharge is common, composed mainly of cervical
mucus and exfoliated vaginal cells.
Common Gynecologic Disorders
Congenital Anomalies of the Female Genital
Tract
Anomalies of the Vulva & Labia
Anomalies of Clitoris
Anomalies of the Hymen
Anomalies of the Uterus
Anomalies of the Ovaries
Anomalies of the Urethra and Anus
Common Gynecologic Disorders
Labial Adhesions
%1.4
estrogen deficiency and inflammation
applying estrogen cream to the fine thin raphe twice a
day for 2 weeks followed by once daily application for
2 weeks.
parents are asked to repeat the course of treatment in
6-month to 1-year intervals if recurrence occurs.
Common Gynecologic Disorders
estrogen cream can be systemically absorbed, parents
may notice transient breast development
Forceful manual separation is not advised
as this is often painful and traumatic to the child
recurrence is much more common.
Surgical separation is rarely justified and only applicable
if urinary problems result and estrogen therapy has
failed.
Common Gynecologic Disorders
Imperforate Hymen
A mucocolpos or hematocolpos can develop
is apparent as a bulging thin membrane at the
introitus with the Valsalva maneuver or crying
Surgical incision
Common Gynecologic Disorders
Vulvitis
vulvar discomfort or itching
The first step is to take a careful history in regards to
any possible irritants
the level of hygiene,
urinary incontinence,
frequency of diaper changes, and
bathing habits.
Diaper dermatitis
Common Gynecologic Disorders
Common organisms causing prepubertal vulvitis are
Candida
usu. under the age of 2
may follow a course of antibiotics in the infant
underlying factors such as juvenile onset
diabetes or immunosuppression
antifungal creams such as clotrimazole,
miconazole, or butaconazole applied twice a
day to the affected area for 10 to 14 days or
until rash is cleared
Common Gynecologic Disorders
Pinworms (Enterobius vermicularis)
Diagnosis is made by
inspecting at night with a flashlight to observe worms
exiting the anus
a morning inspection with "Scotch tape" to the anal
region can identify the eggs.
Treatment consists of mebendazole (Vermox) 100 mg
orally once and repeated in 1 week.
It is advised to treat the entire family to prevent reinfection
Group A -hemolytic streptococcus
appropriate antibiotic for 2 weeks and occasionally for
longer periods of time (up to 4 weeks)
Common Gynecologic Disorders
Contact or allergic vulvitis
Treatment may consist of removing the irritant
if itching is severe
providing an oral medication, such as hydroxyzine
hydrochloride (Atarax), 2 mg/kg/d divided into four
doses,
application of topical hydrocortisone cream 2.5% twice a
day for a week and then discontinuing.
Common Gynecologic Disorders
Lichen Sclerosus
itching, irritation, soreness, bleeding, and dysuria.
The vulva is characteristically white, atrophic, with
parchmentlike skin and occasionally evidence of
subepithelial hemorrhages, excoriations, fissures, and
inflammation
Treatment consists of clobetasol (Temovate) cream 0.05%
applied nightly to the affected area for 6 weeks.
Follow-up should be scheduled at that time and if there is
significant improvement the dose is tapered progressively
until it is being used only one time weekly at bedtime.
Common Gynecologic Disorders
Nonspecific Vulvovaginitis
is the most common gynecological disorder of prepubertal girls
(accounts for over 50% of visits)
Poor hygiene practices at home or daycare program
Inadequate front-to-back wiping
Smaller labia minora, which are less protective of the vestibule,
with a short distance from the anus to vagina
Vulvovaginal epithelium that is not well estrogenized and thus
thinner and more prone to irritation
Foreign body such as toilet paper, small toys, or pieces of cloth,
which may be inadvertently inserted in the vagina by the child
Chemical irritants such as bubble baths, shampoos, or bath oils,
and certain deodorant soaps
Dermatologic conditions such as eczema and seborrhea
Chronic disease and altered immune status
Sexual abuse
Common Gynecologic Disorders
The pathogenesis of vulvovaginitis is not well defined
may be associated with an alteration of the vaginal flora with
an overgrowth of fecal aerobes or an overabundance of
anaerobes contributing to the symptoms of odor and
discharge.
Cultures performed indicate a variety of organisms
considered normal vaginal flora such as diphtheroids,
enterococci, coliforms, and lactobacillus.
Escherichia coli is often found on vaginal culture, suggesting
poor hygiene; contamination with bowel flora may contribute
to the problem.
Common Gynecologic Disorders
Infectious Vulvovaginitis
Hemophilus influenzae, Staphylococcus aureus, group A hemolytic streptococci, and Streptococcus pneumoniae causing
a yellowish to greenish purulent vaginal discharge (S.
pneumoniae infection and group (amoxicillin 40 mg/kg divided
three times a day for 10 days)
Shigella flexneri, an enteric pathogen, can cause a
mucopurulent, sometimes bloody discharge following an episode
of diarrhea in some young girls(trimethoprim (TMP)sulfamethoxazole (Bactrim) 6 to 10 mg/kg/d TMP by mouth,
divided every 12 hours. Treatment may require more than 10 to
14 days of medication.)
Common Gynecologic Disorders
Physiologic Discharge
resulting from maternal estrogen exposure in utero
may appear as clear mucous, whitish in color or clear
On occasion, a bloody discharge is noted and results from
exposure to maternal estrogens in utero, causing transient
endometrial shedding.
This will most often resolve within a few hours to days.
Common Gynecologic Disorders
Condyloma Acuminata
in children less than 2 years of age, the mode of
transmission is vertical from mother to child during
childbirth.
After age 2, sexual abuse is a primary concern in
children presenting with condylomatous lesions (in
approximately one third of cases)
Common Gynecologic Disorders
treatment
trichloroacetic acid
podophyllin
cryotherapy
CO2 laser vaporization therapy
more recently the advent of imiquimod cream (Aldara), an
immune response modifier supplied in a cream base, has
eased and revolutionized therapy for external genital warts (A
thin layer of cream is applied to the wart(s) at bedtime and left
on for 6 to 10 hours, after which it is washed off. Therapy is
for 3 days a week (i.e., Monday, Wednesday, and Friday) and
continued until the warts are completely gone, or up to 16
week )
Common Gynecologic Disorders
Urethral Prolapse
usually presents with unexplained bleeding, often thought to be
coming from the vagina.
The child experiences no pain and has no recent history of
vulvar trauma.
On physical examination a bright red, friable annular mass is
noted just above the hymen surrounding the urethral opening
Treatment consists of estrogen cream to the area nightly for 1 to
2 weeks.
Common Gynecologic Disorders
Foreign Bodies
The vaginal discharge is often dark brownish in color
occurs daily, requiring the use of a panty liner by the child.
The discharge is often malodorous
Common Gynecologic Disorders
Sexual Abuse
Genital infection with Neisseria gonorrhoeae is
associated with a purulent thick yellow discharge
along with vulvar erythema and edema.
Chlamydia trachomatis may present with
vulvovaginitis, pruritis, and discharge. Infants born to
mothers with chlamydia may carry the organism for
up to 18 months
Common Gynecologic Disorders
Anomalies of sexual development and puberty
Vaginal Bleeding
Bleeding disorders
Juvenile Pregnancy
Diagnosis
History
Physical examination
Vaginoscopy
Specimen collection
Collection of Specimens
Vaginal cultures are easily collected by a technique described by
Pokorny using a catheter within a catheter. A 4-inch segment of the
tip of a no. 12 red rubber catheter is placed over the hub end of a
butterfly catheter attached to a 1-mL tuberculin syringe . Sterile
normal saline (0.05 to 1 mL) is instilled slowly and aspirated back to
acquire fluid
Collection of material to evaluate for gonorrhea may be collected by
swabbing visible discharge on the perineum or in a similar manner
as with chlamydia.
Cultures for chlamydia must include material taken directly from the
mucosal surface using a saline-moistened calcium alginate swab
(male urethral swab). The swab is inserted into the vagina as the
child coughs, which makes the hymen gape open and serves as a
distraction.
Radiological tests may be performed in those children
who are unable to cooperate or have specific problems,
such as suspicion of an abdominal mass, abdominal
pain, or precocious puberty.
Pelvic ultrasound
computed tomography
magnetic resonance imaging (MRI) scan
