Pediatric Gynecology: Assessment Strategies and Common Problems

Jane H. Kass-Wolff, RN, MS; Ellen E. Wilson, MD

Disclosures

Semin Reprod Med. 2003;21(4) 

In This Article

Normal Genital Findings

From birth through the first 8 weeks of life, the female infant is under the influence of maternal estrogen. This has a profound effect on the appearance of the female genitalia. The labia majora appear full and puffy and there is a significant thickening and enlargement of the labia minora (Fig. 2). The clitoris is often disproportionately enlarged with the urethral meatus difficult to visualize because of the thickening and redundancy of the hymen. Maternal estrogen exposure may stimulate a mucoid discharge or a small amount of bloody vaginal discharge but these effects begin to recede in ~2 weeks. Discharge and vaginal bleeding persisting after 10 to 14 days is therefore not normal and should be investigated further.[5] Higher estrogen levels promote the metabolism of glycogen in the cells, making the lower genital tract much more susceptible to monilia infections, but as estrogen levels fall the likelihood of monilia infections decreases as will be discussed.

Figure 2.

Estrogenized female genitalia. (Reprinted with permission from Elsevier.)

Estrogen levels continue to fall until about 1½ to 2 years of age, although gonadotropins continue to cause some ovarian stimulation and endogenous production of estrogen during this time. From the age of 3 until 8 or 9 years the estrogen levels are at their lowest and the appearance of the female genitalia is very different. With low levels of estrogen the genital tissues become more and more atrophic. The most prominent landmark in the prepubertal female's external genital area is the clitoral hood and the clitoris but with age this takes on less prominence as the clitoris does not increase in size as do the other structures (Fig. 3). The urethral meatus may vary in size but is often quite small in the prepubertal child. Occasionally the periurethral tissue becomes patulous and appears as an area of bright pink tissue.[4]

Figure 3.

Hypoestrogenized prepubertal genitalia. (Reprinted with permission from Elsevier.)

The labia majora appear as normal skin circling around the more central genital structures (Fig. 4). The labia minora are very thin ridges of tissue that form the medial aspects of the vestibular rim interiorly and course upward toward the midline, meeting just beneath the clitoris.[4] Unlike in the older female they do not provide coverage or protection for the vaginal opening. The vestibule is another important anatomical area in prepubertal exam. This is the recessed mucosa that has as its landmarks the urethral meatus anteriorly and the vaginal orifice posteriorly. The vestibular sulcus is the base of the vaginal orifice and in the prepubertal child appears very erythematous. This erythema is due to the marked density of capillaries that surround this area and with minor trauma may lead to excessive bleeding.[4]

Figure 4.

Anatomic landmarks of the prepubertal female genitalia. (Reprinted with permission of the McGraw-Hill Companies.)

Surrounding the mouth of the vaginal orifice is the rim of tissue called the hymen. The once thick, redundant hymen becomes thin and translucent with varying configurations. The hymen may be annular, crescent-shaped, redundant, and irregular or teardrop-shaped[1] (Fig. 5). Some less common variations of the hymen include the imperforate hymen, microperforate, and the septated hymen. In most instances, correction of these variations is not necessary until the girl reaches puberty.

Figure 5.

Normal hymenal configurations in the prepubertal female. (Reprinted with permission from Elsevier.)

The pH of the vagina is alkaline and consists primarily of columnar epithelium. Vaginal discharge or bleeding is not a normal finding at this time nor are monilia infections, due to the low estrogen levels. The prepubertal ratio of cervix to uterus is 2/3:1/3, respectively, and is an important indicator on pelvic ultrasound of prepubertal status; alteration in this ratio generally presents as onset of precocious puberty. Of note in the prepubertal period, the ovaries are abdominal structures and any enlargement may present as an abdominal mass with associated abdominal symptoms. The ovaries' gradual descent into the pelvis occurs with the onset of puberty.[1]

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