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

Approach to the Exam

The environment in which a child receives health care can influence the outcome of the encounter. Objects such as age-appropriate books, toys, and posters familiar to the child should be available in each examination room. "Child-friendly" nursing staff can significantly aid in the evaluation and examination of the young patient.[1]

The history centers on the presenting complaint with background information regarding medical history. Generally, most questions will be answered by the parent, but it is important to elicit information from the child. In addition, asking the child questions about their school, pets, toys, favorite books, movies, or characters will often help in establishing rapport and putting them at ease. Explaining the procedure utilizing an anatomically correct doll and letting the child repeat the procedure on the doll will often decrease their anxiety significantly.[1]

Examination of the child with gynecologic complaints should begin with plotting the height and weight on a growth chart. Starting with less-threatening portions of the exam, such as checking the ears, neck, heart, and lungs, may help to reassure the child. Evaluating the sexual developmental stage of the breasts is an important part of any prepubertal exam. Inspection and palpation of the breasts to evaluate breast tissue or enlargement of the areola may be an early indication of puberty. An abdominal examination generally is met with little resistance, but distraction can be utilized, such as reading a book, to assist in performing a thorough evaluation.

The genital examination should be performed in a methodical manner with careful visualization of the genital structures described earlier, with careful notation of abnormalities or variations. In older females, the focus of the examination is to evaluate the cervix and internal genital structures but with the prepubertal female, the external visualization of the genitalia can diagnose the majority of the problems that will be discussed later in this chapter. Rarely is there a need to perform an internal examination unless specific problems such as vaginal bleeding, recurrent or unresponsive vaginal discharge, suspected foreign body, or suspected vaginal tumor require further evaluation. The preferred means to evaluate these problems is to do an examination under anesthesia using a fiberoptic vaginoscope, hysteroscope, pediatric cystoscope, or endoscope with irrigating properties.[4,5]

The estrogen status of the child in latency limits the extent of the exam. For instance, a moistened Q-tip applied to the hymenal or vaginal tissues of the 4- or 5-year-old female is quite painful and poorly tolerated and may provoke bleeding. Use of instrumentation such as a pediatric speculum or nasal speculum is frequently traumatic both physically as well as emotionally for the child. Insertion of the small finger for a rectal examination to evaluate the vagina and uterus is often better tolerated. Whether or not a rectal examination is performed the perianal area should be inspected carefully to evaluate for condyloma, pinworms, or other abnormalities.

Alternative positions for the examination can be implemented to provide a thorough exam if the child is exceedingly anxious (Fig. 6A,B). The child can remain on the mother's lap while she sits in a chair, with the mother assisting in helping the child into a frog-legged position as illustrated. Another means is having the mother sit on the examination table in a semi-reclined position with her feet in the stirrups and have the child's legs straddle her thighs.[6] With gentle separation of the labia and having the child cough or take deep breaths the vaginal introitus will open substantially; if not, the labia can be pulled gently toward the examiner and then laterally.[6] Young children who are not overly anxious may cooperate and get into a knee-chest position, allowing the health care provider to apply gentle traction on the labia by separating them with the hymen opening and allowing visual assessment of the lower third of the vagina. Under no circumstances should a child be physically restrained or forced to undergo an examination, as this is traumatic and usually nonproductive.

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