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

Common Gynecologic Disorders

Labial Adhesions

Reported to occur in 1.4% of infants, labial adhesions may result in partial to complete fusion of the labia minora.[8] The agglutination usually begins posteriorly and extends upward toward the clitoris, leaving a small opening anteriorly in most cases. The fused portion of the labia is usually identified by a thin line of demarcation or raphe.[9] Extreme cases include nearly complete labial closure with resultant urinary retention and/or infection (Fig. 8).

Figure 8.

Labial adhesions in prepubertal female. (Reprinted with permission from Elsevier.)

The etiology has been postulated as estrogen deficiency and inflammation with thinning of the superficial mucosal layers. Treatment is not always necessary as resolution has been known to occur spontaneously at puberty once estrogen is produced.[10] However, therapy is quite simple and efficacious, consisting of 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. Once separation of the labia has occurred, a thin coating of lubricant such as A&D ointment once daily is suggested to keep the area moist and prevent recurrence. As estrogen cream can be systemically absorbed, parents may notice transient breast development, and it is not advised to continue therapy for longer than 4 weeks.

Forceful manual separation is not advised as this is often painful and traumatic to the child. In addition, recurrence is much more common. Surgical separation is rarely justified and only applicable if urinary problems result and estrogen therapy has failed.

Imperforate Hymen

Imperforate hymen is often missed on examination of the newborn due to redundancy of the hymenal folds. A mucocolpos or hematocolpos can develop and is apparent as a bulging thin membrane at the introitus with the Valsalva maneuver or crying. This results from accumulation of mucous or bloody secretions from prior maternal estrogen exposure in utero that are not allowed to pass due to the obstruction. Surgical incision is necessary to allow drainage in these cases.

An imperforate hymen may not be noticed until puberty when the patient (with normal secondary sexual development and primary amenorrhea) complains of intermittent lower abdominal pain that worsens each month. A bluish bulge may be seen at the introitus on examination. Treatment consists of making a small cruciate or vertical incision under general anesthesia and removing any redundant segments of hymenal tissue. If the patient has had discomfort for a period of 6 months or more, a laparoscopic examination of the pelvis may reveal superficial endometrial implants due to retrograde menstruation. These will generally regress once correction of the hymenal blockage is performed.

A differential diagnosis includes a transverse vaginal septum that generally is more suprahymenal in location. Transverse vaginal septae occur in 1 in 80,000 females and are more difficult to surgically excise due to their inherent thickness and proximal location.[11] More rarely, they are located at the junction of the middle and upper thirds of the vagina. Ultrasound or MRI scanning may be used to delineate the septal thickness, proximity to the cervix, and the presence of a hematocolpos, hematometra, or hematosalpinx, if menstrual periods have begun.

Vulvitis

Prepubertal females may occasionally complain of vulvar discomfort or itching. Persistent symptoms noted by the parent/caregiver or the child often raise great concern. The first step is to take a careful history in regards to any possible irritants. Questions should be directed to the level of hygiene, urinary incontinence, frequency of diaper changes, and bathing habits. Diaper dermatitis is associated with exposure to urine and stool in infants but also in girls who are developmentally delayed and wearing diapers. This is managed by keeping the area dry, changing diapers more regularly, and applying petroleum-based ointment to serve as a moisture barrier.

Common organisms causing prepubertal vulvitis are candida, pinworms, and group A β-hemolytic streptococcus. Candida is rarely seen in the nonestrogenized prepubertal girl but is common in infants under the age of 2.[12] As in the adult female, candida may follow a course of antibiotics in the infant. However, underlying factors such as juvenile onset diabetes or immunosuppression need to be considered if candida is found in the child who is toilet trained. It is characterized by an erythematous rash with raised, well-demarcated borders and satellite lesions. KOH preparation may help identify hyphae. Treatment consists of 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.

Bacterial causes of vulvitis such as group A β-hemolytic streptococcus should be treated with an appropriate antibiotic for 2 weeks and occasionally for longer periods of time (up to 4 weeks). Additional therapy may consist of sitz baths with baking soda or colloidal oatmeal added one to two times daily. Soap should be avoided and the area can be dried thoroughly with a hair dryer on low heat or cool air. Hygiene must be emphasized along with thorough hand washing before and after using the toilet.

Pinworms, or Enterobius vermicularis, are 1 cm long, thin white worms that can migrate from the anus to the vagina and cause severe nocturnal pruritus.[13,14] Diagnosis is made by inspecting at night with a flashlight to observe the small threadlike worms exiting the anus. Alternatively, 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.

Contact or allergic vulvitis may lead to significant pruritis with scratching and excoriation. Offending agents include: poison ivy, topical creams, ointments and lotions, perfumed or colored toilet paper, bubble baths and soaps, adult or baby wipes, as well as laundry detergents, fabric softeners and dryer sheets, and bleach used to wash undergarments. Treatment may consist of removing the irritant, and if itching is severe, providing an oral medication, such as hydroxyzine hydrochloride (Atarax), 2 mg/kg/d divided into four doses, or application of topical hydrocortisone cream 2.5% twice a day for a week and then discontinuing.

Another cause of vulvitis may be lichen sclerosus, a condition normally seen in menopausal women but also seen in the prepubertal female. The child usually complains of 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. It tends to be symmetrically distributed (hourglass appearance) in the vulvar and perianal area (Fig. 9). The diagnosis in the prepubertal age group is made clinically. 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.

Nonspecific Vulvovaginitis

Vulvovaginal inflammation is the most common gynecological disorder of prepubertal girls and accounts for over 50% of visits to pediatric gynecological clinics.[15] Inflammation may involve the vulva or vagina or both and can result from a variety of stimuli. Several instigating factors that can contribute to nonspecific vulvovaginitis include:

  1. Poor hygiene practices at home or daycare program

  2. Inadequate front-to-back wiping

  3. Smaller labia minora, which are less protective of the vestibule, with a short distance from the anus to vagina

  4. Vulvovaginal epithelium that is not well estrogenized and thus thinner and more prone to irritation

  5. Foreign body such as toilet paper, small toys, or pieces of cloth, which may be inadvertently inserted in the vagina by the child

  6. Chemical irritants such as bubble baths, shampoos, or bath oils, and certain deodorant soaps

  7. Dermatologic conditions such as eczema and seborrhea

  8. Chronic disease and altered immune status

  9. Sexual abuse

The pathogenesis of vulvovaginitis is not well defined but 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.

Symptoms of nonspecific vulvovaginitis include itching, dysuria, and discharge. In these instances, routine vulvar hygiene measures as listed below, are followed.

Recommended vulvar hygiene measures include:

  1. Use front-to-back wiping with warm water after a bowel movement.

  2. Avoid deodorant soaps, bubble baths, or lotions.

  3. Wear only white cotton underwear or if still in diapers, change soon after each urination or bowel movement.

  4. Use unscented toilet paper.

  5. Keep vulvar area clean and dry.

  6. Wash hands prior to and following use of toilet.

  7. Use mild bath soap (e.g., Dove, Neutrogena, Basis, Oilatum, or Cetaphil).

  8. Remove wet bathing suits soon after exiting pool area.

Occasionally, a child may be found to be in a "scratch and itch" cycle where the discharge and inflammation has led to pruritis and the subsequent scratching has led to bacterial infection. Initially, sitz baths in lukewarm water with 2 tablespoons of baking soda, colloidal oatmeal, or Domeboro solution may soothe an acutely inflamed vulva. Antibiotics are commonly used if secondary bacterial infection is suspected and include amoxicillin, amoxicillin/clavulinic acid, or cephalosporin for 7- to 10-day courses. Topical estrogen cream once or twice a day for 7 to 14 days may promote healing if vulvovaginal denudation is suspected due to disturbed bacterial homeostasis. Occasionally a low-dose topical steroid (hydrocortisone 1% or 2.5%) will help relieve itching and inflammation as well.

Infectious Vulvovaginitis

Specific vulvovaginal infections that occur in the prepubertal female are often respiratory, enteric, and, less frequently, sexually transmitted. Sexually transmitted infections in prepubertal children will not be discussed here.

Child protective services should be notified and the child referred to a trained professional for evaluation. Respiratory pathogens found in the vagina of young girls include Hemophilus influenzae, Staphylococcus aureus, group A β-hemolytic streptococci, and Streptococcus pneumoniae causing a yellowish to greenish purulent vaginal discharge.[16] S. pneumoniae infection and group A β-hemolytic streptococci vulvovaginitis are treated with 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. It is treated with 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.[17]

Physiologic Discharge

The newborn may experience some transient vaginal secretions resulting from maternal estrogen exposure in utero. These secretions 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. Mucous secretions may appear again around the time of puberty as estrogen levels rise in the adolescent.

Condyloma Acuminata

Condyloma acuminata, or "genital warts," caused by human papilloma virus (HPV) is seen in the prepubertal child more often today than in the past). Condyloma resembles fleshy tumors in the unestrogenized vulvar mucosa but may have the more verrucous characteristics of adult lesions on the perineum and perianal areas.[2]

Condyloma usually present as asymptomatic lesions noted by the parent or caregiver. Large lesions, however, may present with a child complaining of pain on urination or defecation (Fig. 10).

Figure 10.

Large condyloma in female infant. (Reprinted with permission of The McGraw-Hill Companies.)

Generally, 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 these children, evaluation has found some type of sexual abuse in approximately one third of cases. It is postulated that the incubation period may be markedly prolonged in cases where sexual abuse is not suspected or found.[18] As in the adult, certain subtypes of the HPV warts are potentially oncogenic.

In the past, treatment consisted of trials of trichloroacetic acid, podophyllin, or cryotherapy. CO2 laser vaporization therapy under anesthesia was often considered the most thorough treatment modality and least traumatic for the child. However, 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.[19] 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 weeks.

Urethral Prolapse

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 (Fig. 11). Treatment consists of estrogen cream to the area nightly for 1 to 2 weeks. On follow-up if the prolapse has not resolved a referral to an urologist is indicated.

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