PRACTICAL APPROACH TO PEDIATRICS GYNECOLOGICAL PROBLEMS

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PRACTICAL APPROACH TO PEDIATRICS GYNECOLOGICAL
PROBLEMS
PRESENTED BY NABEEL S. BONDAGJI MD, FRCSC,
FACOG Assistant Prof., KAUH Chairman, Department
of OB/GYN KFSHRC-Jeddah
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• Discharge
• Itching
• Pain
• Bleeding
• Redness

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Causes Vaginal Discharge

• Primary irritants
• poor hygiene
• Foreign body (recurrent smelly discharge) mostly
  toilet tissue) .
• Bacterial infection group A beta-hemolytic
  Streptococcus and enteric pathogens, such as
  Escherichia coli or Shigella organisms causes
  vaginitis with genital erythema.

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Cont. - Vaginal Discharge

• STD can cause Vaginitis in prepubertal girls,
  including Neisseria gonorrhea and Chlamydia
  trachomatis ELISA a very high rate of
  false-positive.
• Child sexual abuse.
• Urethra prolaps.
• Genital warts.

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Physical Examination

• A careful genital inspection
• A clinician who has time, knowledge, and skill
  with children and children behaviors.
• A relaxed or distracted child (books read by the
  mother).
• A good light source

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Cont. - Physical Examination

• A careful genital inspection
• The best position for the patient is lying on
  her back on the examination table in the supine
  frog-leg position with her knees bent and the
  soles of her feet touching.
• The labia majora are then gently spread
  laterally using separation or grasped and pulled
  forward toward the examiner using labial
  traction.
• Prone knee-chest position.

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Physical Examination

• Vaginal discharge.
• Culture with uretheral swab. (Routine culture
  culture for GC chlamydia).
• Inspect the hymen. (Common type crescentic).
• In tears, mainly posteriorly
• Inspect skin of the top labia.
• Eczema, psoriasis and scaling

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Cont. - Vaginal Discharge

• If a child has persistent vaginal discharge with
  negative culture results, examination by with the
  patient under anesthesia is indicated.
• The vagina can be irrigated and examined with the
  smallest Pedersen speculum or sometimes a
  hysteroscope or cystoscope, and the vagina can be
  thoroughly explored for the presence of a foreign
  body.

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Vaginal Itching Causes

• Irritant vulvitis lichen sclerosis atrophicus
  sharply demarcated area of hypopigmentation,
  around the vulva and the perianal area .
• Pinworms can hatch in the anus, travel to the
  vagina, and cause genital itching. The child
  scratch at either the genital or the anal area,
  especially at night.
• Chronic irritation.
• Allergies
• poor hygiene.

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Itching
History

• Duration
• Site more attention to the anal area.
• Nature scratching or rubbing
• Associated symptoms
• Allergic rhinitis
• Upper R.T.I.
• Diarrhea or discharge blood

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Itching
Cont. - History

• Urinary symptoms
• Dribbling
• Retention

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Is Child Toilet Trained? If Not.
Type of Diapers?
No. of Diapers Changed / day?
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If Yes

• Does the baby shower or bath?
• Bath
• Does she use bubble bath or shampoo?
• What kind of soap?
• After bathing
• Does the mother scrub the area?

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• Does the child wear cotton or nylon
• Underwear?
• Tight clothing or not
• Child toilet train
• Does the mother find sticky of stool on the
  underwear?
• Does she noticed bad odor or discharge on the
  panties?

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Physical Examination

• A careful genital inspection
• A clinician who has time, knowledge, and skill
  with children and children behaviors.
• A relaxed or distracted child (books read by the
  mother).
• A good light source

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Cont. - Physical Examination

• A careful genital inspection
• The best position for the patient is lying on
  her back on the examination table in the supine
  frog-leg position with her knees bent and the
  soles of her feet touching.
• The labia majora are then gently spread
  laterally using separation or grasped and pulled
  forward toward the examiner using labial
  traction.
• Prone knee-chest position.

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The standard recommendations for treatment of
presumed irritant vulvitis are as follows

• Have the child take a sits bath in plain warm
  water with no soap of any kind for 20 minutes
  daily.
• Use only white cotton underwear and white
  unscented toilet tissue.
• Stop all bubble baths.
• Proper hygiene after the child has a bowel
  movement.

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Repeated Vulvitis

• Most cause labial adhesion.

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• Adhesion of the labia is a common disorder in the
  female pediatric population.
• Asymptotic and is first noticed during a routine
  physical examination.

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• Etiology of labial adhesions relates to vaginal
  inflammation or irritation.

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Frequency

• In the US 1 2 of females aged 3 months to 6
  years.

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Morbidity

• Labial adhesions occasionally cause outflow
  obstruction, leading to vaginal reflux of urine
  and subsequent vaginal leaking when the child
  stands after voiding.

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Physical

• Thin, pale, semitranslucent membranes cover the
  vaginal os between the labia minora.

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Causes

• Labial adhesions probably are caused by vaginal
  inflammation or irritation, which, in some cases,
  could be the result of sexual abuse.

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Medical Treatment

• Observe
• if treatment is necessary or requested, prescribe
  estrogen cream application. Once the labia
  separate, apply lubricant or antibiotic ointment
  for several more weeks to allow complete healing.
  
• Dienestrol 0.01 cream .

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Cont. - Medical Treatment

• Once the labial adhesions separate, either
  treatment, apply antibiotic ointment for several
  weeks to allow the labial edges to heal without
  repeat adhesion formation.

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Complications

• Estrogen cream application often causes temporary
  hyperpigmentation of the skin in the area of
  application.

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Prognosis

• The prognosis for girls with labial adhesions is
  excellent. If left untreated, the condition
  usually resolves spontaneously at puberty.

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Vaginal Bleeding

• Foreign bodies
• Bacterial vaginitis
• Lichen scleroses
• Child sexual abuse
• Urethral prolapse.
• Condyloma acuminatum, or genital warts, often
  present with bleeding.
• Application of topical estrogen cream.

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Cont. - Vaginal Bleeding

• Endocrine disorders.
• Malignancy (Sarcoma Botryoides)
• Bleeding disorders.
• Acute lacerations of the posterior fourchette,
  hymen, or anus seen by even the inexperienced
  examiner.

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Genital Pain

• Urinary tract infections, vaginal infections,
  vaginal irritation
• Herpes simplex lesions
• Primary varicella or varicella zoster lesions
• Syphilis
• Ulcerative vulvitis of bacterial origin
• Aphthous ulcers
• Behcet disease
• Crohn disease
• Bacterial infection (especially Streptococcus)

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Cont. - Genital Pain

• Culture the lesions for virus and draw serum for
  syphilis serology before any routine bacterial
  culture.
• Improved hygiene and oral antibiotics.

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• The neonate with imperforate hymen typically
  presents with a bulging membrane between the
  labia.
• In severe cases, lower abdominal midline mass may
  be evident on physical examination.

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Thank You
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