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Vaginalagenesis is characterized by thick vestibular tissue, and often there isa dimple surrounded by a vulvar depression where the hymen should be.

Acquired hymenal abnormalities usually are caused by sexual abuse andrarely by accidental trauma. Signs of acute trauma from sexual abuse includehematomas, abrasions, lacerations, hymenal transections, and vulvar erythema.

These conditions usually resolve within ten to fourteen days. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections.

Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. The significance of the diameter of the hymenalorifice is controversial; a large orifice may be consistent with a historyof sexual abuse, but it is not an absolute criterion.

The vulva and anus. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities.

If extensive labial adhesions are present, you maynot be able to adequately examine the hymen and vagina and will need toreexamine the child after she has successfully completed treatment withlocal hygiene measures and topical estrogen see Sidebar, "Common gynecologicfindings in the prepubertal girl".

Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus.

Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis. The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis.

Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing bathing suits are common culprits. Chronic vaginal discharge, which can occur with a vaginal foreign bodyor vaginitis, also can lead to vulvitis, which is characterized by an erythematous,hyperpigmented, or hyperkeratotic line along the dependent portion of thelabia majora.

Treatment is the same as for labialadhesions. Lichen sclerosis also can present as vulvar discomfort or pruritus. It is characterized by atrophy of the vulvar skin, which may distort theanatomy of the labia and clitoris, producing ecchymoses and "bloodblisters.

A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse. Viscous lidocaine and warmsaline for irrigation through an IV set-up may be helpful when examininga child who has an acute straddle injury and bleeding.

After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.

In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. Leukorrhea may be present.

The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen.

For girls olderthan 2 years, the knee-chest position also permits excellent visualizationof the vagina and cervix without instrumentation.

These procedures are usually performed under anesthesia. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.

Dealing with a foreign body. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine.

Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass.

Obtaining cultures. When a child has vaginal discharge or bleeding andthe source such as a foreign body is not obvious, obtain samples for cultureand saline preparation.

If you suspect candidal vulvovaginitis, obtain apotassium hydroxide KOH preparation; a Gram stain may be useful if thedischarge is purulent.

Remember that this procedure can be painful to achild if you use a dry cotton swab or do not perform the examination gently.

A better way of obtaining specimens from the prepubertal child is to usea nasopharyngeal Calgiswab moistened with nonbacteriostatic saline.

Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin. If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort.

You can also ask the child to cough in order todistract her and cause her hymen to open. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently.

If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.

The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium.

Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques.

Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating.

The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.

If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse.

Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.

Referral should be made to a gynecologist with experience in pediatric gynecology. Rectoabdominal exam. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine.

This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses.

The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement.

After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus.

Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors.

After your examination is complete, congratulate the child for her cooperationand bravery. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed.

Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect.

Philadelphia, PA, Raven-Lippincott, Blake J: Gynecologic examination of the teenager and young child. Obstet Gynecol Clin North Am ; Pediatrics ; Gidwani GP.

Approach to evaluation of premenarcheal child with a gynecologicproblem. Clin Obstet Gynecol ; Pokorny SF. The genital examination of the infant through adolescence.

Curr Opin Obstet Gynecol ; Capraro VJ: Gynecologic examination in children and adolescents. Pediatr Clin North Am ; Am J Obstet Gynecol ; Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls.

Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination. The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases.

The history should include the quality of the discharge color, odor, presence of blood , hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions.

Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.

Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body.

Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation.

Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing.

Clinical manifestations includepruritus, vaginal discharge and odor, vaginal bleeding, dysuria, and vulvarredness and irritation.

Nonspecific vulvovaginitis. Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes.

Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies.

Specific vulvovaginitis. Vulvovaginitis also may be associated with aspecific infectious agent. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.

Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus. It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact.

N gonorrhoeaerarely persists beyond the newborn period without symptoms. Thus, a positivevaginal culture should be considered evidence of sexual abuse in the child.

Likewise, C trachomatis rarely persists beyond age 2 to 3 years, and mostinfants and toddlers have been treated since birth with an antibiotic thatwould treat Chlamydia.

Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse.

Thefinding of genital herpes type 2 is a strong indication of sexual abuse. Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.

New onset of Trichomonas vaginitis in theprepubertal child is associated with sexual abuse. HPV is also verticallytransmitted and lesions may appear in the first few years of life.

However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse.

Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area.

Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs.

Adult pinworms maybe visible at night. Noninfectious causes of vulvovaginitis also are common. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge.

Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease.

Vulvarskin disorders are common, and often easily recognizable on exam. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting.

Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds. Children usually are asymptomatic,but they may present with secondary infection.

The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.

Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. Lichen sclerosus may present as vulvar discomfort or pruritus.

It is characterized by atrophy of the vulvar skin, which causes the labiaand clitoral hood to appear thin, white, and parchment-like.

The atrophymay distort the anatomy of the labia and clitoris. Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle.

Other associations. Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. Physiologic leukorrheacan be confused with vulvovaginitis.

Newborns and pubescent girls sometimeshave significant vaginal secretions because of estrogen effect. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells.

Urethral lesions alsoshould be considered. Creative Images. Editorial Images. Creative video. Editorial video.

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