Pediatric gynecology
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  • 1. COMMON PEDIATRIC & ADOLESCENT GYNECOLOGICAL COMPLAINTS www.freelivedoctor.com
  • 2. Gynecological care begins in the delivery room as part of the newborn examination with palpation of the breast buds and examination of the external genitalia www.freelivedoctor.com
  • 3. Newborn Anatomy
    • 1 st few weeks of life, residual maternal sex hormones may have physiologic effects on newborn
    • Breast budding in majority of term female infants and there may be marked breast enlargement or even nipple discharge but no treatment is required
    • Labia majora are bulbous
    • Labia minora are thick & protruding
    • Clitoris is relatively large (normal is 0.6cm 2 or less)
    • Vaginal epithelium dull pink initially and then as maternal residual estrogen levels decline, genitalia take on their juvenile appearance with small labial fat pads and the vaginal epithelium (1-3 cells thick) becomes bright red
    www.freelivedoctor.com
  • 4. Newborn Anatomy
    • Vaginal discharge is common, usually composed of cervical mucus & exfoliated vaginal cells
    • Vaginal bleeding is also common as the estrogen levels fall and the stimulated endometrial lining sheds. Generally stops in 7-10 days.
    • Hymen has varied configuration & size of opening. Initially turgid
    • Vagina is approximately 4 cm long
    • Uterus is enlarged (4 cm) with no axial flexion
    • Ratio b/w Cx & corpus is 3:1
    • Columnar epithelium protrudes through os
    • Ovaries are abdominal organs into early childhood
    www.freelivedoctor.com
  • 5. Early Chilhood Anatomy
    • Little estrogen stimulation
    • Labia majora flatten, labia minora and hymen become thin
    • Vagina has atrophic mucosa and is very susceptible to trauma & infection
    • Cx is flush with vaginal vault as vaginal fornices do not develop until puberty
    • Uterus regresses in size until about age 6
    • Ovaries begin to enlarge & descend
    • By age 7-10 years, genitalia start to show signs of estrogen stimulation with thickening of the mons pubis, labia majora, hymen, & vaginal mucosa.
    • The labia minora become rounded & the vagina elongates to 8cm
    • Uterus starts to grow and rapid endometrial proliferation occurs as menarche becomes imminent
    • # ovarian follicles increases
    www.freelivedoctor.com
  • 6. History & Physical Exam
    • Give child an opportunity to speak with you alone when appropriate
    • Give child as much control as possible over situation & get them involved in the exam if possible
    • Be mindful of abuse and be aware of appropriate steps in suspicious cases
    • Never restrain a child (general anesthetic may be required)
    • Have parents sit on table with child
    • Use frog leg and knee/chest positions in younger children
    • Inspect hymen carefully for signs of breaks or trauma as minor external injuries may hide serious vaginal lesions
    • Inspect anal region but do vaginal/rectal exams only when needed (imaging often better option)
    www.freelivedoctor.com
  • 7. Instruments
    • May need instruments to visualize the upper 1/3- 1/2 of the vagina
    • Office vaginoscope can be tried (0.5 cm in infancy/childhood & 0.8 cm in premenarcheal girls)
    • Water cystoscope allows some distention of vagina & cleans debris
    • Can use urethroscope/laparoscope
    • Topical lidocaine to anesthetize vulva
    • General Anesthesia if exam not easy
    • Huffman-Graves & Pedersen specula should be used for adolescents
    • Saline soaked swabs are used for vaginal samples in children because this is adequate given immature lining
    • Speculum exam with Cx cultures may be necessary in adolescent
    www.freelivedoctor.com
  • 8. Genital Ambiguity
    • 1/14 000 newborns
    • Needs immediate identification and response as life threatening salt wasting congenital adrenal hyperplasia may be cause
    • Ambiguity can result from masculinization of a female child, exogenous hormone ingestion, maternal or fetal overproduction of androgens, incomplete virilization of a male infant, hormonal insensitivity, gonadal dysgenesis, or chromosomal abnormalities
    • Assessment should include lytes, 17-hydroxyprogesterone, cortisol, karyotype, and any other relevant blood work
    • Careful genital exam and pelvic u/s to detail internal anatomy
    • Multidisciplinary approach essential
    www.freelivedoctor.com
  • 9. Clitoral Abnormalities
    • Normal clitoris 1-1.5 cm long and 0.5 cm wide
    • Abnormalities uncommon
    • Clitoromegally usually associated with  androgen exposure (often assoc with labial fusion)
    • Clitoral splitting is rare and caused by a midline fusion defect
    • Bifid clitoris usually assoc with bladder extrophy
    • Extrophy rare (1/30 000 births)
    • > 40% assoc with some genital tract abn
    www.freelivedoctor.com
  • 10. Imperforate Hymen
    • Represents a persistent portion of the urogenital membrane
    • One of most common obstructive lesions in the female genital tract
    • Incidence 1/1000 live born ♀
    • Generally sporadic anomaly
    • Often not diagnosed until puberty with c/o cyclical abd pain & 1 O amenorrhea
    • Classic is bluish bulge at introitus
    • Mucocolpos or hematocolpos may cause pain, difficulty voiding/defecating
    • Variations include imperforate, microperforate, septate, and cribriform hymens
    • Requires surgical resection if clinical significance evident
    www.freelivedoctor.com
  • 11. Transverse Vaginal Septum
    • Results from faulty fusion or defective canalization of the urogenital sinus & mullerian ducts
    • 1/75,000 women
    • 46% upper, 40% mid, & 14% lower vagina
    • Septa in the upper vagina more likely to be patent
    • Complete septum has similar signs & Sx as an imperforate hymen except without the bulge at the introitus
    • Membrane excised with surrounding ring of subepithelial tissue & may then require an end to end reanastomosis of upper and lower vaginal mucosa (depending on the thickness of the septum)
    www.freelivedoctor.com
  • 12. Longitudinal Vaginal Septum
    • Duplication of vagina very rare & often associated with duplication of vulva, bladder, & uterus
    • More commonly, longitudinal septa form when the distal ends of the mullerian ducts fail to fuse properly
    • Surgical excision not required unless symptomatic or worries re: SVD
    www.freelivedoctor.com
  • 13. Vaginal Agenesis
    • Incidence 1/5000
    • Most common cause is Mayer-Rokitansky-Kuster-Hauser Syndrome (46XX)
    • Not inherited but is an accident of development
    • External genitalia normal with variable levels of uterine development, although often cervical & uterine agenesis are present
    • May be urinary tract, spinal, middle ear, & other mesodermal structural abnormalities
    • 75% with MRKH have complete vaginal agenesis and 25% have a short vaginal pouch
    www.freelivedoctor.com
  • 14. Vaginal Agenesis
    • Typically normal female karyotypes with normal ovaries and ovarian function
    • Normal secondary sexual characteristics
    • Often present with 1 O amenorrhea
    • Creation of a vagina should be delayed until pt wishes to be sexually active
    • Vaginal dilators or surgical creation
    • Complete androgen insensitivity may also present as vaginal agenesis and must be correctly identified 2 O risk of gonadoblastoma (4-5% risk)
    • Chromosomal analysis is definitive
    www.freelivedoctor.com
  • 15. Uterine Abnormalities
    • Result from agenesis of the mullerian duct or a defect in fusion or canalization
    • Most are asymptomatic & are only picked up incidentally or when they interfere with reproduction
    • Bicornuate uterus (37%), arcuate uterus (15%), incomplete septum (13%), uterine didelphys (11%), complete septum (9%), & unicornuate uterus (4%)
    • Mullerian anomalies occur in 1-3% ♀
    www.freelivedoctor.com
  • 16. Unicornuate Uterus
    • Single horned uterus with corresponding fallopian tube & round ligament
    • Results from agenesis of 1 mullerian duct with absence of structures on 1 side
    • If other hemiuterus present, a small rudimentary horn is created
    • If this horn does not communicate with other cavity or vagina, may develop dysmenorrhea and hematometra
    • Higher risk preterm labor, infertility, endometriosis, & malpresentation
    www.freelivedoctor.com
  • 17. Uterine Didelphys
    • Failure of fusion of the mullerian duct may result in 2 separate uterine bodies
    • Generally good reproductive outcomes
    • Vaginal septae may require resection if causing difficulty with intercourse, vaginal delivery, or pain from obstructed menstruation
    www.freelivedoctor.com
  • 18. Bicornuate Uterus
    • Results from partial fusion of the mullerian ducts which leads to varying degrees of separation of the uterine horns
    • Reproductive function is generally good
    www.freelivedoctor.com
  • 19. Septate Uterus
    • Results from failure of canalization or resoption of the midline septa between the 2 mullerian ducts
    • Higher risk of miscarriage with increasing length of septa
    • Hysteroscopic resection may need to be considered
    www.freelivedoctor.com
  • 20. Vulvovaginitis
    • Most common gyne complaint of children
    • Children are susceptible to pruritus & vaginal discharge from irritation/infection as the vulva is thin without labial fat pads and pubic hair, closer to the anus, unestrogenized vagina is atrophic, pH is excellent for bacterial growth, & perineal hygiene is suboptimal
    • Itch/scratch cycle and subsequent inflammation & bleeding
    www.freelivedoctor.com
  • 21. Vulvovaginitis
    • Sand boxes, wet clothes, etc contribute
    • May have large extension onto thighs
    • Note of other derm conditions/lesions and whether there are signs of abuse
    • Wet mount may show numerous leuks
    • Cultures & evaluation of vaginal secretions as appropriate
    • Most cases resolve with better hygiene & avoidance of irritants
    www.freelivedoctor.com
  • 22. www.freelivedoctor.com
  • 23. Foreign Bodies
    • Very common in children
    • Often present with vulvovaginitis, pain, foul smelling purulent/bloody d/c
    • Often fragments of toilet paper but may be toys etc which child may not remember or admit to
    • Foreign bodies in the lower 1/3 vagina can often be flushed out with warm saline irrigation
    • Vaginoscopy in many cases appropriate
    www.freelivedoctor.com
  • 24. Labial Agglutination
    • Common in prepubertal children
    • Etiology unknown but likely secondary to low estrogen levels
    • Skin covering labia is thin and local irritation may denude the labia causing adherence in the midline and reepithelialization
    • Must distinguish from vaginal atresia
    • Most children are asymptomatic but may have urinary Sx & recurrent infections
    • Tx if symptomatic is estrogen cream bid for 7-10 days
    • Surgical separation may be necessary in some cases
    • Recurrence common
    www.freelivedoctor.com
  • 25. Trauma
    • Straddle injuries most common cause of genitalia trauma in young girls
    • Seasonal peak in spring with bikes
    • Contusions generally require no tx
    • Hematomas are generally controlled with pressure & an ice pack although an enlarging hematoma may need incision & ligation of bleeders
    • May need to pack vagina
    • Catheter if hematoma blocking urethra
    • Pelvic X-ray & Abx as appropriate
    • Must rule out more severe injury (eg above hymenal ring)
    www.freelivedoctor.com
  • 26. Abuse
    • May victims are not seen immediately
    • Suspect
    • Know who to call & be sure of evidence collection
    • Tx all injuries, good perineal care, screen for STD’s & tx as needed
    • Pregnancy test if appropriate
    • Counselling & support
    www.freelivedoctor.com
  • 27. Neoplasms
    • Uncommon but about 50% genital tumors found in children are premalignant or malignant
    • Benign tumors of the vulva/vagina include teratomas, hemangiomas, simple cysts of the hymen, granulomas, & condylomata acuminata,
    • Only large, suspicious, or symptomatic lesions require surgical removal
    • Embryonal vaginal carcinomas most commonly seen < 3y
    • Tumors arise in the submucosal tissues & spread rapidly beneath an intact vaginal epithelium so that the mucosa bulges into a series of polypoid growths (botryoid sarcoma)
    www.freelivedoctor.com
  • 28. Neoplasms
    • Ovarian tumors most common genital tumor (1% total)
    • Most common neoplasm in girls is the dermoid
    • 70 % germ cell
    • Abdominal pain & mass most common sx
    • Tumors present abdominally
    www.freelivedoctor.com