The adolescent pelvic examination allows thorough examination of the female external and internal genital structures and anus. A pelvic examination in the emergency setting is indicated for an adolescent female presenting with vaginal discharge, abnormal uterine or vaginal bleeding, amenorrhea, lower abdominal pain, severe dysmenorrhea, exposure to a sexually transmitted disease (STD), suspected pregnancy, genital or anal pruritus, suspected foreign body, pelvic inflammatory disease, or suspected sexual assault (1,2,3,4). Pelvic examinations have been traditionally indicated in the ambulatory setting for all sexually active teens, for patients seeking birth control, for STD surveillance, and for routine health assessment in all women over approximately 17 years of age (1,5,6). With the advent of nucleic acid amplification tests (NAATs), which offer the ability to screen for Chlamydia trachomatis and Neisseria gonorrhoeae noninvasively using urine samples, the need for pelvic examinations for STD surveillance has decreased, although obtaining pap smears and looking for other STDs such as herpetic lesions and human papillomavirus lesions still makes pelvic examinations necessary (7,8,9).

Properly trained pediatricians, emergency physicians, and other health care providers can perform pelvic examinations with skill and accuracy. Consultation with specialists is sometimes required. Patients with possible oncologic problems or those who are pregnant should be referred to an obstetrician and/or gynecologist (OB/GYN). Consultation with an endocrinologist may be necessary for hormonal aberrations such as virilization or delayed puberty.

Despite its value, the pelvic examination is often associated with dread by both patient and physician (10). Patient anxiety is especially great at the time of the first pelvic examination and may reach an anxiety level similar to that seen in patients before surgery (11). The most common patient concern is of pain from the procedure, and this fear is directly related to the information peers have passed on to the patient (11). Additional sources of anxiety include embarrassment over having breasts and genitals exposed and examined, feelings of vulnerability during the examination, perception of losing control of one’s body, concern that a gynecologic disorder will be discovered, and concerns about personal cleanliness and hygiene (11,12). Positioning, presence of a support person, and gender of the clinician have all been associated with adolescents’ perception of the discomfort and the level of anxiety associated with the procedure (12,13,14).

Reproductive and sexual functions are obviously sensitive subjects, and examinations of the genital and anal area require a thoughtful approach. Using force or restraint is always contraindicated. Sedation or anesthesia is acceptable only in the most extreme cases when examination cannot be deferred, such as patients with severe, uncontrollable vaginal bleeding. Patient requests regarding gender of clinician should be accommodated whenever possible (10,15).

Pelvic examination of the adolescent differs from the genital examination in the prepubertal child (Chapter 91) in its inclusion of an internal speculum and bimanual examination. Pelvic examinations are typically performed on adolescent patients with Tanner stages of 3 or above. Tanner stages are analogous to sexual maturity ratings and reflect the presence of secondary sexual characteristics (16).

Although few would argue that a pelvic examination is an important part of a comprehensive physical examination in the adolescent patient, it remains a procedure viewed as technically difficult. With adequate training, the correct equipment, an unhurried approach, and a sensitive demeanor, the procedure can be completed with a minimum of discomfort to the patient.

The external and internal structures of the adolescent female genital and anal anatomy are similar to those described in the prepubertal child. They differ, however, in terms of size and estrogen effect. The length of the vagina grows from approximately 3 to 4 cm in the infant to approximately 10 to 12 cm in the sexually mature adolescent female (17). The translucent hymenal membrane in the prepubertal child changes under the influence of estrogen and appears pink, thickened, and opaque on examination. With puberty, the labia majora, mons pubis, and perineal area increase in pigmentation and develop pubic hair. The vaginal pH becomes acidic, normal vaginal flora changes, and a physiologic leukorrhea composed of desquamated epithelial cells and cervical mucus develops (18).