chapter 18 Gynecologic Assessment
The most frequently neglected and poorly performed part of the physical examination of children is the examination of the genitalia. Explanations include the examiner’s personal inhibitions and inexperience, reluctance to cause anxiety or embarrassment to the child, and the parents’ inhibitions. This is unfortunate because examination of the genitalia may reveal unsuspected abnormalities that require treatment or may provide information that helps establish a diagnosis.
When an examination of the genitalia in young or adolescent girls is carried out tactfully and skillfully, it is remarkable how little anxiety is produced and how quickly any anxiety can be diffused. Making a genital examination a routine part of a girl’s physical examination from an early age may help to promote lifelong compliance with regular gynecologic assessments. In 2008, two groups of young women were questioned, hospital outpatient obstetric and gynecology clinic attendees, and secondary school students about gender preference and about the involvement of medical students with intimate examinations. Several common themes emerged. Attributes such as availability, competence, sensitivity, and skill were more important than physician gender. Also, patients’ comfort with physicians of either gender stemmed from previous positive interactions with their doctors. Exposure to male physicians during childhood enhanced comfort with male physicians as young women matured. Finally, the results suggested that increasing experience with intimate examinations resulted in greater comfort with these examinations and a greater willingness to involve medical students of either gender.
Anxiety and tension are highly communicable disorders. When a physician is apprehensive about performing a gynecologic assessment, his or her apprehension is quickly communicated to the patient. A soft reassuring voice, showing respect for the child’s privacy and modesty, and chatting about unrelated issues are important to reassure the child. Discussing school, family, and hobbies will help most children undergo a gynecologic assessment in a reasonably relaxed way.
Approach to the Physical Examination
An infant or very young child can be examined most easily while she is semirecumbent on her mother’s lap with her hips flexed and abducted. Put lateral and downward pressure on the labia majora so that you can visualize the introitus, hymen, and lower third of the vagina (Fig. 18–1). An alternative, equally effective technique is to hold the labia majora gently between your thumbs and forefingers and gently draw them forward (Figs. 18–2 and 18–3).
FIGURE 18–1 Lateral retraction of the labia majora while a prepubertal girl lies in a frog-legged position.
FIGURE 18–2 Forward retraction of the labia majora facilitates inspection of the hymenal area in this prepubertal child. An annular hymen is easily seen.
A child who is age 2 years or older can also be examined in the knee-chest position. The child holds her bottom in the air with her knees 10 to 15 cm (about 4 to 6 inches) apart, allowing her stomach to sag against her thighs. Have an assistant or parent gently retract the labia majora on one side laterally and upward while you do likewise on the other side. This positioning facilitates the inspection of the external genitalia and causes the pubococcygeus muscle to relax, allowing the vagina to fall open. You can visualize the entire length of the vagina and frequently identify the cervix. Use the otoscope (without a speculum) to provide magnification and good illumination along the length of the vagina. Do not allow the otoscope to touch the external genitalia or to enter the vagina.
Examination of external genitalia
Examination of the external genitalia should include a systematic inspection of the clitoris, urethra, labia majora, labia minora, perihymenal tissues, hymen, posterior fourchette, and perineal body. Document the hymenal configuration and confirm its patency.
Variations in normal hymenal configuration have been well described (Figs. 18-4 to 18-6). Fimbriated hymens are characterized by redundant folds of hymenal tissue with scalloped rims that circumscribe the vaginal introitus. Annular or circumferential hymens are smooth, uniform skirts of hymenal tissue that completely surround the vaginal introitus. Posterior rim or crescentic hymens appear as smooth folds of tissue arranged from 2 o’clock through 11 o’clock around the introitus, with minimal or no hymenal tissue present inferiorly under the urethra.
FIGURE 18–4 Posterior rim hymen.
(From Pokorny S: Physical examination of the reproductive systems of female children and adolescents. Curr Probl Obstet Gynecol Fertil 8:202, 1990.)
FIGURE 18–5 Circumferential hymen.
(From Pokorny S: Physical examination of the reproductive systems of female children and adolescents. Curr Probl Obstet Gynecol Fertil 8:202, 1990.)
(From Pokorny S: Physical examination of the reproductive systems of female children and adolescents. Curr Probl Obstet Gynecol Fertil 8:202, 1990.)
The hymenal orifice at the introitus varies in size and placement, the variations being directly influenced by the configuration of the hymenal tissue. You should be able to identify microperforate hymen, imperforate hymen, and cribriform hymen. The orifice of a microperforate hymen can be difficult to identify, but gentle probing directly beneath the urethra with a small moist swab helps locate the opening. The unestrogenized hymen is a very sensitive structure, thus care should be taken with any manipulation. Transverse hymenal bands and tags have been reported in 3% to 4% of girls and can be identified at the time of the newborn examination.
The diameter of the hymenal opening into the vagina varies with a child’s level of relaxation during the examination, age, the stage of pubertal development, and the configuration of the hymen. There is overlap in diameters recorded for varying age groups. Between ages 5 and 10 years, however, the upper normal limit of the transverse diameter of the hymenal orifice (in millimeters) should not exceed the child’s age in years. In a child in whom the transverse diameter is larger than expected for the age, you should question the possibility of a prior penetrating injury or prior instrumentation of the vagina.
Periurethral bands are observed in approximately 50% of prepubertal girls. These bands are bilateral in 91%, creating false pockets on either side of the urethral meatus.
The appearance of the labia and perihymenal tissues may suggest that the child has been exposed to endogenous (or possibly exogenous) estrogen. The labia and perihymenal tissues of an unestrogenized prepubertal girl are poorly developed and appear red. Labial agglutination (Fig. 18–7) and chronic skin changes, such as increased pigmentation, may suggest a chronic inflammatory process. Document the presence of a purulent discharge, smegma, or leukorrhea. A thicker, lesser fusion of the posterior aspect of the labia minora may suggest excessive androgen stimulation due to congenital adrenal hyperplasia, especially if the labial fusion is associated with clitoral enlargement. If clitoromegaly is present, measure the clitoris glans in both transverse and longitudinal diameters. Normal values for clitoral size at various ages and stages of sexual development are available in pediatric gynecologic references.
Indications for vaginoscopy
Instrumentation of the vagina is rarely required in the evaluation of prepubertal girls. Indications for vaginoscopy include undiagnosed vaginal bleeding, refractory vaginal discharge, and suspicion of intravaginal foreign body. Before beginning vaginoscopy, show the child all the instruments, and let her touch them (Fig. 18–8). If you intend to obtain cytologic and bacteriologic specimens during vaginoscopy, use only water as a lubricant. Cystoscopes, hysteroscopes, and anoscopes have all been used for vaginoscopy.
Office vaginoscopy can be carried out successfully when the child understands what is to be done and trusts you. Because the vagina of a prepubertal girl is a short (4 to 5 cm), nonpliant cylinder that can be traumatized easily, place any instrument gently. The hymenal membrane is particularly sensitive. Applying 2% lidocaine jelly to the introitus may help make the examination less uncomfortable. If the child is tense and the hymenal opening does not relax, postpone vaginoscopy until the child is less anxious and better able to cooperate. A child should never be forcibly restrained during such an examination. On rare occasions, the gynecologic examination of a very young or very anxious child may best be carried out with anesthesia or conscious sedation.
Bacteriologic cultures
Bacteriologic cultures, when required, should be obtained from the prepubertal child’s vagina. Vulvar sampling is not sufficient. It is not necessary to sample the endocervical canal, as you would in adults because sexually transmitted infections in this age group involve the vagina, not the cervix.
Even the seemingly simple task of obtaining a culture specimen from the vagina can be difficult because the prepubertal vaginal mucosa, being hypoestrogenic, is easily abraded.
It is important to premoisten culture swabs with nonbacteriostatic saline solution or sterile water. Use appropriately sized swabs for culturing, always choosing the smallest swab available (Fig. 18–9). Prior to collecting bacteriologic or viral specimens from the prepubertal child’s vagina, it may be prudent to discuss your needs with your local laboratory or microbiologist because the availability of testing methods will vary among facilities. Diagnostic modalities could range from culture, microscopy, antigen detection tests, nucleic acid detection test, or serology. The sensitivity and specificity of tests will vary according to the specimen type and the organism assayed. So seek an expert opinion first to ensure that you do the most appropriate test because children do not like vaginal sampling.
FIGURE 18–9 A Calgiswab (top) or a plastic eyedropper (bottom) can be used to obtain bacteriologic specimens from the prepubertal vagina.
Vaginal specimens may be obtained while the child is either in the knee-chest position or in the supine position, whichever effects greatest relaxation of the hymenal orifice, allowing the swab to be passed into the vagina without touching the sensitive hymenal membrane. Some clinicians report success with the use of vaginal irrigation specimens for culture. A malleable plastic sterile eyedropper or butterfly catheter tubing, encased in a red rubber catheter and with the needle removed, has been used to flush the vagina with sterile nonbacteriostatic saline solution or sterile water.
Bimanual rectoabdominal examination is indicated in any prepubertal girl who presents with undiagnosed vaginal bleeding or in whom an intravaginal foreign body or a pelvic mass is suspected. As mentioned previously, the vagina in prepubertal girls is short, nonpliant, and easily abraded. You can obtain more information if you perform a rectoabdominal examination with the child in a supine, frog-legged position. A bimanual examination should enable you to identify the small uterus as a midline structure. Ovaries are abdominal organs in prepubertal girls; therefore, they should not be normally palpable on a bimanual examination.
Examining adolescent girls
Gynecologic examination of an adolescent girl begins with the interview. If a young girl is uncomfortable being interviewed alone and requests her parent’s presence, make sure to phrase the questions so that the girl is aware that she, and not her parent, is the patient and is the person controlling the interview. If it is difficult to separate the parent from the child, defer confidential personal questioning to another visit, when the youngster may be more relaxed. Some physicians establish ground rules with the teenager and her parents, telling them that at a predetermined age, such as 12 years, you will spend some time talking with the young girl alone. It is very important, when dealing with adolescents, to convey to them a sense of self and to reassure them that everything they tell you is confidential and will not be conveyed to their parents without their consent. You also must establish with a young patient that if she is pursuing life-threatening behaviors, you will be compelled to involve other health care providers and her parents, even without her consent.
Obtaining the History
A complete gynecologic history can indicate whether gynecologic disease is present. Document the age of onset and progress of pubertal change (thelarche, adrenarche; see Chapter 16). The mother’s age at menarche is often a good predictor of when her daughter will experience her first menstrual period. Menarche commonly occurs 2 years after thelarche, when breast development reaches Tanner stage 4.
Menses can be characterized in terms of duration of flow, amount of flow, and interval between menses (Fig. 18–10). The normal duration of flow varies from 3 to 7 days. Persistence of menses for longer than 10 days warrants evaluation. When asking about the cycle interval, make sure that the days of menstrual flow are included in the estimate. Day 1 of the menstrual cycle is the first day of the menstrual flow. A range of 25 to 35 days should be accepted as falling within the range of normal; shorter or longer intervals may require evaluation and treatment. Cycles can remain anovulatory for 2 to 4 years after menarche. Therefore, early cycle irregularity may reflect immaturity of the hypothalamic-pituitary-ovarian axis rather than gynecologic disease.
FIGURE 18–10 The menstrual calendar is a useful tool for prospectively recording menses.
(Courtesy of Dr. JEH Spence, Ottawa Civic Hospital, Ottawa, Ontario, Canada.)
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