Key points
- •
It is important to give the child a sense that she will be in control of the examination process. Emphasize that the most important part of the examination is just “looking” and that there will be conversation during the entire process.
- •
Many gynecologic conditions in children can be diagnosed by inspection alone.
- •
The vaginal epithelium of the prepubertal child appears redder and thinner than the vaginal epithelium of a woman in her reproductive years.
- •
The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman.
- •
The vagina of a child is 4 to 5 cm long and has a neutral pH.
- •
During the physical examination, including rectal examination, of the prepubertal child, no pelvic masses except the cervix should be palpable. The normal prepubertal uterus and ovaries are nonpalpable. The relative size ratio of cervix to uterus is 2:1 in a child.
- •
Many adolescent girls do not want other observers, such as mothers, in the examining room.
- •
It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation and discharge.
- •
Positive identification of gonorrhea or chlamydia in a child with premenarcheal vulvovaginitis is considered diagnostic of sexual abuse. However, many infants are infected with Chlamydia trachomatis during birth and remain infected for up to 2 to 3 years in the absence of specific antibiotic therapy.
- •
The major factor in childhood vulvovaginitis is poor perineal hygiene.
- •
A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body.
- •
In the period surrounding the time of puberty, children often develop a physiologic discharge secondary to the increase in circulating estrogen levels.
- •
The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene.
- •
The majority of cases of persistent or recurrent nonspecific vulvovaginitis respond to improved hygiene and treatment of irritation resulting from trauma or irritating substances.
- •
The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole.
- •
The most common vaginal foreign body in preadolescent girls is a wad of toilet tissue.
- •
Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. However, it is important to do a thorough workup because of the serious sequelae of some of the causes of vaginal bleeding.
- •
Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment.
- •
The usual cause of genital trauma during childhood is an accidental fall. Most such traumas involve straddle injuries.
- •
Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. Because of compassion and empathy, the gynecologist may underestimate the extent of the anatomic injuries.
- •
Small follicular cysts in preadolescent girls are usually self-limiting.
- •
Ultrasound should be used as the initial diagnostic imaging technique for the evaluation of the pelvis in children and adolescents.
- •
Ovarian tumors constitute approximately 1% of all neoplasms in premenarcheal children. In preadolescent girls, both benign and malignant ovarian tumors are usually unilateral. Routine biopsy of the normal-appearing contralateral ovary should be avoided.
- •
Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common.
- •
The most common malignancy in preadolescent girls is a germ cell tumor.
- •
Even though ovarian neoplasms are rare in children, this diagnosis must be considered in a young girl with abdominal pain and a palpable mass.
- •
The surgical therapy of an ovarian neoplasm in a child should have two goals: the appropriate surgical removal of the neoplasm and the preservation of future fertility.
- •
Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance.
- •
Presence or absence of Doppler flow in the ovary on ultrasound is not diagnostic of ovarian torsion, and the decision to pursue surgical intervention should be based on the level of clinical suspicion.
Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. This chapter considers gynecologic diseases of children from infancy through adolescence. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters.
The evaluation of children’s gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . The evaluation of young girls is age dependent. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. Thus the office visit and the gynecologic physical examination are performed differently in a prepubertal child compared with an adolescent girl or a mature reproductive-age woman.
Gynecologic visit and examination of a child
General approach
Considerable effort should be devoted to gaining the child’s confidence and establishing rapport. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. If the interaction is poor during the first visit, the negative experience will detract from future physician-patient interactions ( ).
The pediatric gynecologic visit may be unique to both the child and the parent. Most pediatric visits are preventive in nature, but the pediatric gynecologic visit is usually problem oriented . This may create considerable and understandable anxiety in the child and parent. The majority of children’s gynecologic problems are treated by medical , rather than surgical, means .
The most common gynecologic condition of children is vulvovaginitis . Other commonly seen diagnoses at a pediatric gynecology visit include labial adhesions, vulvar lesions, suspicion of sexual abuse, and genital trauma. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia.
A successful gynecologic examination of a child demands that the physician employ an exam pace that conveys both gentleness and patience with the time spent, without seeming to be hurried or rushed. One excellent technique is for the physician to sit, not stand, during the initial encounter. This conveys an unhurried approach. The ambiance of the examining room may decrease the anxiety of the child if familiar and friendly objects such as children’s posters are present. Interruptions should be avoided. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit.
Performance of the gynecologic exam in a child
The components of a complete pediatric examination include a history, inspection with visualization of the external genitalia and noninvasive visualization of the vagina and cervix, and, if necessary, a rectal examination ( ).
Obtaining a history from a child is not an easy process. Children are not skilled historians and will often ramble, introducing many unrelated facts. Much of the history must be obtained from the parents . However, young children can help define their exact symptoms on direct questioning.
In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. One way to describe genital area and breasts is to call them “ private areas ” and define this as meaning areas that are covered by a bathing suit. The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse.
After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . It is important to give the child a sense that she will be in control of the examination process. A helpful technique is to place the child’s hand on top of the physician’s hand as the abdominal examination is being performed and to give her some choices, such as having a doll, an electronic tablet, or a toy with her. This will give the child a sense of control and divert the child’s attention if she is ticklish or is squirming. Emphasize that the most important part of the examination is just “looking” and there will be conversation during the entire process. To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant.
A child’s reaction will depend on her age, emotional maturity, and previous experience with health care providers. She should be allowed to visualize and handle any instruments that will be used. Many young children’s primary contact with providers involves immunizations; children should be assured that this visit does not involve any “shots.” It is also helpful to assure the adult accompanying the child that speculums are not part of the examination.
Occasionally it is best to defer the genital examination until a second visit . This is a difficult decision and is based on the extent of the child’s anxiety in relation to the severity of the clinical symptoms. Physicians may elect to treat the primary symptoms of vulvovaginitis for 2 to 3 weeks, realizing that on rare occasions they could be missing something more serious. It is recommended that the examination start with the nongenital areas , such as listening to the heart and lungs; an abdominal examination and inspection of the skin should be performed. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. A child should never be restrained for a gynecologic examination . Often reassurance and sometimes delay until another day are the best approaches. In rare circumstances, it may be necessary to use continuous intravenous conscious sedation or general anesthesia to complete an essential examination. The most important technique to ensure cooperation is to involve the child as a partner. Ideally children should feel they are part of the examination rather than having an exam “done to them.”
Draping for the gynecologic examination may produce more anxiety than it relieves and is unnecessary in the preadolescent child. A handheld mirror may help in some instances when discussing specifics of genital anatomy. It is critical to have all tools, culture tubes, and equipment within easy reach during a pediatric genital examination. Children often cannot hold still for long intervals while instruments are being located.
The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. 12.1 ). An infant may be examined on her mother’s lap. Pads should be placed in the mother’s lap because examination often is associated with urination. Young children may be examined in the frog leg position, and children as young as 2 to 3 years of age may be examined in the lithotomy position with use of stirrups, although this is generally used for girls aged 4 to 5 years and older.
Once the child is positioned, the vulvar area and introitus should be inspected. Many gynecologic conditions in children may be diagnosed by inspection . The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. 12.2 ). Asking the child to pretend to blow out candles on a birthday cake may facilitate the process. Visualization of the introitus is better achieved using the previously described traction and the Valsalva maneuver than separation because it gives a deeper view of the structures and partial visualization of the vagina.
The second phase of the examination involves evaluation of the vagina . This can be accomplished without the insertion of any instruments. One method is to use the knee-chest position (see Fig. 12.1 , B ). The child lies prone and places her buttocks in the air with legs wide apart. The vagina will then fill with air, aiding the evaluation. The child is told to have her abdomen sag into the table. An assistant pulls upward and outward on the labia majora on one side while the examiner does the same with the nondominant hand on the contralateral labia. Then an otoscope or ophthalmoscope is used as a magnifying instrument and light source but is not inserted into the vagina.
While the light from the otoscope or ophthalmoscope is shone into the vagina, the examiner can evaluate the vaginal walls and visualize the cervix as a transverse ridge, or flat button, that is redder than the vagina. This technique is generally successful in cooperative children unless there is a very high crescent-shaped hymen, in which case it is too difficult to shine the light into the small aperture of the vaginal introitus. A foreign object and the cervix may be visualized using this technique. After inspection of the vagina and cervix, vaginal secretions may be obtained for microscopic examination and culture (the technique is described later).
Normal findings: Hymen and vagina of a prepubertal child
The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. 12.3 ). Hymens are often crescent shaped but may be annular or ringlike. They may have septums, microperforations, or fingerlike extensions or be completely imperforate. There are no reported cases of congenital absence of the hymen. A mounding of hymeneal tissue is often called a bump. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. Hymens in newborns are estrogenized, resulting in a thick, pink, elastic redundancy. Older unestrogenized girls have thin, nonelastic hymens with significant signs of vascularity. Not every variant of hymen is normal, and transections between 3 and 9 o’clock should raise a suspicion for abuse because these are likely acquired rather than congenital (discussed further in Chapter 9 ).
The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . Recurrent vulvovaginitis, persistent bleeding, suspicion of a foreign body or neoplasm, and congenital anomalies may be indications to perform a vaginoscopy and examine the inside of the vagina.
Vaginoscopy in a prepubertal child most often requires sedation with a brief inhalation or intravenous anesthetic, but in select circumstances it can also be performed in the office with older, cooperative children. The introduction of any instrument into the vagina of a young child takes skillful patience. The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. There are many narrow-diameter endoscopes that will suffice, including the Kelly air cystoscope, contact hysteroscopes, pediatric cystoscopes, small-diameter laparoscopes, plastic vaginoscopes, handheld disposable hysteroscopes (e.g., Endosee Handheld Hysteroscopy System, CooperSurgical Inc., Trumbull, CT), and special smaller, narrower speculums designed by Huffman and Pederson. The ideal pediatric endoscope is a cystoscope or hysteroscope because the accessory channel facilitates the retrieval of foreign bodies while at the same time allowing a vaginal lavage to be performed. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. A complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children.
The last step in the pelvic examination may be a rectal examination. This is often the most distressing aspect of the examination and may be omitted, depending on the child’s symptoms. Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. The normal prepubertal uterus and ovaries are nonpalpable on rectal examination. The relative size ratio of cervix to uterus is 2:1 in a child, in contrast to the opposite ratio in an adult. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. In this age of reliable access to ultrasonography, the internal genital examination to evaluate the uterus and ovaries can be performed with the assistance of sonography , often sparing the child from a rectal or pelvic examination.
The office visit and examination of the adolescent girl
Adolescence is the period of life during which an individual physically matures and begins to transition psychologically from a child into an adult . This period of transition involves important physical and emotional changes. Before puberty, the girl’s reproductive organs are in a resting, dormant state. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescent’s hormonal milieu. Because the pubertal changes are often a cause of concern for adolescent girls and their parents, the gynecologist must offer the adolescent patient an empathetic, kind, knowledgeable, and gentle approach. These interactions between the physician and the adolescent girl allow the physician an opportunity to gain the patient’s trust and educate the pubertal teenager about pelvic anatomy and reproduction.
The critical factors surrounding the pelvic examination of an adolescent girl are different from those of examinations of children 2 to 8 years old. Many adolescent girls do not want their mother, guardian, or other observers in the examining room, and in many adolescent gynecology visits, a full pelvic examination is unnecessary ( ). Common indications for a pelvic examination in an adolescent are listed in Box 12.1 .
Delayed puberty
Pelvic pain
Suspicion of intraabdominal disease
Dysfunctional uterine bleeding
Undiagnosed vaginal discharge
Inability to insert tampons
Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . A patient in early adolescence (aged 12 to 14 years) may behave similarly and need similar support as those in the prepubertal stages. They may ask for their mothers to be there, be fearful of the examination concept, and need more than one visit to achieve the goals of the visit. Those in middle or late adolescence (aged 15 to 19 years) may be more accepting of the idea of an examination and more likely to cooperate with the proper counseling and in the appropriate setting.
Adolescents often come for examinations with the preconceived idea that it will be very painful. Slang terminology for speculums among teens includes the threatening label “the clamp.” Teens should be assured that although the examination may include mild discomfort, it should not be painful . Providers can counsel patients that they will inform them of each step in the process and then ask the teen if she is ready before performing each step. This places the teen in control of the tempo and allows her to anticipate the next element of the examination. Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. In this setting it may be helpful to use the “extinction phenomenon,” in which the examiner provides pressure on the perineum lateral to the introitus before insertion of the speculum.
Problems in prepubertal children
Vulvovaginitis
Vulvovaginitis is the most common gynecologic problem in prepubertal girls. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation (discomfort/pruritus) or discharge ( Table 12.1 ) ( ).
| Features | Number | Percentage |
|---|---|---|
| S ymptoms | ||
| Itch | 81 | 40 |
| Soreness | 108 | 54 |
| Bleeding | 37 | 19 |
| Discharge | 104 | 52 |
| S igns | ||
| Genital redness | 167 | 84 |
| Visible discharge | 66 | 33 |
| Perianal soiling | 35 | 18 |
| Specific skin lesion | 28 | 14 |
| None | 5 | 2-4 |
The prepubertal vagina is neutral or slightly alkaline. With puberty , the prepubertal vagina becomes acidic under the influence of bacilli dependent on a glycogenated estrogen-dependent vagina. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment.
The severity of vulvovaginitis symptoms varies widely from child to child. The pathophysiology of the majority of instances of vulvovaginitis in children involves a primary irritation of the vulva, which may be accompanied by secondary involvement of the lower one-third of the vagina. Most cases involve an irritation of the vulvar epithelium by normal rectal flora or chemical irritants . This is referred to as nonspecific vulvovaginitis. There often are predisposing factors that lead to vulvar irritations, such as the use of perfumed soaps or the pressure from tight seams of jeans or tights, which create denudation, allowing the rectal flora to easily infect the irritated epithelium. Cultures from the vagina indicate normal rectal flora or Escherichia coli. In a primary care setting, nonspecific vulvovaginitis accounts for the majority of vulvovaginitis cases.
There are both physiologic and behavioral reasons why a child is susceptible to vulvar infection. Physiologically the child’s vulva and vagina are exposed to bacterial contamination from the rectum more often than are the adult’s. Because the child lacks the labial fat pads and pubic hair of the adult, when a child squats, the lower one-third of the vagina is unprotected and open. There is no significant geographic barrier between the vagina and anus. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. The vaginal epithelium of a prepubertal child has a neutral or slightly alkaline pH, which provides an excellent medium for bacterial growth. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. The normal vagina of a prepubertal child is colonized by an average of nine different species of bacteria: four aerobic and facultative anaerobic species and five obligatory anaerobic species.
A major factor in childhood vulvovaginitis is poor perineal hygiene ( Box 12.2 ). This results from the anatomic proximity of the rectum and vagina coupled with the fact that, after toilet training, most youngsters are unsupervised when they defecate. Many youngsters wipe their anus from posterior to anterior and thus inoculate the vulvar skin with intestinal flora. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. Children’s clothing is often tight fitting and nonabsorbent, which keeps the vulvar skin irritated, warm, moist, and at risk for vulvovaginitis.
Nonspecific
- 1.
Poor perineal hygiene
- 2.
Intestinal parasitic invasion with pruritus
- 3.
Foreign bodies
- 4.
Urinary tract infections with irritation
Specific
Bacterial
- 1.
Group A β-hemolytic streptococci
- 2.
Streptococcus pneumoniae
- 3.
Haemophilus influenzae / parainfluenzae
- 4.
Staphylococcus aureus
- 5.
Neisseria meningitides
- 6.
Escherichia coli
- 7.
Shigella flexneri/sonnei
- 8.
Other enterics
- 9.
Neisseria gonorrhoeae
- 10.
Chlamydia trachomatis
Protozoal
- 1.
Trichomonas
Mycotic
- 1.
Candida albicans
- 2.
Other
Helminthiasis
- 1.
Enterobius vermicularis
Viral/bacterial systemic illness
- 1.
Chickenpox
- 2.
Measles
- 3.
Pityriasis rosea
- 4.
Mononucleosis
- 5.
Scarlet fever
- 6.
Kawasaki disease
Other viral illnesses
- 1.
Molluscum contagiosum in genital area
- 2.
Condylomata acuminate
- 3.
Herpes simplex type 2
Physical/chemical agents
- 1.
Sandboxes
- 2.
Trauma
- 3.
Bubble baths
- 4.
Other
Allergic/skin conditions
- 1.
Seborrhea
- 2.
Lichen sclerosus
- 3.
Psoriasis
- 4.
Eczema
- 5.
Contact dermatitis
Tumors
Other
- 1.
Prolapsed urethra
- 2.
Ectopic ureter
In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. Similarly, a child with an upper respiratory tract infection may autoinoculate her vulva, especially with specific organisms (see Box 12.2 ). Vulvovaginitis in children may also be caused by a variety specific pathogens such as group A or group B b-hemolytic streptococci, Haemophilus influenzae, and Shigella boydii ; Neisseria gonorrhoeae, Trichomonas vaginalis, and Chlamydia trachomatis may also be responsible in cases associated with abuse but are significantly less common.
Pinworms are another cause of vulvovaginitis in prepubertal children. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. The classic symptom of pinworms is nocturnal vulvar and perianal itching. At night the milk-white, pin-sized adult worms migrate from the rectum to the skin of the vulva to deposit eggs. They may be discovered by means of a flashlight or by dabbing of the vulvar skin with clear cellophane adhesive tape, ideally before the child has arisen in the morning. The tape is subsequently examined under the microscope.
Despite widespread belief, mycotic (yeast) vaginal infections are not common in prepubertal children because the alkaline pH of the vagina does not support fungal growth. Mycotic vaginal infections may be seen in immunosuppressed prepubertal girls such as those with human immunodeficiency syndrome (HIV) or diabetes or on chronic steroid therapy. It can also present as a chronic colonization (diaper rash) in patients using diapers. Other specific causes of vulvovaginitis may include systemic diseases and chickenpox and herpes simplex infection.
There is nothing specific about the symptoms or signs of childhood vulvovaginitis. Often the first awareness comes when the mother notices staining of the child’s underwear or the child complains of itching or burning. The quantity of discharge can vary greatly, from minimal to copious. The color ranges from white or gray to yellow or green. A discharge that is both bloody and purulent is likely not from vulvovaginitis but from a foreign body (see Vaginoscopy for Prepubertal Bleeding without Signs of Puberty later in this chapter), although patients infected with some pathogens, particularly Shigella boydii, often present with a bloody or blood-tinged discharge . The signs of vulvovaginitis are variable and not diagnostic, but they include vulvar erythema, edema, and excoriation.
The differential diagnosis of persistent or recurrent vulvovaginitis not responsive to treatment should include considerations of a foreign body, primary vulvar skin disease (allergic or contact dermatitis), ectopic ureter, and child abuse. If the predominant symptom is pruritus, then pinworms or an irritant/nonspecific vulvitis is the most likely diagnosis.
The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. An ectopic ureter emptying into the vagina may only intermittently release a small amount of urine; thus this rare congenital anomaly should be considered in the differential diagnosis in young children.
Treatment of vulvovaginitis
The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. The child should be instructed to void with her knees spread wide apart (even while facing the toilet to improve urine draining) and taught to wipe from front to back after defecation. Loose-fitting cotton undergarments should be worn. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. Instructing patients to use nonmedicated, nonscented wipes rather than toilet paper may prevent the self-inoculation of the vagina with small pieces of toilet paper, which can initiate a chronic discharge.
Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. The majority of symptoms improve with hygienic changes and sitz baths (warm water, no soaps or chemicals). Using this approach for a 2-week period should resolve most symptoms in patients with nonspecific vulvovaginitis. When this intervention fails, there should be greater suspicion of bacterial colonization; in this case a reasonable approach is the use of broad-spectrum oral antibiotics such as amoxicillin or trimethoprim/sulfamethoxazole given for 10 to 14 days. Without continuation of the hygiene measures, however, broad-spectrum antibiotics will only offer temporary relief and the problem is likely to recur ( ).
If patients are going to be treated with antibiotics, one should attempt to collect a sample of the vulvovaginal discharge for culture before initiation of the antibiotics . In noncooperative children, treatment should not be withheld if a specimen cannot be collected and empiric treatment may be started., many techniques have been described for attempting to collect a specimen, including the use of a very slim urethral Dacron swab moistened with nonbacteriostatic saline (used for collection of male urethral cultures). Pokorny has described another method for collecting fluid from a child’s vagina using a catheter within a catheter ( ). This easily assembled adaptation uses a No. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. 12.4 ). The outer catheter serves as an insulator, and the inner catheter is used to instill a small amount of saline and aspirate into the vaginal fluid. The results of the vaginal culture may demonstrate a single organism that is a respiratory, intestinal, or sexually transmitted disease pathogen. The presence of sexually transmitted organisms in a child is usually a strong indication that sexual abuse may have taken place, and appropriate referral and follow-up is necessary (see Chapter 9 ).
