Introduction
The pediatric gynecologic examination (PGE) should only be performed when indicated. Unnecessary PGE in both the child and adolescent can lead to overmedicalization of their conditions, feelings of exploitation, and even trauma. If you are an unskilled trainee in the PGE, it is best to only do one examination where both you and the provider are present at the same time for the PGE. This will decrease the time the patient is in this vulnerable examination position and subject to touch by both you and the provider. Ideally, you should be taught how to perform the PGE on models during simulation sessions before doing them for the first time on a patient. Many simulation curriculums exist. In what follows you will find the indications for a PGE based on age and pubertal status.
Indications for examination in the child/prepubertal patient
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Confirmation of normal anatomy
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Vulvar complaints
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Abnormal vaginal discharge
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Suspected abuse
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Vulvovaginal trauma
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Prepubertal vaginal bleeding
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Precocious puberty/assessment of pubertal status
Indications for examination in the adolescent/postpubertal patient
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Confirmation of normal anatomy
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Vulvar complaints
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Abnormal vaginal discharge
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Suspected abuse
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Vulvovaginal trauma
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Abnormal uterine bleeding such as postcoital bleeding
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Intrauterine device/intrauterine system insertion (IUD/IUS)
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Suspected pelvic inflammatory disease (PID) or sexually transmitted infection (STI)
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Hyperandrogenic symptoms
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Delayed puberty/primary amenorrhea/assessment of pubertal status
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Dyspareunia
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Inability to insert tampons
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Pregnancy
Approach to the examination
Having a systematic approach to the PGE is important. It should be performed in a consistent fashion such that one does not forget any parts of the PGE, which could then entail a repeat examination for the patient. The PGE should be tailored to the patient’s age and maturity and their previous experiences. Trauma-informed care should always be practiced. Restraining a patient to examine them should be avoided unless they are under 2 years of age and caregivers are agreeable. Consent should always be obtained from patients and/or caregivers before performing a PGE. It is important to explain that the examination will not be painful nor change the look or function of the hymen.
Explain to the patient how to self-position and offer alternative positions. Ensure the patient is draped appropriately and only exposes body parts that need to be. Before starting, ask the patient if they want to see the instruments/swabs you will be using and, if so, take the time to do this. They may also benefit from seeing images before the examination or using a mirror to watch you do the examination.
Labial separation and labial retraction (somewhat firm downward retraction while grasping the labia majora bilaterally) are very helpful in the prepubertal population for assessment of the hymen and lower vagina ( Fig. 4.1 ). Similarly, it is important in the postpubertal patients when assessing for hymenal anomalies (e.g., imperforate hymen, septate hymen), vaginal agenesis (assessing for a dimple), and vaginal septa. Trainees providing gynecologic care should learn this part of the PGE on a pediatric and/or simulated model before attempting them on a patient (see Fig. 4.1 ). Finally, it is important to know what is normal on a PGE before being able to identify pathology ( Table 4.1 , Figs. 4.2 and 4.3 ).
| COMMON ANATOMIC FINDINGS IN NEWBORN, PREPUBERTAL, AND ADOLESCENT GIRLS | |||
|---|---|---|---|
| Newborn | Prepubertal | Postpubertal Adolescent | |
| Clitoris | Clitoral hood may be thickened at birth | Average length 3 mm, width 3 mm | Average width 2–4 mm, longitudinal diameter 5.1 ± 1.4 mm |
| Hymen | May be thicker, fimbriated, and protrude beyond introitus |
| Estrogenized and thickened |
| Labia majora | May be edematous | Small, flatter | Increased fullness distinct from surrounding tissue |
| Labia minora | May be thick and protrude beyond labia major | Thin and short, rudimentary extension of clitoral hood extending one–third the length of the labia majora | Become elongated, but may not become fully developed until late puberty |
| Vagina |
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|
|
| Cervix | Prominent, with fundus-cervix ratio 1/2 | Flush with vagina with small central opening | Adult shape, usually dull pink, may have a prominent ectropion |
| Uterus | Average uterine length 3.5 cm, maximal thickness 1.4 cm, echogenic endometrium | Length including cervix 3.2 cm, thickness 1 cm, thin endometrium may not be visible | Length 4.72 cm at Tanner stage 2 breasts, 7.4 cm at Tanner stage 4 breasts |
| Ovaries |
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|
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Approach to the pediatric/prepubertal examination
Consent for the examination should be obtained from the caregiver and assent from the child based on their age and maturity ( Box 4.1 ). It is a good opportunity to review with the child what “private parts” are, who is allowed to see and touch them, and in what context.
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“Is it ok if I examine your private parts today?”
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“I am a doctor and your parent has given permission for this examination because we need to check why you are bleeding.”
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“Do you agree?”
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“Lie down on the table on your back.”
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“Now bend your knees.”
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“Make sure your feet are close to your bottom. Pretend your legs are butterfly wings and open them wide.”
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Use basic language that is appropriate to the child’s developmental state.
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Use simple terms and short phrases to get them correctly positioned.
We typically position in the child in the frog-leg or butterfly position ( Fig. 4.4 ). If the child is uncomfortable with this position, ask them to do it sitting on their caregiver or consider the knee-chest position as seen in Fig. 4.4 . Some children prefer to not be draped. Gowns are usually not necessary, as you are only exposing the bottom half of their bodies. As they are undressing, examine their diaper or underwear, looking for any bleeding or discharge.
