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Pediatric Gynecology

M. Thamrin Tanjung,
Prof.Dr.dr.Sp.OG(K)
M. Rusda Harahap, dr.Sp.OG(K)

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

Gynecological care
Evaluation

of the external genitalia


continues through routine well-child
examinations, permitting early
detection of infections, labial
adhesions congenital anomalies,
and even genital tumors.

complete gynecologic examination


is indicated when a child has
symptoms or signs of a genital
disorder.

Specially designed
equipment

To prevent undue discomfort and


consequent anxiety about future
examinations.
vaginoscope,
virginal vaginal speculum

The first few weeks of


life.
During

the first few weeks of life, residual


maternal sex hormones may produce
physiologic effects on the newborn.
Breast budding occurs in nearly all
female infant born at term.
In some cases, breast enlargement
May be fluid discharge from the nipple.
No treatment is indicated.

The first few weeks of life


(Cont.)
The labia majora are bulbous, and the labia minora

are thick and protruding


The clitoris is relatively large, with a normal index
of 0.6 cm2 or less.
The hymen initially is turgid,
Vaginal discharge covering is common, comprised
mainly of cervical mucus and exfoliated vaginal
cells.
The uterus is enlarged (4 cm in length) and
without axial flexion; the ratio between the cervix
and the corpus is 3: 1.
Vaginal bleeding may occur as estrogen levels
decline following birth and the stimulated
endometrial lining is shed. Such bleeding usually
stops within 7-10 days.

Early childhood (0-6 years)


The

female genital organs receive little


estrogen stimulation.

The

labia majora flatten and the labia


minora and hymen become thin

The

clitoris remains relatively small,


although the clitoral index is unchanged.

The

vagina, lined with atrophic mucosa


with relatively few rugae, offers very little
resistance to trauma and infection.

Since

vaginal fornices do not develop until


puberty,
the cervix in childhood is flush with the
vaginal vault, its opening appearing as a
small slit.
The uterus regresses in size, regaining the
size present at birth at around age 6.
As the child matures, the ovaries begin to
enlarge and descend into the true pelvis.
The number and size of ovarian follicles
increase. They may attain significant size
and then regress.

Late childhood (age 710 year)

The external genitalia again show signs


of estrogen stimulation:
the mons pubis thickens,
the labia majora fill out, and the labia
minora become rounded.
The hymen thickens, losing its thin,
transparent character.

Early puberty (age 10-13


years
)
During early puberty (age 10-13 years),
the genitalia cake on adult appearance.
The major glands (Bartholin's glands) begin
to produce just prior to menarche.
The vagina reaches adult (10~12 cm) and
becomes more distensible, the mucosa
thickens,vaginal secretions grow more
acidic and lactobacilli reappear.
With the development of vaginal fornices,
the cervix becomes separated from the
vaginal vault

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)

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

FA: Calgiswab for obtaining vaginal specimens in the


prepubertal girl. B: Assembled catheter-within-acatheter, for obtaining specimens from a
prepubertal child. (From Pokorny SF, Stormer LVN.
Atraumatic removal of secretions from the
prepubertal vagina. Am J Obstet Gynecol
1987;156:581; with permission.)

Types of specula (from left to right):


infant, Huffman, Pederson, and Graves.

Otoscope (without a speculum) for visualizing hymen


and vagina.

(A) Examination of patient under anesthesia, (B) using a


Killian nasal speculum with fiberoptic light (obtained from
Codman and Shurtleff, Inc., Pacella Drive, Randolph, MA).

Methodes of examination
Placing

a child up to 5 years of age on her


parent's lap affords a better opportunity to
perform an adequate examination (Fig 314).
Older children may be placed on the
examination table, but the use of stirrups
is not generally necessary if the patient is
asked to flex her knees and abduct her legs.
The knee-chest position is useful in
visualizing the upper vagina and cervix.

FIG. 1-4. Positioning the child in the frog-leg position with the aid of her
mother. (Courtesy of Dr. Trina Anglin, Office of Adolescent Health, Health
Resources and Services Administration (HRSA), Washington, DC.)

Positioning the prepubertal child in the frog-leg


position. She can lie horizontally or with the head of
the examining table raised. [Courtesy of Dr. Trina
Anglin, Office of Adolescent Health, Health
Resources and Services Administration (HRSA),
Washington, DC.]

Positioning the child in the lithotomy position with the


use of stirrups. (Courtesy of Dr. Trina Anglin, Office of
Adolescent Health, Health Resources and Services
Administration (HRSA), Washington, DC.)

Positioning the child in the lithotomy position with


the aid of her mother. (Courtesy of Dr. Trina Anglin,
Office of Adolescent Health, Health Resources and
Services Administration (HRSA), Washington, DC.)

Examination of the prepubertal child in the


knee chest position.

The Tanner stages of human breast development. (Adapted from


Grumbach MM, Styne DM. Puberty: Ontogeny, neuroendocrinology,
physiology and disorders. In: Wilson JD, Foster DW, eds. Williams
textbook of endocrinology, 8th ed., Philadelphia: WB Saunders, 1992;
and from Marshall WA, Tanner JM. Variations in pattern of pubertal
changes in girls. Arch Dis Child 1969;44:291.)

The Tanner stages for the development of female pubic hair. (Adapted
from Grumbach MM, Styne DM. Puberty: Ontogeny,
neuroendocrinology, physiology and disorders. In: Wilson JD, Foster
DW, eds. Williams textbook of endocrinology, 8th ed., Philadelphia:
WB Saunders, 1992; and from Marshall WA, Tanner JM. Variations in
pattern of pubertal changes in girls. Arch Dis Child 1969;44:291.)

External genitalia of the


prepubertal child.

Examination of the vulva, hymen, and anterior


vagina by gentle lateral retraction (A) and gentle
gripping of the labia and pulling anteriorly (B).

Types of hymens (photographed through a


colposcope): (A) crescentic hymen, (B) annular
hymen, and (C) redundant hymen with crescent
appearance after retraction.

Types of hymens: (A) normal, (B) imperforate, (C)


microperforate, (D) cribriform, and (E) septate.

Microperforate hymen.

Microperforate septate
hymen.

Microperforate septate
hymen.

Imperforate hymen.

Septate vagina.

Microperforate hymen. A: Opening difficult to


visualize. B: Opening gently probed.

Hymenal tags.

Child and Adolescent Gynecologic


Problem

Gonadal disgenesis
Turner

syndrome (45,X)
Sweyer syndrome (46,XY)
Mixed gonadal dysgenesis (45,X /
46,XY)
Abnormalities of the X
chromosome

Pediatric Gynecologic
Disorders

VULVO VAGINAL LESIONS


II.
NEOPLASMS
III. CONGENITAL ANOMALIES
IV. DEVELOPMENTAL DEFECTS
V.
NORMAL & ABNORMAL
PUBERTAL DEVELOPMENT
VI. SPECIAL PROBLEMS OF THE
ADOLESCENT
I.

Pediatric Gynecologic
Disorders
I.

VULVOVAGINAL LESIONS
1. Lichen sclerosis et
atrophicus
2. Trauma
3. Labial adhesion
4. Prolapsed urethra
5. Vaginal discharge

Vaginal Discharge
Normal

: mucoid discharge it
results from maternal estrogen
Pathologic discharge :
Infections
Hemolytic streptococcal vaginitis:
bloody or serosangguineous discharge
Monilial vaginitis
A foreign body: persistent vaginal
discharge
Nonspecivic vaginitis

Labial adhesion
Adhesion

of labia minora in the midline


Result from inflammation or skin
disease
Encourages retention of urine &
vaginal secretions.
Management:
- improve hygiene
- Lubrication of the labia & gentle manual
separation
- Topical estrogens
- surgical

II. NEOPLASMS
VAGINA

Sarcoma botryoides
OVARIAN

- Non germ cell origine


Lipoid cell tumors(estrogen
producing)
Granulosa-theca cell
tumors(estrogen producing)

- Germ cell origine

Sarcoma Botryoides
From

mesnchymal tissue of the


cervix/vagina
Appears edematous, grape-like
mass, bleeds readily on touch
Management : a combination of
surgery and chemotherapy

Ovarian tumors
Germ cell tumors
Benigne cystic teratoma
Benign cyst
Arrhenoblastoma (androgen
producing)
Dysgerminomas & gonadoblastomas
Endodermal sinus tumors
Embryonal carcinoma (hCG
secreting tumors)
Immature teratomas(malignant)

III. Congenital Anomalies


Mullerian

agenesis: Mayer-von
Rokitansky-Kuster-Hauser(MRKH)
syndrome
Ectopic ureter with vaginal
terminus
Vaginal ectopic anus

IV. Developmental Defect of the


External Genitalia (Ambiguous
Genitalia)
Congenital adrenal hyperplasia

(CAH)
Adrenal tumors
Maternal ingestion of androgens
Childhood ingestion of androgens
Androgen insensitivity syndrome
(testicular feminization)
True hermaphroditism
Maternal virilising tumor during
pregnancy(luteoma of pregnancy)

V. Normal & Abnormal


Puberty

A. Normal puberty
B. Normal physical changes

Growth spurt
Thelarge
Adrenarche and pubarche
Menarche

C.

Precocious puberty

D.

Delayed puberty

Central
Peripheral

Hypergonadotropic hypogonadism
Hypogonadotropic hypogonadism

Normal Puberty

Normal physical changes


1.
2.

3.

Growth spurt:, 1 yr before


menarche, peak 11-12 yr
Thelarge : onset of breast
development, begins between 9-11
yr, a sign of ovarian estrogen
production, completed 3 yrs
Adrenarche and pubarche.
Adrenarche:the production of
androgens. Pubarche:development
of axillary and pubic hair that
results from adrenal and gonadal
androgens

Examination of the
Newborn Infant
A. GENERAL EXAMINATION
B. CLITORIS
C. VAGINA
D. RECTOABDOMINAL
EXAMINATION

A. General Examination
may

reveal abnormalities suggesting


genital anomaly eg:
webbed neck,
abdominal mass,
edema of the hands and legs, coarctation
of the aorta
The external genitalia are inspected and
palpated and evaluated:
Does it appear normal?
Is it in its proper location?
Will it function normally later in life?

LABIAL ADHESIONS
Agglutination

of the labia minora, termed


labial adhesions or, in the lower half,
vulvar adhesions, occurs primarily in
young girls aged 3 months to 6 years
Labial adhesions are not seen in newborns
because of estrogen effects on the vulva.
Occasionally, adhesions occur for the first
time after age 6, and adhesions presenting
at any age may persist to the time of
puberty.

Vulvar

irritation may play a role in


causing the formation of the
adhesions or the progression from an
initially small posterior adhesion to a
near-total fusion.
The vaginal orifice may be
completely covered, causing poor
drainage of vaginal secretions.
Parents often become alarmed
because the vagina appear absent

The

diagnosis of labial adhesions is made by


visual inspection of the vulva.
The treatment of labial adhesions remains
controversial.
Spontaneous separation may occur, particularly
with small vulvar adhesions at the posterior
fourchette and with estrogenization at puberty.
If the opening in the agglutination is large
enough for good vaginal and urinary drainage,
lubrication of the labia with a bland ointment
and gentle separation applied by the mother
over several weeks, may be helpful.

For

adhesions that impair vaginal or


urinary drainage, the most effective
treatment is the application of an
estrogen-containing cream

We

prescribe an estrogen-containing
cream (e.g., Premarin) twice daily for
3 weeks and then at bedtime for
another 2 to 3 weeks. Approximately
half of adhesions will resolve in 2 to 3
weeks (105), and therapy can then
be changed to ointment.

After

separation has occurred, the labia


should be maintained apart by daily
baths, good hygiene, and the
application of a bland ointment at
bedtime for 6 to 12 months.

Forceful

separation is contraindicated
because it is traumatic for the child and
may cause the adhesions to form again.

Labial abscess.

Lipoma of labia in an 8-year-old girl


who had had a labial mass for 1
year.

B. Clitoris
The

clitoris deserves particular


attention, because:
Enlargement : almost always
associated with congenital adrenal
hyperplasia.
Other causes : true
hermaphroditism, male
pseudohermaphroditism.

Enlargement of
Clitories

Two newborn girls with virilization and salt-losing


congenital adrenocortical hyperplasia: (A) and (B)
patient S.C., (C) patient M.T.

C. Vagina
The

vaginal orifice
Labia are separated or retracted.
If it is not, it can be found by gently inserting a
small, well lubricated pediatric feeding tube
When an opening cannot be found, the infant most
likely has an imperforate hymen or vaginal
agenesis.
Infrequently, associated inguinal hernias suggest
the possibility that the child is a genetic male,
particularly when there is a mass in the hernial sac.
If the vaginal orifice cannot be located, further
investigation is warranted.

Imperforate hymen in a
baby.

Imperforate
Hymen

D. Rectoabdominal
Examination
To

complete the primary evaluation, a


rectoabdominal examination is performed.
Usually, the uterus and adnexa in the newborn
cannot be palpated on rectal examination.
Occasionally, a small central mass representing
the uterine cervix can be felt on examination.
When an ovary is palpable, it denotes a marked
enlargement and warrants further investigation
(eg, ultrasonography) to rule out the presence of
an ovarian tumor. Negative findings are valuable
because they generally exclude a pelvic tumor.
Rectal examination also confirms patency of the
anorectal canal.

Examination of the
premenarcheal child
Focus

on the main symptoms identified in


this population: pruritus, dysuria, skin
color changes, and discharge.
Placing a child up to 5 years of age on her
parent's lap
Older children may be placed on the
examination table, but the use of stirrups is
not generally necessary if the patient is
asked to flex her knees and abduct her legs.
The knee-chest position is useful in
visualizing the upper vagina and cervix.

Examination of the
premenarcheal child
A. PHYSICAL EXAMINATION
1. General inspection.
2. Breasts
3. Abdomen
4. Genitalia.
B. Vaginoscopy

CONGENITAL ANOMALIES
VAGINA
UTERUS
OVARIUM
URETHRA
ANUS

ANOMALIES OF THE
VAGINA

1. IMPERFORATE
2. TRANSVERSE VAGINAL
SEPTUM
2. LONGITUDINAL VAGINAL
SEPTUM
3. VAGINAL AGENESIS
4. PARTIAL VAGINAL AGENESIS

ANOMALIES OF THE
UTERUS

1. RUDIMENTARY UTERINE
HORN
2. UNICORNUATE UTERUS
WITH PARAMESONEPHRIC
CYST

ANOMALIS OF THE
OVARIUM
drawn by the round ligament into the inguinal canal
or the labium majus.
A firm inguinal mass should alert the examiner to
the possible presence of an aberrant gonad,
possibly containing testicular elements, even
though the external genitalia are female.
A karyotype should be obtained when a girl
presents with an inguinal gonad.
At the time of hernia repair, the gonad should be
biopsied. If it proves to be an ovary, it should be
returned to the peritoneal cavity and the hernia
repaired. If a testis is identified, the gonad should
be removed.

Sarcoma botryoides
=botryoid

rhabdomyosarcoma
One of rare mesenchymal tumors, grows in
the form of polypoid grapelike masses and
derives its name from this gross appearance
Clinical characteristics
The most common clinical finding is vaginal
bleeding. They may appear as a polypoid
mass, somewhat yellow in color and are
friable: thus, they (possibly) may break off,
leading to vaginal bleeding or infections.

Epidemiology

Sarcoma botryoides normally is found in children


under 8 years of age. Onset of symptoms occurs
at age 3 years (38.3 months) on average. Cases
of older women with this condition have also
been reported.
Treatment and prognosis
The disease used to be uniformly fatal, with a 5year survival rate between 10 to 35%. As a
result, treatment was radical surgery. New
multidrug chemotherapy regimens with or
without radiation therapy are now used in
combination with less radical surgery with good
results, although outcome data are not yet
available.