Professional Documents
Culture Documents
Objectives
Infancy to Puberty
Vulvovaginitis
Adhesive vulvitis
Accidental genital trauma
Ovarian tumors
Precocious puberty
Gynecologic examination
of a child
Slow pace, gentleness and patience
Ambiance
Rapport
Reassurance
Parental presence
Components
History
Abdominal exam
Inspection with visualization of the
PE
Hymen crescentic, redundant,
imperforate
Vaginal epithelium red, thin
Vaginal canal 4-6cm long
Secretions neutral pH
Inspection and
visualization
Younger child can be examined on
Rectal exam
May be omitted
Non palpable uterus
2:1 ratio, cervix:uterus
Indications
Bleeding
Pelvic pain
Foreign body
Pelvic mass
Vulvovaginitis
Most common gyne problem in
premenarcheal
80% to 90% of opd visits
Introital irritation
Discharge
Vulvovaginitis vulvar
irritation
Topical allergy
Skin or respiratory infection
Foreign body
UTI
Vulvar skin disease
Ectopic ureter
Pinworm infection
Sexual abuse
Susceptibility to
vulvovaginitis
Lack of labial fat pads and pubic hair
Epithelium lacks estrogen
pH is neutral
Vagina lacks glycogen, lactobacilli
and anitbodies
Poor perineal hygiene
Treatment
Hygiene clean, dry and cool
Weeping lesions hot sitz bath
Foreign body
Between 3 to 9 yo
Toilet paper, toys, crayons, sand
Vaginal discharge
Remove by forceps, irrigation
Vaginal bleeding
Foreign body
Neoplasia
Precocious puberty
Urethral prolapse
Trauma
Sexual assault
Vulvovaginitis
Lichen sclerosis
Condyloma accuminata
Blood dyscrasia
Exposure to estrogen
Vaginal bleeding
Shigella
Group A beta-hemolytic
streptococcus
7-10 days after a sore throat
Adhesive vulvitis
Self-limiting consequence of chronic
vulvitis
Labia minora agglutinates and fuses
Mistaken for congenital absence of vagina
Common between 3 to 6 yo
No symptoms except for difficulty in
voiding if fusion involves the urethra
No treatment necessary
Estrogen cream 2x daily
Accidental genital
trauma
Fall, straddle injury
Sexual abuse
Hematoma or laceration
General anesthesia may be needed to
investigate the extent of the injury
If non-expanding: observation, serial
examination, ice pack then hot sitz
If retroperitoneal hematoma or internal
organ injury is suspected, laparoscopy
or laparotomy may be indicated
Tetanus toxoid injection
Ovarian Tumors
Abdominal pain
Abdominal enlargement increasing
abdominal girth
Ultrasound, abdominal CT, MRI
CA 125, AFP, hCG, inhibin, CEA, LDH,
estradiol and testosterone
Ovarian tumors
Unilateral
Benign or malignant
Germ cell tumor most common in
preadolescents
Immature teratomas surgery alone is
Ovarian tumors
Goal of surgery: removal of
Precocious puberty
Appearance of signs of secondary sexual
Premature Thelarche
Breast development
Neonatal may be normal up to 6
months
1 4 yo
2 4 cm breast bud
Unilateral or bilateral
Benign self-limiting
No treatment
Premature Pubarche
Isolated development of pubic hair
Premature adrenarche axillary hair
No clitoromegaly, bone age is not
advanced
Increased DHEA and DHEA-S by the
adrenals
Not progressive
No treatment, observation
GnRH-Dependent Precocious
Puberty
Idiopathic development 70% of
cases
Abnormal EEGs CNS
Premature maturation of the HPO axis
May develop ovarian follicular cysts
As early as 3-4 years old
Emotional problems shy and
withdrawn
GnRH-Dependent Precocious
Puberty
Headaches
Visual disturbance
Seizures with inappropriate laughter
(gelastic seizures)
GnRH-Dependent Precocious
Puberty
CNS lesions near hypothalamus near 3rd
ventricle
Tuberculosis, encephalitis, trauma,
hamartomas, teratomas, secondary
hydrocephalus, neurofibromatosis,
granulomas, craniopharyngiomas, cranial
irradiation,
Space occupying masses are most difficult
to treat
Poorly understood why it produces
precocious puberty
GnRH-independent precocious
puberty
Most common estrogen-secreting
ovarian tumor
Granulosa cell tumors - > 8cm
Sertoli-Leydig cells,
choriocarcinomas, and benign
follicular cysts rare cause
Produce hCG or estrogen
McCune-Albright syndrome
Polyostotic fibrous dysplasia
Triad: caf-au-lait spots, fibrous
Adrenocortical neoplasms
Isosexual or heterosexual
Congenital adrenal hyperplasia
If treated during neonatal period, normal
puberty
If untreated, girl will develop
heterosexual puberty because of
androgens
If treated late in childhood, isosexual
development may follow initial treatment
of adrenal disease
Hypothyroidism
Usually associated with delayed
pubertal development
Rare: may cause precocious puberty
Bone age is retarded (specific)
Hashimotos thyroiditis
Low thyroid hormones negative
feedback increase TSH
increase gonadotrophins
Iatrogenic
Estrogen cream, pills
Regresses after discontinuation
Diagnosis
History and PE
Rule-out life threatening neoplasms
Laboratory exams
Brain CT or MRI
EEGs
Ultrasound
Bone aging by hand-wrist x-rays every 6
months (if 95% advanced: ovarian
estrogen)
Hormonal assays including thyroid function
GnRH stimulation test LH increases if true
precocious puberty, LH does not increase if
incomplete (peripheral sources)
Management of Precocious
Puberty
Extirpation of tumors (ovarian,
hamartomas)
Continuous chronic GnRH analogue
administration (agonists) most
effective between 4-6yo
Down regulation of GnRH receptors
McCune Albright
Counseling