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Gynecologic examination of the newborn and child

Gynecologic examination of the newborn and child
Authors
Marc R Laufer, MD
S Jean Emans, MD
Section Editors
Leonard E Weisman, MD
Teresa K Duryea, MD
Deputy Editor
Mary M Torchia, MD
Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 |This topic last updated: Mon Jan 25 00:00:00 GMT 2010 (More)

INTRODUCTION — Gynecological evaluation of the prepubertal child is approached by directing attention to the specific complaint or question to be answered [1] . Educating the child and her family prior to this examination is important both for their reassurance and for gaining their trust. Inspection of the genital region should follow a focused general examination. Knowledge of normal prepubertal anatomy and use of accurate nomenclature are essential for describing and documenting anatomic findings (figure 1).

Gynecological examination of newborns and children will be reviewed here. Evaluation of common vulvovaginal complaints in these patients is discussed separately. (See "Vulvovaginal complaints in the prepubertal child".)

INDICATIONS — Examination of external genitalia is a normal part of the routine physical examination. This examination is discussed in detail elsewhere. (See "The pediatric physical examination: The perineum", section on 'Genitourinary system'.)

Internal examination in children is restricted to those with genitourinary complaints that cannot be addressed with external evaluation or in situations of suspected genitourinary pathology. These include vaginal bleeding, persistent discharge, trauma, cystic or solid masses, ulcerative or inflammatory lesions, suspected congenital anomalies, or sexual abuse.

HISTORY AND PHYSICAL EXAMINATION — The medical history is obtained from both the child, if possible, and her parent(s) or legal guardian. Prior to the examination, she should be told the reason for the office evaluation. A prior traumatic incident or examination can cause girls to become apprehensive and uncooperative. The provider should explain why examination of this area is needed and how the examination will be performed, including what instruments, if any, will be used. Allowing her to maintain some control of the environment is also important. As an example, she can be offered the opportunity to select the gown that she will wear and to view the light source (otoscope, magnifying glass, or direct light).

The goal of the examination is to obtain information without traumatizing the child. The patient can be asked to climb onto the examining table; alternatively, younger patients may be examined while sitting in a parent's or guardian's lap. Evaluation of the vulva can be done with the child lying supine with the legs in a "frog-leg" or "butterfly" position and, if needed, for complaints requiring visualization of the vagina, in a "knee-chest" position (figure 2).

Rarely, an adequate examination cannot be performed in the office setting, and so an examination under anesthesia may be required. This can be done in an outpatient ambulatory surgical unit with mask general anesthesia or intravenous conscious sedation. (See "Procedural sedation and analgesia in children".)

When performing an anesthesia examination, a lighted Killian nasal speculum (figure 3) and a fiberoptic scope (cystoscope, flexible hysteroscope) are useful for examining the prepubertal vagina. A liquid distention media can be used for vaginoscopy once vaginal cultures and/or a Papanicolaou smear have been obtained. (See "Vaginoscopy".)

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HOW TO OBTAIN CULTURES FROM CHILDREN — There are some special issues to consider in obtaining cultures from children. If the child is awake, Calgiswabs moistened with sterile saline can be used to obtain the specimen by gently inserting the swab through the hymenal ring without touching the edges of the hymen. Alternatively, a soft sterile eyedropper or a small feeding tube or urethral catheter with a syringe can be gently inserted through the hymenal opening to aspirate secretions or to obtain a vaginal wash sample. Another method uses saline squirted into the vagina while three swabs are held near the hymenal ring with the labia manually closed over them. The child is then asked to cough to expel the saline from the vagina onto the swabs. The swab should be transported to the laboratory using Culturette II and plated by the laboratory on genitourinary media (eg, blood, MacConkey, chocolate). Cultures are more useful and more likely to be positive in girls who have discharge evident at the time of the examination.

If gonorrhea infection is possible, a test for Neisseria gonorrhoeae is done by plating the swab obtained on modified Thayer-Martin-Jembec medium at the time of the examination or by sending the appropriate swab or urine sample for NAAT (nucleic acid amplification test) [2] . The laboratory should be informed that the specimen was obtained from a prepubertal child so that identification of Neisseria gonorrhoeae is precise. Similarly, a positive NAAT must be confirmed with a second NAAT.

Cultures for Chlamydia trachomatis are performed using a saline moistened male urethral swab specifically designed for this purpose. Cultures are less sensitive than NAATs but do not require confirmation. For most patients, specimens for NAAT testing are obtained from urine or a vaginal sample; a positive test needs to be confirmed with a second NAAT that targets a different sequence. The medical legal implications require careful testing and confirmation. Treatment should be delayed prior to a confirmatory test. (See "Screening for Chlamydia trachomatis".)

Genital cultures are transported using a Calgiswab or Culturette II and plated by the laboratory on genitourinary media (eg, blood, MacConkey's, chocolate). A Nickerson Biggy agar can be used for detection of Candida sp if the child has itching.

OTHER TESTS

Microscopy of vaginal secretions — Microscopy is less useful diagnostically for evaluating vaginitis in prepubertal girls than adolescents. Saline microscopy can be performed to look for Trichomonas. Signs of bacterial vaginosis include positive whiff (amine) test, defined as the presence of a fishy odor when 10 percent potassium hydroxide (KOH) is added to vaginal discharge samples; clue cells (>20 percent) on saline wet mount; or a homogeneous, grayish-white discharge (not present before puberty), but are rare in prepubertal girls. The addition of 10 percent KOH is helpful for diagnosing Candida vaginitis. Culture for Candida may be useful if microscopy is negative. (See "Diagnostic approach to women with vaginal discharge".)

Maturation index — Girls with precocious pubertal development may rarely (and only if atraumatic) have a vaginal smear obtained as part of their evaluation to determine degree of estrogenization using the maturation index. Vaginal smears for maturation index are used more commonly to evaluate adolescents with amenorrhea if visual inspection does not confirm estrogen effect on the vaginal mucosa. In the Meisel system, 100 cells are counted and scored 0 points for parabasal cells, 1/2 point for intermediate cells, and 1 point for superficial cells.

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The sum of points is interpreted as follows:

  • 60 to 70 points - newborns
  • 0 to 30 points - prepubertal girl
  • 31 to 45 points - hypoestrogenic female
  • 45 to 60 points - pubertal female
  • 90 to 100 points - hyperestrogenic female

Vaginal pH — The vaginal pH in prepubertal and pubertal girls is 6.5 to 7.5 and 3.5 to 4.5, respectively. Therefore, vaginal pH is not useful for diagnosis of bacterial vaginosis and vaginal trichomonas infection in prepubertal girls.

EVALUATION OF PELVIC ORGANS — The cervix/uterus and adnexa in the child can be evaluated through examination using a finger placed rectally and the other hand abdominally with the patient lying supine. If a mass is suspected or cannot be excluded, then an abdominal pelvic ultrasound is indicated.

Examination of the vulva in the child may be facilitated by using a colposcope, especially in cases of sexual abuse. The colposcope magnifies the area being examined and allows photography of areas of interest. However, magnification with an otoscope, hand lens, or 35 mm camera with macro-lens can also be used.

EVALUATION OF THE HYMEN — Examination of the hymen is an important part of the evaluation of girls who may have been sexually abused. The examiner must be able to distinguish the normal hymen and its normal variants from abnormal hymens [3-5] . However, 80 to 90 percent of girls who are known victims of sexual abuse have a normal genital examination. Anatomic variants sometimes mistaken for signs of sexual abuse include midline sparing (linea vestibularis), lichen sclerosus, failure of midline fusion, urethral prolapse, labial adhesions, pemphigoid, and other dermatologic conditions. (See 'Congenital abnormalities of the hymen' below and "Vulvar lichen sclerosus".)

Hymens change with age. Newborns have redundant, estrogenized, thick, elastic hymens, often with a prominent ridge at six o'clock. White discharge due to maternal and fetal/newborn estradiol-stimulated mucus production may appear at the hymenal orifice.

The hymen of prepubertal girls is unestrogenized, thin, and easy to assess. It may appear as a posterior rim, annular, redundant, and sleeve-like configuration (figure 4). In contrast, pubertal girls have thick, estrogenized, elastic hymens with white discharge.

Descriptions of hymenal tissue — Clinicians should be cautious about making judgments about abnormalities of the hymen in children being evaluated for sexual abuse. Several texts have provided atlases and descriptions of abnormal findings. In prepubertal girls, a complete transection of hymenal tissue between three and nine o'clock (lower half) is highly suspicious for trauma. Accidental trauma usually spares the hymen, whereas sexual abuse may cause this type of injury in a small number of girls. The transverse width of the hymenal opening in millimeters can be measured but is not diagnostic of sexual abuse [6] .

Bumps refer to elevations of hymenal tissue that are usually attached to longitudinal intravaginal rugae. They are a normal variant. A hymenal fold at six o'clock may appear as a bump but disappears in the knee-chest position. Rarely, a bump may occur between three and nine o'clock adjacent to a partial transection.

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Thickening of the hymen occurs upon estrogenization but may also develop after trauma. Folding of the hymen may give a false appearance of thickening. This finding should be confirmed in a knee-chest position.

Midline sparing (linea vestibularis) refers to a symmetric, flat avascular area of the posterior vestibule observed in 10 percent of normal newborns. It can sometimes be confused with scarring, which usually occurs on the hymen and posterior fourchette.

Congenital abnormalities of the hymen — Congenital abnormalities of hymens occur in approximately 3 to 4 percent of the female population. These anomalies are comprised of imperforate, microperforate, cribiform, and septate hymens (figure 5). Of note, a study of 1131 female newborns did not find any cases of congenital absence of the hymen [7] .

SUMMARY AND RECOMMENDATIONS

  • Examination of external genitalia is a normal part of the routine physical examination of children, while internal examination is restricted to those with genitourinary complaints or suspected of genitourinary pathology. (See 'Indications' above.)
  • The goal of the examination is to obtain information without traumatizing the child. The child can be asked to climb onto the examining table; alternatively, younger patients may be examined while sitting in a parent's or guardian's lap. Evaluation of the vulva can be done with the child lying supine, with the legs in a "frog-leg" or "butterfly" position or, if needed to visualize the vagina, in a "knee-chest" position (figure 2). (See 'History and physical examination' above.)
  • Internal organs can be evaluated abdominally with a rectal examination, but ultrasound imaging is more commonly employed. (See 'Evaluation of pelvic organs' above.)
  • Obtaining vaginal cultures in children is done without a speculum and requires special techniques. (See 'How to obtain cultures from children' above.)
  • The examiner must be able to distinguish a normal hymen and its normal variants from abnormal hymens. However, a normal hymen does not exclude the possibility of sexual abuse. (See 'Evaluation of the hymen' above.)

REFERENCES

  1. Emans, SJ, Laufer, MR, Goldstein, DP. Pediatric and Adolescent Gynecology, 5th ed, Lippincott, Williams, and Wilkins, Philadelphia 2005.
  2. Girardet RG, Lahoti S, Howard LA, et al. Epidemiology of sexually transmitted infections in suspected child victims of sexual assault. Pediatrics 2009; 124:79.
  3. Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics 1991; 87:458.
  4. Berenson AB, Heger AH, Hayes JM, et al. Appearance of the hymen in prepubertal girls. Pediatrics 1992; 89:387.
  5. McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for nonabuse: a descriptive study. Child Abuse Negl 1989; 13:179.
  6. McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990; 86:428.
  7. Jenny C, Kuhns ML, Arakawa F. Hymens in newborn female infants. Pediatrics 1987; 80:399.

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