PEDIATRIC AND ADOLESCENT GYNECOLOGY pptx

527

The reproductive tract in pediatric and adolescent patients differs

from that of the adult, requiring special techniques and equipment

for examination. The gynecologic problems addressed in children

and adolescents may differ markedly from those of adult women

but may be no less serious. Both the anatomy and physiology of

the reproductive tract will change from the hormone-stimulated state

of the newborn to the relatively estrogen-free state of the young

child to the blossoming of womanhood during adolescence.

ANATOMIC AND

PHYSIOLOGIC CONSIDERATIONS

NEWBORN

The newborn female reproductive tract has experienced prolonged

stimulation by transplacentally acquired maternal hormones. With

transection of the umbilical cord, these hormone levels fall, with

slow reversal of their effects over the first month of life. Breast buds

are present in most female newborns, and some will produce milk

if massaged. Breast massage should be avoided to prevent infection

or continued milk production.

At birth, the clitoris is prominent, with a clitoral index of

0.6 cm2 (clitoral index length in centimeters width in cen￾timeters). The labia minora are large and may protrude through bul￾bous labia majora. The hymen is prominent and red, protecting a

vagina that averages 4 cm long. A whitish vaginal discharge of mu￾cus and exfoliated cells with an acid pH may be prominent. The

uterus may be enlarged (4 cm long), with cervical eversion present.

The endometrium may slough and vaginal bleeding may occur

within a few days after birth. Parents can be reassured that the

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PEDIATRIC AND

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BENSON & PERNOLL’S

528 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

bleeding will stop by 10 days of age. The ovaries have not descended

from the abdomen and cannot be palpated if normal.

YOUNG CHILD (UNDER 7 YEARS)

With little estrogen stimulation, the external genitalia have invo￾luted from birth. The labia majora are flat, and the labia minora are

thin, as is the hymen. The clitoris is no longer prominent, but the

clitoral index remains unchanged. The mucous membranes are pink

and only slightly moist. The diameter of the hymenal opening is

0.4 cm. The vagina is
5 cm long, and its secretions have an al￾kaline pH. Vaginal fornices do not develop until puberty. Therefore,

the cervix is appositioned against the vaginal vault and is difficult

to see or palpate. If seen, the cervical os is a small slit. The re￾gressed uterus does not return to the size of the newborn until 6 y.

The ovaries have many follicles that decrease in number until

menarche. During this time, the ovaries begin their descent into the

true pelvis.

OLDER CHILD (7–10 YEARS)

As estrogen stimulation returns, the mons pubis thickens, the labia

majora fill out, and the labia minora become more rounded. The

hymen thickens, and the opening enlarges to 0.7 cm. The vaginal

mucosa thickens, and the vagina elongates to 8 cm. The body of

the uterus enlarges primarily by myometrial proliferation. The en￾dometrium gradually thickens. The ovaries enlarge and descend

lower into the pelvis. The follicles enlarge, although none will par￾ticipate in ovulation, then gradually regress in size. Breast buds may

appear.

YOUNG ADOLESCENT (10–13 YEARS)

During this phase of development, the external genitalia continue

to approach adult appearance. Bartholin glands begin to produce

mucus immediately before menarche. The hymenal opening en￾larges to about 1 cm. The vagina lengthens to adult size (10–12 cm),

and vaginal secretions become acidic. The vaginal fornices develop.

The body of the uterus becomes twice as long as the cervix. The

ovaries descend further into the true pelvis. Breast development

continues, with buds progressing to small mounds. Other second￾ary sex characteristics develop (pubic and axillary hair), the body

becomes more rounded, and the adolescent growth spurt begins.

GYNECOLOGIC EXAMINATION

NEWBORN

Because internal examination usually is unnecessary and difficult

at this age, examination is usually limited to the external genitalia.

Assessment includes the overall appearance, and looking for anom￾alies in addition to ambiguity of sex differentiation. An abnormal

or enlarged clitoris may suggest congenital adrenal hyperplasia. The

hymen is inspected for patency (to rule out imperforate hymen or

vaginal agenesis). Rectal examination may detect the cervix, but

normally no other reproductive organs will be palpable.

CHILD

Avoiding the use of stirrups often enhances the child’s cooperation.

An adequate view of the genitalia can be obtained with the child in

the frog leg position (knees flexed, legs fully abducted) on the ex￾amination table or in the mother’s lap. Enlisting the child’s coop￾eration is often facilitated by direct conversation and explanation

during the examination. After a general examination, including in￾spection and palpation of the breasts, attention may be directed to

gentle palpation of the abdomen. Ovarian tumors in this age group

usually occur in the low to midabdomen.

Evaluation of the external genitalia includes evidence of proper

hygiene as well as lesions of the skin, inflammation, tumors, exco￾riations, or vaginal discharge. The labia minora should be separate

posteriorly. Ascertaining the presence of a vaginal opening is usu￾ally accomplished by direct visualization. Digital rectal examina￾tion must be gentle.

If visualization of the upper one third of the vagina is neces￾sary (e.g., foreign body, abnormal bleeding, screening for in utero

DES exposure, or penetrating injury), a vaginoscope, cystoscope,

or laparoscope may be used and examination under anesthesia may

be necessary. In the younger child, a 0.5 cm instrument can be used.

In the older child, an 0.8 cm instrument usually can be passed

through the hymenal orifice.

YOUNG ADOLESCENT

At this age, the girl may be very sensitive about the changes in

her body. She should be an active participant in the history and

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530 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

examination process. She should be asked whether or not she wishes

her mother to be present, and a female assistant should be present

if the mother is not. It is important to reassure her that she may be

embarrassed or somewhat uncomfortable but that the examination

will not be painful and her hymen will not be damaged. Sufficient

time must be available to allow for an unhurried examination and

full explanation of each procedure.

Explaining and teaching breast self-examination during the

breast examination helps to establish this preventive measure. Stir￾rups usually are accepted in this age group. After examination of

the external genitalia, the cervix and vagina may be inspected us￾ing a long-bladed Huffman-Graves vaginal speculum. If the hy￾menal opening is of sufficient size, bimanual palpation may be ac￾complished with a single finger in the vagina. If not, the uterus and

ovaries may be palpated using the rectal approach.

After the examination, it is crucial to discuss the findings with

the patient and address her concerns. Patient–doctor confidential￾ity should be maintained. If there is some problem of which the par￾ents should be made aware (e.g., pregnancy), advising the patient

and serving as a supportive advocate may assist her in the neces￾sary communication(s).

CONGENITAL ANOMALIES OF

REPRODUCTIVE TRACT TYPICALLY

DIAGNOSED BEFORE MENARCHE

ABNORMALITIES OF THE HYMEN

There are so many normal variations in the appearance of the hy￾men (e.g., size and number of orifices, thickness) that essentially

the only true anomaly is imperforate hymen. The solid membrane

of the imperforate hymen is thought to be a persistent portion of

the urogenital membrane formed whenever the mesoderm of the

primitive streak abnormally invades the urogenital portion of the

cloacal membrane.

Obstruction of the vaginal outlet by the imperforate hymen

causes a buildup of vaginal secretions, initially a mucocolpos, and

later (postmenarche) a hematocolpos. The mucocolpos may be seen

as a flat or mildly protruding, thin, shiny membrane. The vagina is

distended and may fill the pelvis. Sonography will distinguish be￾tween this condition and vaginal agenesis. Hematocolpos is diag￾nosed in an amenorrheic adolescent with a bulging purplish red hy￾menal membrane and distended vagina. Blood may fill the uterus