Columbus: pediatric gynecology

Question 0

What factors predispose prepubertal girls to vulvovaginitis?

Answer 0

Hypoestrogenization of genital tissue
Minimal fat in labia majora
Close proximity to anus
Poor toileting hygiene
No pubic hair to keep clothing off skin

Question 1

Describe approach to examining pediatric patients

Answer 1

Frog leg or knee to the chest position
No speculum
Saline moistened small Dacon swabs
Avoid touching the hymen

Question 3

What history should be considered for vaginal irritation in girls?

Answer 3

Laundry including type of detergent fabric softener and bleach
Bath including soap, baths or showers, rinsing and bubble bath
Clothing such as swimsuits, leotards, leggings or tight pajamas
Toileting including wiping technique, underwear staining, diapers
Any discharge or staining in underwear

Question 4

How are pinworms treated? What other precautions are needed?

Answer 4

Mebendazole 100 mg tablet, repeat in two weeks

All family members in home can be treated

Wash linens in hot water and bleach

Question 5

What is the parasite responsible for pinworm vulvovaginitis?

How is it spread?

What are predominant symptoms?

Answer 5

Enterobius vermicularis

Fecal oral spread

Itching worse at night and early morning

Question 5

What is the most common vaginal foreign body in girls?

How does this present?

How is it treated?

Answer 5

Toilet tissue

Malodorous discharge, brownish blood daily

Apply 2% lidocaine gel to hymen manually, use catheter-in-catheter technique for vaginal irrigation with normal saline

Question 6

How are pinworms treated?

What other precautions are needed?

Answer 6

Mebendazole 100 mg tablet, repeat in two weeks

All family members in home can be treated
Wash linens in hot water and bleach

Question 7

How is vulvovaginitis in girls treated empirically?

Answer 7

Antibiotics including amoxicillin, Augmentin, or Bactrim
Vulvar skin care guidelines
Short course of triamcinolone 0.1% ointment for moderate inflammation
Antihistamines, sedating at night

Question 8

How are labial adhesions managed operatively?

Answer 8

Pretreat with topical estrogen for at least 7 days
Conscious sedation or monitored anesthetic
Lubricated cotton swab to push through opening
Post procedure lidocaine gel
Expect dysuria for 36 hours, use warm bathtub to void if necessary
Topical estrogen for 5 days postop
Avoid irritants to prevent recurrence

Question 9

How are labial adhesions treated?

Answer 9

Topical estrogen cream twice per day for two weeks then at night for up to six weeks
Discontinue once completely open
Call for estrogen-related side effects
Follow up visit in 2-6 weeks

Question 10

How is lichen sclerosus treated in girls?

Answer 10

Clobetasol oint 0.05% b.i.d. for 2 weeks, then daily for 2 weeks
Taper to triamcinolone oint 0.1% b.i.d. for 2 weeks, then daily for 2 weeks
Hydrocortisone 2% daily to b.i.d. and slowly taper
May need anabiotic treatment for concomitant bacterial infection

Question 11

How does lichen sclerosus present in girls?

Answer 11

Intense, intractable itching
May include dysuria, pain, bleeding
“Figure 8 pattern” with pale, fine wrinkled skin
Vaginal sparing

Question 12

How should parents be counseled about prognosis for lichen sclerosus in girls?

Answer 12

Average flares 2.2 times per year
Flares can be treated with triamcinolone or hydrocortisone
Strict adherence to vulvar skin care guidelines helps prevent scarring

Question 13

How is penetrating vaginal trauma evaluated?

Answer 13

Examination under anesthesia and possible surgical evaluation to assess for retroperitoneal injury

Question 14

How does urethral prolapse present?

What ethnic group is most commonly involved?

How was it treated?

Answer 14

Prolapsed intraurethral mucosa beyond the meatus causes constriction with edema and possible necrosis. Patients usually present with spotting, frank bleeding or dysuria

Most common in African-American girls

Treated with sitz baths and topical estrogen cream. Rarely Foley catheterization is needed to relieve obstruction. If no response after five days, may need surgical excision of mucosa

Question 15

What are exam findings consistent with pediatric sexual abuse?

Answer 15

lacerations of the vulva, posterior fourchette, anus or transection of hymen

Question 16

When should evaluation be performed if thelarche is not followed by menarche?

When should a evaluation be performed in the absence of any pubertal development?

When should evaluation be performed in the presence of hirsutism?

Answer 16

Within three years.

Age 13

Age 14

Question 17

When should amenorrhea evaluation be performed in a patient with a history of excessive exercise or eating disorder?

When should evaluation be performed if there is amenorrhea in the setting of a possible outflow obstruction?

Answer 17

Age 14

Age 14

Question 18

When should evaluation for amenorrhea be started without other considerations?

Answer 18

Age 15

Question 20

What adolescent menstrual conditions beside amenorrhea require evaluation?

Answer 20

History of regular monthly menses that become markedly irregular
Menses that occur more often than every 21 days or less frequently than every 45 days
Occur 90 days apart even for one cycle
Last more than seven days
Require frequent pad or tampon changes more than every 1-2 hours

Question 21

According to ACOG which patients should have von Willebrand screening?

Answer 21

Adolescents with severe menorrhagia prior to hormone therapy
Adults with menorrhagia without another cause
Patients scheduled to undergo hysterectomy when menorrhagia is the only indication

Question 21

What is the differential diagnosis for heavy bleeding in adolescents?

Answer 21

Post menarchal anovulatory abnormal uterine bleeding
PCOS related anovulatory abnormal uterine bleeding
Pregnancy related bleeding
Congenital or acquired bleeding disorder

Question 22

What historical findings warrant bleeding disorder screening?

Answer 22

Bleeding with dental work or previous surgeries
Prolonged bleeding with small injuries
Nosebleeds are easy bruising
Family history of menorrhagia postpartum, hemorrhage or hysterectomy at early age
Menses greater than seven days with “flooding or gushing” or menses that limit daily activities
Anemia

Question 23

What is the differential diagnosis for oligomenorrhea or secondary amenorrhea in adolescents?

Answer 23

Pregnancy
PCOS
Medication induced
Hypothalamic amenorrhea

Question 24

What are treatment options for adolescent menorrhagia?

Answer 24

Cyclic OCP’s, continuous OCP’s, progestin only OCP’s
Depo-Provera
Mirena IUD
High-dose oral progestins such as norethindrone 5 mg 1-3 times daily or MPA 10-30 mg daily
Depo leuprolide
Tranexamic acid 1300 mg TID for five days (off label in adolescents)

Question 25

What is the differential diagnosis for dysmenorrhea in adolescence?

Answer 25

Outflow tract obstruction and endometriosis

Question 26

What is the female athlete triad?

Answer 26

Disordered eating, amenorrhea and osteopenia

Question 28

How is endometriosis treated in adolescence?

Answer 28

NSAIDs or cyclic OCP’s for three months
Laparoscopic biopsy and conservative organ-pairing surgery
Postop continuous OCP’s
GnRH agonist therapy post op for OCP failure if > 16 years old