PEDIATRIC AND ADOLESCENT GYNE (AB) Flashcards
What are the key components of a complete and age-appropriate gynecologic examination in a pediatric patient?
“History taking. general pediatric assessment. external genital examination. Tanner staging and sometimes pelvic examination.”
What are the normal gynecologic findings in pediatric patients?
“Thin. non-elastic hymen. neutral to slightly alkaline vaginal secretions and a narrower. thinner vaginal canal.”
Why are prepubertal children more vulnerable to vulvovaginitis?
“They have a thinner vaginal epithelium. a neutral pH and lack protective estrogenized secretions.”
What are the common causes of vaginal bleeding in children?
“Foreign bodies. trauma. vulvovaginitis. precocious puberty and sexual abuse.”
How should adhesive vulvitis be managed?
“Topical estrogen cream. petroleum jelly and good hygiene practices.”
What are the common causes of genital trauma in pediatric patients?
“Accidental injuries. straddle injuries. sexual abuse and self-inserted foreign bodies.”
What are the characteristics of pediatric ovarian masses?
“Most are benign. commonly functional cysts or benign tumors but some may be malignant and require surgical intervention.”
What anatomical differences exist between a prepubertal female and an adult female?
“Prepubertal females have a thinner. less elastic vaginal canal. non-estrogenized hymen and a neutral vaginal pH.”
What are some key considerations when evaluating gynecologic problems in children?
“Gaining trust. establishing rapport. ensuring a gentle exam pace and avoiding unnecessary instrumentation.”
What are the common gynecologic conditions seen in pediatric patients?
“Vulvovaginitis. labial adhesions. vulvar lesions. genital trauma and suspicion of sexual abuse.”
What should be done before conducting a gynecologic examination on a child?
“Explain the procedure. ensure a comfortable environment and have a female assistant present if the examiner is male.”
What is the recommended approach for history-taking in pediatric gynecology?
“Begin with non-threatening questions. obtain most information from caregivers and use child-friendly language.”
Why is establishing rapport with a pediatric patient important during a gynecologic exam?
“Poor interaction during the first visit may lead to anxiety and reluctance in future medical encounters.”
What is the significance of Tanner staging in pediatric gynecology?
“It helps assess pubertal development by evaluating breast and pubic hair growth.”
What is the purpose of inspecting the external genitalia in a pediatric patient?
“To diagnose common pediatric gynecologic conditions such as vulvovaginitis. labial adhesions and foreign bodies.”
What technique can be used to visualize the introitus in a pediatric patient?
“Downward and outward pressure on the labia majora or asking the child to blow to increase abdominal pressure.”
What is the preferred position for a pediatric gynecologic examination?
“Sitting on the mother’s lap is the most comfortable and acceptable position.”
What are the normal hymenal variations in prepubertal girls?
“Fimbriated. circumferential/annular and posterior rim hymens.”
Why should speculums be avoided in prepubertal girls?
“Even the smallest speculum size can be painful and frightening.”
What are the characteristics of vaginal secretions in prepubertal girls compared to adult women?
“Neutral to slightly alkaline pH whereas adult vaginal secretions are more acidic.”
What is vaginoscopy and when is it indicated?
“It is the insertion of an instrument to visualize the vaginal canal and cervix. usually requiring sedation in prepubertal girls.”
What should never be done during a vaginal examination in a pediatric patient?
“Forcing an examination or using restraints. as it is traumatic and inappropriate.”
How does puberty affect the vaginal canal?
“It becomes wider. more elongated and more distensible due to estrogen influence.”
What approach should be taken when performing a speculum exam on an adolescent female?
“Use the appropriate size speculum and allow the patient to see and touch the instruments to demystify the procedure.”
What are common fears of adolescent females regarding gynecologic examinations?
“They often fear that the examination will be painful or invasive.”
What is the most common gynecologic problem in prepubertal females?
Vulvovaginitis
What percentage of pediatric gynecologic consultations are due to vulvovaginitis?
80-90%
What are common symptoms of vulvovaginitis?
Introital irritation (discomfort/pruritus) and discharge
What is the typical vaginal pH in prepubertal females?
Neutral to slightly alkaline
What are some physiological and behavioral reasons that contribute to vulvovaginitis?
Poor perineal hygiene, close proximity of rectum and vagina, scratch-itch cycle
What organisms can cause vulvovaginitis?
Viruses, bacteria, parasites, and fungi
What are common signs of vulvovaginitis?
Staining of underwear, itching, burning sensation
What are some differential diagnoses for vulvovaginitis?
Foreign body, primary vulvar skin disease, ectopic ureter, child abuse
What is the first-line treatment for vulvovaginitis?
Improvement of perineal hygiene and sitz baths
What are additional treatments for vulvovaginitis?
Avoidance of irritants (tight clothing, chemicals), broad-spectrum antibiotics (amoxicillin, cotrimoxazole), specimen collection for culture
What is labial adhesion?
Adherence or agglutination of the labia minora due to denuded epithelium
What is a telltale sign of labial adhesion?
A translucent vertical midline
What condition can labial adhesion be confused with?
Imperforate hymen
What are treatment options for labial adhesion?
Observation if asymptomatic, topical estrogen cream, topical corticosteroids
What findings suggest sexual abuse in labial adhesion?
Labial agglutination with scarring of the posterior fourchette
What characterizes physiologic discharge of puberty?
Gray-white coloration, non-purulent, due to desquamation of vaginal epithelium
What treatment is recommended for symptomatic physiologic discharge?
Sitz baths and frequent changing of underwear
Why is urethral prolapse common in prepubertal and postmenopausal females?
Lack of estrogen weakens the perineum and urethra
What is the clinical presentation of urethral prolapse?
Prepubertal bleeding, red donut-like structure at urethral meatus
What are treatment options for urethral prolapse?
Observation, topical estrogen, antibiotics if infected
What is lichen sclerosus?
A skin dystrophy common in prepubertal and postmenopausal women due to lack of estrogen
What is the suspected cause of lichen sclerosus?
Autoimmune disorder
What are symptoms of lichen sclerosus?
Pruritus, vulvar discomfort, prepubertal bleeding, dysuria, constipation
What is the characteristic appearance of lichen sclerosus?
Lichenified, hypopigmented parchment-like skin in an hourglass or figure-eight pattern
How is lichen sclerosus diagnosed?
Biopsy
What is the treatment for lichen sclerosus?
Avoiding irritation/trauma, sitz baths, comfortable clothing, high-potency topical steroids (clobetasol) for 4-6 weeks
What is prepubertal bleeding without secondary signs of puberty?
Vaginal bleeding before the development of thelarche or adrenarche
What are the key stages of puberty?
Thelarche (breast development), adrenarche (pubic hair growth), menarche (first menstruation)
What is precocious puberty?
Thelarche or adrenarche occurring before age 6
What are some causes of prepubertal vaginal bleeding?
Foreign body, vulvar excoriation, lichen sclerosus, vaginitis, labial adhesion separation, urethral prolapse, warts, malignancy
What is a common cause of vaginal bleeding in neonates?
Maternal estrogen withdrawal
What is always a concern when evaluating prepubertal vaginal bleeding?
Rule out sexual abuse
What percentage of pediatric gynecologic consultations involve foreign bodies?
0.04
What are common types of vaginal foreign bodies?
Paper, small hard objects, sand, gravel, stones, toy parts
What symptom is associated with vaginal foreign bodies?
Foul, bloody, purulent discharge
What procedure is used to remove embedded foreign bodies?
Vaginoscopy with sedation
What infection can cause prepubertal bleeding and often lacks gastrointestinal symptoms?
Shigella vaginitis
What is the confirmatory test for Shigella vaginitis?
Culture and sensitivity
What rare condition presents with café-au-lait spots, bone lesions, and precocious puberty?
McCune-Albright syndrome
What causes McCune-Albright syndrome?
Somatic mutation in neural crest cells during embryogenesis
What malignancies can cause prepubertal vaginal bleeding?
Sarcoma botryoides, endodermal sinus tumor
What is sarcoma botryoides?
A vaginal malignancy found in prepubertal females, usually before age 6
What is endodermal sinus tumor of the vagina?
“A vaginal malignancy that typically occurs before age 2”
What diagnostic test is performed to rule out vaginal malignancies?
Vaginoscopy with biopsy
What is the most common cause of genital trauma in prepubertal patients?
Straddle injury
What is a key concern with penetrating genital injuries?
Potential internal injuries (e.g., vaginal wall, cul-de-sac, abdominal cavity, urinary bladder)
How can you assess for internal injury in penetrating genital trauma?
Observe urine output and abdominal status (e.g., palpation for tenderness, Foley catheter insertion for bloody urine output)
What is the management for superficial vulvar injuries with no active bleeding?
No need to repair
What should be done for a small vulvar laceration with rapid bleeding?
Repair by ligating the bleeding vessel
Why is anesthetic required when repairing genital lacerations?
Genitalia is highly sensitive to pain
What is the initial conservative management for a non-expanding vulvar hematoma?
Ice pack/cool sitz bath for the first 24 hours, then warm sitz bath or warm compress after 24 hours
When should surgical intervention be done for a vulvar hematoma?
If the hematoma is rapidly expanding
What is the most common modus operandi for gaining access to a child for sexual abuse?
Babysitting
What is the main criterion for diagnosing sexual abuse?
Sexual abuse as a chief complaint (CC) is usually sufficient
What should be done if a child presents with purulent vaginal discharge and a history suggestive of sexual abuse?
Report the case even if CC is only foul-smelling vaginal discharge
When is urgent evaluation required for sexual abuse cases?
If abuse occurred within 72 hours, risk of repeated abuse, visible injuries needing treatment
Why is it important to interview the child separately from parents in suspected sexual abuse cases?
The child may withhold or alter information if relatives are present
What should be done before a genital exam in suspected child sexual abuse?
Conduct an interview first to ensure the child is comfortable
Why should a pelvic exam in a child not be forced?
To prevent re-traumatization and psychological distress
What is the most common type of perpetrator in child sexual abuse cases?
A known and trusted individual (e.g., relative, neighbor, babysitter)
What is a key legal obligation for physicians in suspected child sexual abuse?
Report to authorities (e.g., social workers, WCPU, PNP)
What infections should be screened for in sexually abused children?
Hepatitis, syphilis, gonorrhea, chlamydia, HIV, HPV
When should forensic evidence collection be done in suspected sexual abuse?
Within 72 hours of the incident
How long is sperm detectable in the prepubertal vagina?
Motile sperm: 8 hours, Non-motile sperm: ~24 hours, Sperm fragments: up to 72 hours
What percentage of sexually abused children acquire STIs?
0.05
Why should emergency contraception be offered to sexually abused women or adolescents?
To prevent pregnancy if the patient is at peak ovulation
Does emergency contraception cause abortion?
No, it prevents ovulation and alters hormone patterns
What is a reliable marker for sexual abuse in hymen evaluation?
Complete transection of the hymen or clefts extending to 3-9 o’clock
What is considered evidence of penetration in hymen evaluation?
Transection at 5, 6, or 8 o’clock positions
What is the most likely mode of transmission for genital warts appearing before 3 years old?
Maternal-child transmission
What is the most likely mode of transmission for genital warts appearing after 3 years old?
Sexual transmission
What is the treatment for genital warts in children?
Trichloroacetic acid (TCA) or topical imiquimod cream
What is the most common ovarian cyst in children and adolescents?
Functional ovarian cyst
What type of ovarian mass is usually benign but can be malignant?
Teratoma (Dermoid cyst)
What is the main risk of ovarian torsion?
Loss of ovarian function due to compromised blood supply
Why does ovarian torsion occur more commonly on the right side?
More free space in the right lower quadrant (RLQ); left side is restricted by the rectosigmoid
What is the best management for small, non-growing ovarian cysts in children?
Expectant management with serial ultrasound monitoring
When is surgical intervention necessary for ovarian cysts in children?
If the cyst is >10 cm, growing rapidly, or causing severe pain
What should be checked during surgery for ovarian masses?
The contralateral ovary for hidden pathology
What is the priority when surgically managing ovarian masses in children?
Preserving fertility while removing diseased tissue
What is the preferred management for prenatal ovarian cysts >4 cm?
Antenatal aspiration or CS delivery if large enough to obstruct labor
