PEDIATRIC GYNECOLOGY

Question 1

How long is the PREPUBERTAL VAGINA

Answer 1

4-6 cm

Question 2

These are positions used in examining the pediatric patient for gynecologic anomalies

Answer 2

Frog leg position

Knee chest position

Question 3

How would you instruct the mother and the pediatric patient to assume that the knee chest position

Answer 3

Dapa po si Camille tapos dapat po mas mataas po ang pwet so nakabend po yung knees. Maari niya pong rest ang ulo niya sa kamay niya.

Question 4

Give the visualization techniques for inspecting the vestibule and hymen

Answer 4

Supine lateral spread method

Supine lateral traction method

Question 5

VISUALIZATION TECHNIQUES FOR THE VAGINE

Answer 5

Otoscope - into the vaginal introitus with truncated earpiece removed,

Nasal Speculum - visualize vagina and cervix, preferrable done under anesthesia, though PAINFUL

VAGINOSCOPY - endoscope is used (5 mm smalles diameter) anesthesia used in the OR; least traumatizing to the hymen

Question 6

If you would like to examine the internal pelvic organs in a child, which maneuver or examination would you do?

Answer 6

Recto Abdominal Examination

Question 7

Indications of doing a rectoabdominal exam

Answer 7

1. You are suspecting Vaginal foreign body
2. Pelvicoabdominal mass or pain
3. Abnormal pubertal development

Question 8

Normal vaginal length of late childhood and adulthood

Answer 8

7-8.5 cm

8-12 cm

Question 9

Most common gynecologic complaints in pediatric patients

Answer 9

Vaginal discharge

Question 10

Info for vaginitis it is only the Volver that is usually inflamed together with a vagina. It is never the cervix and beyond that are inflamed. True or false

Answer 10

True

Question 11

Why does a child with vulvovaginitis present with urinary problems

Answer 11

Technically it is not due to urinary tract in origin but the secondary when you’re in passes through an inflamed vulva

Question 12

Why are prepubertal girls at risk?

Explain anatomic, physiologic and behavioral causes?

Answer 12

Hypoestrogenic (hormonal milieu)
Labia minora is think (barrier to introitus is weak)
Anus close to vaginal opening

Children’s tendency to poor hygiene
Explore bodies
Irritabts against vulva (🧼harsh soap, bubble baths)

Question 13

Etiology of NON SPECIFIC VULVOVAGINITIS

Answer 13

no particular etiology; usually combination of normal microbiologic flora

There is alteration in the local microbiologic Florida or host defense and homeostatic Mechanisms secondary to poor perineal and fecal hygiene

Question 14

What are the treatment options for non-specific vulvovaginitis

Answer 14

1. 2 to 3 week regimen of hygienic measures and avoidance of any identified irritates
2. MILD INFLAMMATION - SITZ BATH TO improve pruritis symptoms (ins: He was a basin of lukewarm water just enough to submerge the vulvar area for 15 to 20 minutes twice a day for 2 to 3 weeks)

Question 15

If this church is still persistent recurrent despite the measures after non-specific for vaginitis what would you consider now?

Answer 15

Foreign body

Question 16

What causative Asians are known to cause bacterial vulvovaginitis

Answer 16

Group a beta hemolytic streptococcus
Haemophilus influenza. Both are respiratory pathogen’s.

Shigella- blood tinged mucopurulent

Question 17

Viral causative agents for specific vulvovaginitis

Answer 17

HSV, HPV

HPV - maternal and child transmission occurs before 3 yo
Finger ng mom may warts tapos pepe ng bata may warts rin

Question 18

Why are candida infections rare in the non-estrogenenized prepubertal
girl

Answer 18

If lacking estrogen there would be no source of glycogen which is food for candida

Risk factors would include recent antibiotic use immunosuppression juvenile on site that diabetes

Question 19

What are parasitic causes of infective vulvovaginitis

Answer 19

Enterobius vermicularis or the pinworm

PATHOGNOMONIC: Severe nocturnal perineal and perianal pruritus is pathognomonic

Question 20

What is the diagnostics and treatment for Enterobius vermicularis

Answer 20

Scotch tape swab usually demonstrates the D shape ova

Mebendazole 30 mL oral suspension is given to >2 yo, 2 doses, 2 weeks apart

Albendazole <2 yo, 1 dose

DONT FORGET to TREAT HOUSEHOLD MEMBERS

CHANGE BED COVERS

Question 21

“absent vaginal opening”

Give DDX
If it is LABIAL FUSION. (Adhesive Vilvitis), what is the pathognomic sign?)

Answer 21

Impeforate hymen vs Transverse vaginal septum vs Vaginal agenesis vs Adhesive Vulvitis

(+) Translucent vertical midline “fusion line”

Question 22

What is pathognomonic for adhesive vulvitis

Answer 22

Translucent vertical midline “fusion kune”

Not treatment necessary unless there is already recurrent vulvovaginitis, pain/discomfort, bleeding, voiding problems

Question 23

Treatment for Adhesive Vulvitis

Answer 23

ESTROGEN CREAM applied 2x a day for 2-8 weeks

hygiene

Surgical treatment

Question 24

Common causes of VAGINAL BLEEDING give 5 discussed during lecture

Answer 24

1. Vaginal Foreign Body
2. Urethral Prolapse
3. Straddle Injury. (Vulvar Trauma)
4. Embryonal Rhabdomyosarcome (Sarcoma Botryoides)
5. Endodermal Sinus Tumor - occurs before 2 yo

Question 25

Most common vaginal foreign body

Answer 25

Tissue

Question 26

Presents as recurrent foul smelling, blood tinged mucopurulent vaginal discharge

Answer 26

Vaginal foreign body

Question 27

If vaginal foreign body is lodged in the lower vaginal canal, what examination would be helpful

Answer 27

You can ”milk” the foreign body out with Rectoabdominal Examination

Question 28

For vaginal foreign body, if milking with rectoabdominal maneuver does not work, what can be done?

Answer 28

Direct visualization of the vaginal canal and FB extraction may be done under anesthesia

Question 29

In urethral prolapse, what prolapses beyond the meatus?

Answer 29

Mucosa from the distak urethral lumen

Question 30

When there is “vaginal mass” what would you think of other than foreign body?

Answer 30

Urethral prolapse

Question 31

History to elicit in urethral prolapse

Answer 31

Blood staining in undergarments

Dysuria, hematuria, urinary retension

Question 32

Observed during PE in urethral prolapse

Answer 32

Ring or bud of beefy friable red tissue arising from the urethra

Very inflamed urethral opening

Question 33

GIVE THE MANAGEMENT FOR URETHRAL PROLAPSE

Answer 33

Tub soaks or sitz bath
eliminate need for valsalva
TOPICAL ESTRogen - without estrogen, structures ar not rigid and urethral easier to prolapse

SURGICAL EXCISION under anethsia When conservative or medical therapy fails or when recurrent
Patient is post pubertal

Question 34

When you see this, you rule in the possibility of sexual abuse?

Answer 34

HYMENAL TRANSECTIONS between 4 to 8 oclock positions and injuries POSTERIOr to the humen

Question 35

On PE you see a prolapsing GRAPELIKE MULTICYSTIC MASS seen at the introitus. What is this?
This occurs usually prior to age ___

Give treatment

Answer 35

Sarcoma Botryoides

6 yo

Conservative surfery + chemotherapy (VINCRISTINE, ACTINOMYCIN, CYCLOPHOSPHAMIDE) + radiation

Question 36

On PE you see a prolapsing fleshy mass protruding from the vagina. What is it?
Histologic pattern : (+) characteristic Schiller Duval bodies, elevated AFP

What labs to request give treatment
Give treatment

Answer 36

ENDODERMAL SINUS TUMOR

Serum AFP dapat ELEVATED

Conservative surgery + Chemotherapy (Cisplatin, Bleomycin, Etoposide)