[GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR.

ISIDRO

PEDIATRIC AND ADOLESCENT GYNECOLOGY ESTROGEN LEVELS IN CHILDHOOD

Dr. Isidro

CONSIDERATIONS
 Evaluation of gynecologic problems in the children is not the
same as approaching such problems in adult women.
 When evaluating Pediatric Gynecology patients, we
have to consider a lot of factors most specially the
emotional aspect, the psychological aspect, as well as
the physiological aspect.
 Remember that hormonal surge occurs during
these stages, especially in adolescents.
PPT Notes:
 The gynecologic physical examination of the genitalia
in a young girl is therefore different in a prepubertal
child than in an adolescent of reproductive age, OR a
mature reproductive woman. Outpatient visit by a
prepubertal child should be structured differently from
that of an adolescent of reproductive age, or a mature
reproductive woman.
 Presence of the mother may facilitate examination of
a 4 year old girl but may inhibit the cooperation of a
teenager.
 Young girls should be made to feel that they are
participating and NOT being coerced in their
examination.
 Fetal Period  Increased estrogen level
 Neonatal Period/Early Childhood Period  Abrupt
decrease
 Early Childhood to Middle Childhood Period  Plateau
 Late Childhood Period  Increase
ADOLESCENT GYNECOLOGY
 Adolescence and puberty produce dramatic changes in
physical, hormonal, and emotional changes
 Physician: Emphatic, kind, knowledgeable, and gentle
approach
GYNECOLOGIC EXAMINATION OF A CHILD
GENERAL APPROACH
 Pace of examination should convey gentleness and patience
(NEVER HURRIED OR RUSHED)
 SIT not stand on the initial encounter
 Standing reflects authority

CONSIDERATIONS IN PEDIATRIC GYNECOLOGY  Create sense of familiarity in the examining room ambiance
CONSIDER THE FOLLOWING FACTORS  Avoid interruptions
 Psychology  Their attention span is very short
 Growth and Development
 Physiology  Instruments that may frighten the child should not be in
 Anatomy view

CONSIDERATIONS IN PEDIATRIC GYNECOLOGY THE GYNECOLOGIC EXAM

 Gaining of the child’s confidence and establishing rapport  History, inspection and visualization of vulva, vagina, and
are extremely important cervix, and possibly a rectal exam  Included in a complete
pediatric exam
 Poor interaction in the first visit detracts from future
physician-patient interaction  Rectal exam is very invasive and painful so sometimes
 Mostly, pediatric gynecologic visits are preventive and this is not included
problem oriented  Ask about the history from the mother or from the
 Most problems are medical rather than surgically treated legal guardian
 Common:
 Vulvovaginitis HISTORY AND GYNECOLOGIC EXAM
 Most common problem encountered in the out-  Child can contribute to the history of her symptoms if
patient department with regards to Pediatric questioned directly
patients  Opportunity to provide age-appropriate education on sexual
 Labial Adhesions abuse
 Vulvar Lesions PPT Notes:
 Suspicion of Sexual Abuse Educate child on vocabulary
 Genital Trauma  E.g. “genitals and breast”  Areas covered by swim
suit are the private areas

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO

TIPS FOR THE KID GYNECOLOGIC EXAM  Pelvic Exam

 Reassure that it will not hurt  Many pediatric gyne conditions can be diagnosed by
 Give child sense of control inspection
 Emphasize that the most important part is “just looking”  Introitus will gape open when gentle downward and
 Needs cooperation of patient and a medical assistant outward pressure is applied on lower thigh or labia
 Allow child to visualize and handle any instrument that is to majora
be used on her  Ask child to blow
PPT Notes: Useful technique is to have the child’s hand  To enlarge and separate the labial folds
on top of the doctor’s during abdominal exam, give her
choices such as toys or dolls to hold (for diversion) 2. EVALUATION OF THE VAGINA
 A child’s reaction will depend on her age, emotional
maturity, and previous experience with healthcare providers
 A pelvic exam is sometimes deferred to a second visit based
on the child’s level of anxiety in relation to severity of the
clinical symptoms*
 Restraints are NEVER used
 Rarely, continuous IV sedation or general anesthesia maybe
needed to complete an essential examination  Knee-chest position is used to view vagina and cervix
 MOST IMPORTANT: TO INVOLVE CHILD AS PARTNER AND  Ophthalmoscopes used as a magnifying and light source
TO EMPHASIZE THAT THERE ARE NO SHOTS. but is NOT inserted

THE GYNECOLOGIC EXAMINATION NEWBORN

 Draping may be anxiety provoking and is NOT necessary in  Puffy labia majora
the preadolescent  Thickened labia minora
 Handheld mirror  Redundant hymenal folds
 All necessary equipment should be easy to reach during the  Mucosa is pink & moist
examination  Vaginal pH is acidic
**Remember this 

PELVIC EXAM
1. EVALUATION OF EXTERNAL GENITALIA NEONATAL HYMEN
 This is a normal newborn cervix
which is ESTROGENIZED
resulting into thick elastic
redundancy.
 In older unestrogenized girls, the
hymen is thin and non-elastic.

PRE-PUBERTY
 Labia majora loses fullness
 Labia minora and hymen
become thinner and flatter
 Labia minora do not fully
cover the vaginal vestibule
 Perineum and perivaginal
 PPT Notes: The first part of the pelvic exam is tissues rigid and inelastic
evaluation of the external genitalia. An infant may be **Remember this 
examined while sitting on her mom’s lap. The mother’s
lap is covered first by pads as some examinations may NORMAL EXTERNAL GENITALIA AND HYMEN
be associated with urination. Young children may be
examined in the frog’s legs position. Children as young
as 2-3 years can be examined in the dorsal lithotomy
with use of stirrups. This latter position is the general
one used for kids 4-5 years and older.

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO

NORMAL VARIANTS: HYMEN  Usually sedation is needed and is done in the OR

PPT Notes: THE IDEAL PEDIATRIC ENDOSCOPE IS A

CYSTOSCOPE OR HYSTEROSCOPE BECAUSE THE
ACCESSORY CHANNEL FACILITATES VAGINAL
LAVAGE. Nasal speculum or otoscope is too short for
older girls but have the advantage of built-in light
source. Local anesthesia of the vestibule is
adminsitered. The MD can divert the child’s
attention from the scope by simultaneous gentle
compression of one of the patient’s buttocks. The
vaginal examination is NEVER done under duress or
force.
HYMENAL BUMPS
3. RECTAL EXAMINATION
 The most distressing aspect
 Maybe omitted depending
on symptoms
 Indications:
 Genital Tract Bleeding
 Pelvic Pain
 Suspicion of Foreign Body
or Pelvic Mass

 We can palpate the uterus and the cervix during the

 A mounding of hymenal tissue is called a bump. This is rectal exam.
normal and attached to longitudinal ridges within the
vagina.  PPT Notes: The child is warned that the exam elicits
sensation of pressure of bowel movement. THE
PRE-PUBERTAL PERIOD NORMAL PREPUBERTAL UTERUS AND OVARIES ARE
 Thickening of hymenal tissue (picture) NONPALPABLE IN THE RECTAL EXAM. The relative
 Normal Prepubertal Vagina ratio of cervix to uterus is 2:1 in the child in contrast to
 Vaginal epithelium is redder and the opposite ratio in the adult. Except for the cervix,
thinner any mass discovered on rectal exam in the prepubertal
 Length is 4-6 cm child is considered ABNORMAL.
 Adults: 9 cm
EXAMINATION OF THE ADOLESCENT
 Neutral or slightly alkaline pH of secretions
 Critical factors are different from that of girls 2-8 years
 Narrower, less
distensibility, thinner  Many prefer privacy without parents, guardians or others in
the room
 Mucosa is thin, relatively
atrophic and has reddish  Stage wherein the child is conscious  As much as
hue possible, they don’t want anybody inside the room
 Vaginal pH is neutral to
 In many visits, a full pelvic exam is not necessary
alkaline
 Reassure that the examination is not painful
 VAGINOSCOPY: Indications in  PPT Notes: Preconceived notions of the adolescent:
the Pediatric Patient That the exam is very painful
 Recurrent vulvovagintis  Counsel patients that they will be informed of every step and
 Persistent bleeding asking them if they are ready before doing each step*
 Suspicion of foreign body or
PPT Notes: Allows feeling of control and anticipation
neoplasm
of the next procedure
 Congenital anomalies

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO

GYNECOLOGIC PROBLEMS IN PREPUBERTAL CHILDREN BEHAVIORAL

VULVOVAGINTIS  Poor perineal hygiene
 Most common problem among  Posterior to anterior wiping
prepubertals  Scratch-itch cycle
 80-90% of visits to gynecologists due to  Infrequent hand-washing
classic symptoms of:  Tight-fitting, nonabsorbent clothing
 Introital irritation (discomfort/pruritus) **Remember this 
 Discharge
PPT Notes:
Vulva and vagina are more exposed to bacterial
 Clinical Features of Children Presenting with Vulvovaginitis
contamination from rectum than in adults due to the
SYMPTOMS SIGN
above reasons. Lack of fat pads and pubic hair exposes
 Itch  Genital Redness the lower third of the vagina when child squats. There
 Soreness  Visible Discharge is no significant geographic barrier between vagina
 Bleeding  Perianal Soiling and anus. Vulvar and vaginal epithelium lacks the
 Discharge  Specific Skin Lesions protective effect of estrogen and thus are sensitive to
 None irritation and infection. Minora and vulvar skin are thin
and are red because of the capillary network are easily
 PPT Notes: The prepubertal vagina is neutral or visualized. The neutral or slight alkaline vaginal pH
slightly alkaline. With puberty, this becomes acidic due provides good medium for bacterial growth. There is a
to bacilli dependent on glycogenated estrogen- lack of glycogen and lactobacilli and an insufficient
dependent vagina. Breast budding is a reliable sign level of antibodies to offer much resistance. The
that the vaginal pH is shifting to an acidic normal vaginal flora of the prepubertal girl is colonized
environment. by about nine species of bacteria-4 aerobic and
facultative anaerobic and 5 obligatory anaerobic sp.
 Major factor is poor perineal hygiene especially as
 Pathophysiology (Non-specific Vulvovagintis) there is close proximity of the vagina to the anus
 Often involves primary irritation of the vulva (mostly by coupled with the fact that after toilet training, most
normal rectal flora or chemical irritants -- nonspecific kids are unsupervised when they defecate. Most wipe
vulvovagintis) from posterior to anterior resulting to inoculation of
 Accompanied by secondary involvement of lower third of rectal flora. Minor vulvar irritation may lead to the itch
vagina scratch cycle with secondary seeding as kids may not
 PPT Notes: Most cases of irritation of vulvar wash their hands frequently. Clothing are tight and
epithelium is from normal rectal flora or chemical nonabsorbent which keeps the vulvar skin irritated,
irritation. This is called NONSPECIFIC warn, moist, and therefore prone to vulvovaginitis.
VULVOVAGINITIS. In cases of the former, there are
often predisposing vulvar irritations from perfumed
 Other Causes of Vulvovaginitis (Specific)
soaps, tight clothing in the perineal area e.g. seams of
 Bacterial
blue denims, etc. which causes denudation thus
 Viral
permitting the rectal flora to easily infect the irritated
 Protozoal (Trichomonas)
areas. Vaginal cultures often give results of normal
rectal flora or E. coli. In a primary care center,  Suspect sexual abuse
nonspecific vulvovaginits makes up the majority of  Mycotic (Candidial)
vulvovaginitis cases.  Helminths (Pinworms)
 Physical, Chemical agents
 Reasons for Susceptibility  Allergic conditions
PHYSIOLOGIC  Tumors
 Others (Anatomic Anomalies - E.g. Ectopic Ureter)
 Lacks labial fat pads and pubic hair
 No significant barrier between vagina and anus
 Epithelium lack protective effect of estrogen
 Thin minora and vulvar skin
 Neutral or slightly alkaline pH
 Vagina lacks lactobacilli and glycogen
 Insufficient levels of antibodies

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO
VULVOVAGINTIS CAUSED BY PINWORMS
 Enterobius vermicularis
 20% of infected girls develop
vulvovaginits
 Classic Symptom: Nocturnal Vulvar
and Perianal Itching
 “Scotch Tape Test”
 PPT Notes: At night, the adult worms migrate from the
rectum to the vulvar skin to lay eggs. These may be
discovered by flashlight or obtained by scotch tape
before child has arisen in the morning and this is then
examined under microscope.
 Discharges Caused by Vulvovaginitis
 Discharge may vary from minimal to copious and color
ranges from white to gray to yellow or green
 Green  Gonococcal = Suspect child abuse
 Signs are variable and not diagnostic
 Differentials in Persistent or Recurrent Cases:
 Foreign Body
 Primary Vulvar Skin Disease
 Ectopic Ureter
 Child Abuse
 If pruritus is predominant  Pinworm or
irritant/nonspecific VV
 PPT Notes: Bloody and purulent discharge is usually
not VV but due to a foreign body but some pathogens
such as Shigella boydii often presents with a bloody or
blood-tinged discharge
 Treatment
 Improvement of local perineal hygiene
 Avoidance of irritants (bubble baths, harsh soaps etc.)
 Wet compress of Burrow’s solution (acute weeping
lesions)
 Educate child to void with knees wide apart and to wipe
from front to back
 Loose fitting cotton undergarments
 Zinc oxide or cod liver bland creams
 Low potency steroid creams
 Oral antibiotics
PPT Notes:
 Perineal hygiene is the cornerstone of treatment. Most
cases are cured solely by this as many symptoms
improve with hygienic changes and sitz baths.
 Relief of vulvar irritation maybe facilitated by using
blands creams as above which are applied several
times a day. Low potency steroids can also be used.
Medium potency ones are reserved for more severe
cases as well as oral antibiotics given for 10-14 days.
The choice of antibiotics maybe helped by vaginal
cultures but mostly these will not yield a specific
pathogen. IN recurrent cases. A broad spectrum agent
maybe appropriate to decrease the E.coli inoculum.
 Results of culture may at times yield a single organism
which is a respiratory pathogen, intestinal, or a
sexually transmitted organism. The presence of the
last is usually a strong indication of sexual abuse and
appropriate referrals and follow-ups are mandatory.
LABIAL ADHESIONS/ADHESIVE VULVITIS
 Ours in extremes of ages  Young
and menopause
 Midline agglutination of labia minora
 Pathognomonic: Translucent vertical
midline line
 PPT Notes: This is agglutination of denuded epithelium
of adjacent labia minora creating a “flat’ appearance
of the vulvar surface. Often are PARTIAL and only
involve the upper or lower aspects of the vulva.
(ABOVE is a complete adhesion). Small adhesions are
common in preschool children; 20% may have some
degree of adhesion on routine exam.
 Differentials
IMPERFORATE HYMEN VAGINAL AGENESIS
 Imperforate Hymen  Most classical symptom would
be a bulging mass – because it could be menses that
could not flow out of the vagina
 PPT Notes: Inexperienced examiners may confuse this
with imperforate hymen or vaginal agenesis as all of
these occlude visualization of the introitus. In
imperforate hymen, the minora normally appear as an
upside down V and no hymenal fringe is seen in the
intoritus. In agenesis, the fringe is normal but the
vagina ends blindly behind this.
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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO

 Desquamation of vaginal
epithelium by acid-producing
bacilli incorporated into
normal flora (estrogenic
environment)
 Often needs only reassurance
or hot sitz bath and frequent
underwear changes (if irritation ensues)

URETHRAL PROLAPSE
 Not rare in children
 More common in girls from 2-6 years old (time when  Most common presentation:
estrogen levels are lowest) Prepubertal Bleeding
 Non-estrogenized labia predisposes to denudation  Often preceded by sharp increase in
 Very rare for the fusion to be complete abdominal pressure (E.g. Coughing)
 PPT Notes: It is rare for fusion to be complete. In  Complete: Red Donut-like Structure
severe cases both urethral and vaginal orifices are  Maybe partial or incomplete
covered but rarely is the fusion complete. Even when  Occasionally maybe necrotic and blue-
the urethra is covered, the child may expel urine via black
openings on top of the adhesions. Sometimes though  Treatment:
the partially fused labia may form a pouch in which  Conservative and Non-interventional
urine can collect and later dribble presenting as  Rarely - surgery for necrosis
incontinence.
 Maybe associated with urinary infections PPT Notes:
 Distal aspect of urethral mucosa may prolapse along
 Treatment entire 360 degrees of the urethra as above.
 Do not attempt to separate by pulling the labia apart!  Maybe difficult to distinguished from botryoid sarcoma
 Topical Estrogen of the vagina
 Some have applied estrogen creams or antibiotics but
 PPT Notes: Topical estrogen is the most common prospective studies have not been done to confirm
treatment for this and is applied twice a day at the therapeutic value
site of fusion. Spontaneous separation usually
occurs in 2-8 weeks. If resolution takes longer,
reexamination is done to check if the cream is being LICHEN SCELOROSUS ATROPHICUS
dabbed at the actual site of fusion or just lateral to  Common in prepubertals and
it. This is indicated if there is a line of pigmientation postmenopausals
that appears just to the side of the actual fusion line.  Maybe autoimmune?
Correct reapplication is then taught to the caregiver.  Pruritus and Vulvar Discomfort
 Prepubertal bleeding, constipation, dysuria
 Zinc Oxide or Petroleum Jelly (prevention of
reagglutination)
 Histology
 PPT Notes: Bland ointments such as zinc oxide or
petroleum jelly are applied for one month after
spontaneous separation to prevent reagglutination.
Reagglutination is seen in 1 of every 5 cases.

 Other Concerns on Labial Adhesions

 Maybe associated with sexual abuse (if there is
concomitant scarring of the posterior fourchette in girls >
6 years old with new onset adhesions)

PHYSIOLOGIC DISCHARGE OF PUBERTY

 Seen in early stages of puberty
 Grayish-white, or yellowish but non-purulent

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO
 PPT Notes: Diagnosis maybe difficult for the
inexperience but not for clinicians with expertise on
this condition. If in doubt, small punch biopsy
preferably under general anesthesia is performed for
the prepubertal child.
 Lesions DO NOT go beyond the labia
majora
 Hour glass or figure of 8 (genital and
perianal involvement)
 Skin is parchment–like, whitish
 Secondary changes from scratching
 PPT Notes: Scratching-excoriations, bloody blisters
Prepubertal bleeding
 Treatment
 Avoidance of irritation and trauma to the area
 Avoidance of straddle activities when symptomatic
 Hot sitz soak instead of soap scrubs of the area
 Avoidance of tight clothing
 Judicious use of clobetasol in selected cases*
(Condition may improve with puberty)
 PPT Notes: Safety has not been evaluated in patients
<12 years and may be associated with adrenal
suppression in children and parents should be
educated on this. Application of the agent must be
done sparingly by the parent and tapering of dosage
if there is a response or within a two week interval.
May be tried for patients in which avoidance of
trauma, irritation and medium potency steroids have
not worked.
PREPUBERTAL BLEEDING WITHOUT SECONDARY SIGNS OF
PUBERTY
 IN CHILDREN WITH BLEEDING WITHOUT ANY BREAST
DEVELOPMENT, THERE IS ALMOST NEVER AN ENDOCRINE
CAUSE (EXCEPT IN A VERY RARE PRESENTATION OF McCUNE
ALBRIGHT SYNDROME)
 PPT Notes: MCCUNE ALBRIGHT SYNDROME is a
genetic disorder of bones, skin pigmentation and
hormonal problems along with premature puberty.
Typical cases have breast development.
DIFFERENTIAL DIAGNOSIS
 Foreign Body
 Genital Trauma
 Sexual Abuse
 Lichen Sclerosus
 Shigella Vaginitis
 Breakdown of Labial Adhesions
 Urethral Prolapse
 Friable Genital Warts or Vulvar Lesions
 Vaginal Tumors
 Rare Presentation of McCune Albright Syndrome
 Isolated Menarche??
 Dermatologic Conditions with Secondary Excoriations
 Nongenital Bleeding (Rectal or Urinary)
FOREIGN BODY
 Mostly in girls 3-9 years old
 History often non helpful
 PPT Notes: History is often non
helpful because adults have not
witnessed it or the child fails to
recall insertion.
 Small wads of tissue  most common
 Some easily visualized on knee chest position
 Insertion may be due to pruritus or simple curiosity
 Foul smelling bloody vaginal discharge
 Purulent, nonbloody discharge
 Time lapse between insertion and symptoms
 Objects may imbed within vaginal wall*
 Management
 Unexplained bleeding mandates vaginoscopy
 ASAP especially for children <6 years old (to rule out
malignancy)
 Removal:
 Vaginoscopy
 Sometimes forceps or by irrigation
 “Repeat performers” are common
 PPT Notes: Repeat performers using tissue 
Change to wipes
SHIGELLA VAGINITIS
 50% present with prepubertal bleeding
 Usually without concomittant GIT symptoms
 Culture  Any child without any obvious cause of PP
bleeding
VAGINAL TUMORS (rare)
ENDODERMAL SINUS
SARCOMA BOTRYOIDES
TUMOR
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 Sarcoma Botryoides  Extensive Lacerations  General anesthesia, wound

 Grape-like structures extruding out of the vagina
 Malignant lesions
 PPT Notes: In Sarcoma Botryoides, almost all cases in
the vagina occur in those <6 years and Endodermal
Sinus Tumor, in <2 years old. Even if these are very rare,
they should be considered in every young child. Both are
aggressive such that prompt diagnosis is crucial.
Vaginoscopy should be done in any child with no obvious
cause of PP bleeding.
ACCIDENTAL GENITAL TRAUMA
 The usual cause of accidental genital trauma during
childhood is a fall. Seventy five percent of trauma to the
vulva and vagina are straddle injuries. However, sexual
abuse remains an important consideration.
VAGINAL TRAUMA: LACERATION AND STRADDLE INJURIES
 PPT Notes: One of the most common causes of genital
trauma in a child is a straddle injury. This occurs when
the child stands or hovers with her legs apart over a hard
object then falls with the perineum against the object.
This often occurs on playground climbing structures or
fence rails. In cases when injury is associated with
hymenal transection, sexual abuse must be considered
strongly. Rarely, such injuries may be due to a
penetrating injury such as when falling into a stick horse
or broom. In cases when hymenal transection occurs, the
examiner MUST ascertain that the object has not
penetrated into the vaginal wall resulting into a
dangerous hematoma, cul-de-sac perforation or
abdominal cavity perforation with potential visceral
damage. A vaginoscopy or laparoscopy is generally
needed to rule out these three.
 Evaluate the site, extent and amount of
bleeding (under anesthesia)
 Gentle washing via irrigation with sterile
warm water
 Consider booster shots of tetanus toxoid (if
last immunization is >5 years ago)
 PPT Notes: Typical lacerations involve denudation
around the urethra or labia. The posterior fourchette is
uncommonly involved.
 Superficial (First Degree) Lacerations  Usually no need for
repair (if bleeding is controlled)
 Slightly Deeper  Steri strips or single well placed sutures
to stop the bleeding (esp. in inferior labia minora) under
local anesthesia
irrigation and debridement, ligation of bleeders, repair of
injuries
 Suspected Retroperitoneal or Intraabdominal Injury 
Laparoscopy, exploratory celiotomy
VULVAR HEMATOMA
 Predisposing Factor: Lack of vulvar fat
pads
 Common Causes:
 Blunt trauma
 Sharp trauma
 Sexual abuse
 Auto and bike accidents
 Kicks
 Self-inflicted
 Extent determined by visualization and palpation
 Treatment for Nonexpanding Type:
 Serial observation
 Ice packs or cool sitz bath
 Pain meds
 PPT Notes: Size varies. Initially, there is bleeding into the
loose connective tissue. When pressure from expanding
hematoma exceeds venous pressure, the hematoma
stops growing. In most cases, surgical exploration is
avoided. It is seldom to find a specific vessel to ligate in
quickly expanding hematomas within 2 minutes of
observation except in the uncommon cases wherein
there is arterial laceration. Urethral injury or anxiety in
experiencing pain when urinating may cause difficulty of
voiding.
SEXUAL ABUSE IN THE PREPUBERTAL CHILD
 Global increases  25% of girls are sexually abused during
childhood
 Most Common Perpetuator: Male acquaintance known by
family
 Fathers  21% of the time
 Other Male Relatives  19%
 Mothers  4-8%
 Common modus operandi-babysitting
 History
 Two situations that necessitate provider query into
potential sexual abuse:
1. Child/family that presents with potential sexual abuse
as the chief complaint
2. Child is seen for another complaint (e.g. purulent
discharge) but the provider considers possibility of
abuse based on history or PE
 Urgent Evaluation
1. Abuse has occurred within 72 h (for forensic evidence)

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO
2. Child is currently in danger (repeated abuse or self-harm)
3. Obvious injuries
(If none of the above is present, the child and family can be
evaluated on non-urgent basis)
PPT Notes:
 Specially trained personnel should be involved ASAP. In
many settings, these children are referred to a sexual
abuse team on a nonemergency basis. If such teams
are not available, it is critical that they provide and be
aware of OTHER community resources.
 If possible, the child and her family are interviewed
separately by a qualified mental health provider
(social worker or psychologist) experienced in
evaluation of sexual abuse cases.
 Conduct of Evaluation
 The interview is done prior to a genital exam if there are
no compelling medical reasons:
1. Child may not be able to separate the exam from
touching done during the abuse making subsequent
history taking difficult.
2. In most cases, the exam is normal. The family should not
rely on this to determine need for counselling or
intervention.
3. This allows rapport between the mental health provider
and the family that will facilitate trust and treatment
 The interview should be in a NON threatening manner
 Queries to the child should be open ended and
nonjudgmental
 Leading questions are avoided
 Legal Issues in Reportage
 It is required that suspected or known sexual abuse be
reported
 If provider is unsure if a report is required, then the
situation is discussed with the local child protection
services or the social worker
 Such discussions should be documented on the patient’s
chart
 PE and Evaluation for STDs
 Thorough GENERAL EXAMINATION with findings properly
documented in the chart
 Parents should be counseled that the genital exam of an
abused child may be normal
 If abuse occurred within 72 hours, collection of forensic
evidence is important
PPT Notes:
 Physical evidence is present only in about 5%.
 Collection of all clothing and undergarments is critical.
About two thirds of forensic evidence are obtained
from linens and clothing.
Motile sperm is present in the prepubertal vagina for
about 8 hours and nonmotile sperm for 24 hours. Their
presence is shorter than in reproductive women due to
the absence of cervical mucus.
**Study this table 
 Evaluation for STIs
 Providers must decide whether this is indicated
 Gonorrhea and Chlamydia cause vaginitis NOT cervicitis in
the prepubertal so a vaginal culture is done
 Testing for STIs is also influenced by the typical incubation
period*
 PPT Notes: Therefore, if a child is abused in an
isolated incidence, an STI may not be discovered by
testing immediately after the abuse.
 A purulent discharge should prompt testing and is a red
flag of ONGOING rather than isolated sexual abuse
(Picture on the
Right)
 Intracellular
Diplococci 
NEISSERIA
GONORRHEA
 The Hymen in Sexual Abuse
 THERE IS A SIGNIFICANT VARIATION
IN CHILDREN AND THE STATE OF THE
HYMEN IS NOT A RELIABLE
INDICATOR OF SEXUAL ABUSE.
GENITAL WARTS
 HPV may be transmitted by mother-to-
child transmission (delivery) or by
sexual or nonsexual transmission
after birth
 Lesions appear prior to 3 years of age
 Mother-to-child transmission
 Lesions in 3 year old and up 
Consider sexual transmission
 50% of lesions regress over 5 years
 Expectant management is reasonable
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 Treatment in children may be difficult*  Complications

 PPT Notes: Caustic treatment such as with TCA are 1. Torsion
painful even if there is local anesthesia. Topical 2. Rupture/Leak
imiquimod has been approved for those >12 years of 3. Malignancy
age but can cause significant vulvar irritation. Laser 4. Infection
treatment is an option but should be done under
inhalational anesthesia and can be associated with  Diagnosis
significant postop pain. 1. Ultrasound
 Transrectal or Transvaginal Ultrasound 
Transrectal is preferred
NEOPLASMS IN CHILDREN
 The most common gynecologic neoplasm in children is of 2. CT Scan
ovarian origin.
 Treatment
OVARIAN NEOPLASMS  Conservative Surgery  Oophorocystectomy
 1% of all childhood malignancies
 8% of all malignant and abdominal tumors OVARIAN CANCER (Most common  Decreasing frequency)
 10-30% operated on during childhood and adolescence are  Dysgerminoma  Most Common 
malignant  Malignant Teratomas
 Endodermal Sinus Tumor
GYNECOLOGIC CONDITIONS IN NEONATES AND INFANTS:  Embryonal Carcinoma
 OVARIAN CYSTS  Epithelial Cell Tumors

PRECOCIOUS PUBERTY
 This is the onset of sexual maturation at any age that is 2.5
SD earlier than the normal age for the population
 In other words: Development of sexual maturation before
the ages of 8-9 years in girls and boys

CLASSIFICATION
 Seen antenatally by ultrasound I. TRUE PRECOCIOUS PUBERTY (GnRH-Dependent)
 SIMPLE CYSTS  CAUSES:
 Most common  Idiopathic
 Resolve spontaneously average 2.6 months  CNS Lesions: Hamartomas, Craniopharyngioma, etc
 Serial monthly ultrasound  Most common
 Frequency is low
 Majority are benign  Primary Hypothyroidism

1.Functional  2.Neoplastic  II. PSEUDOPRECOCIOUS PUBERTY (GnRH-Independent)

FOLLICULAR CYSTS TERATOMAS  Isolated precocious thelarche
 Isolated precocious menarche
 Estrogen-secreting tumors of the ovary or adrenals in girls
 Ovarian cysts
 McCune-Albright Syndrome
 Most common
 Peutz-Jeghers syndrome
 Iatrogenic

 Clinical Manifestations PREMATURE THELARCHE

1. Abdominal Pain  Most common  Isolated development of the
2. Presence of a mass breast tissue prior to age 8 years,
3. Urinary frequency/obstruction most commonly occurring
4. Constipation/Diarrhea between 1 and 3 years of age. It
5. Vaginal bleeding may affect 1 or both breasts.

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 [GYNECOLOGY] PEDIATRIC AND ADOLESCENT GYNECOLOGY – DR. ISIDRO

 On examination, the somatic growth pattern is not

accelerated, bone age is not advanced and smear of vaginal
secretion fails to show estrogen effect.

PREMATURE PUBARCHE/ADRENARCHE
 Defined as the appearance of pubic or axillary hair prior to
age 7 years in white girls and 6 years in black girls. Such hair
growth may be idiopathic and of clinical significance.
 It usually results from an earlier than-usual increase in the
secretion of androgens by adrenal glands. Thorough
evaluation of the gonadal and adrenal function should be
made to exclude such abnormalities.

PREMATURE MENARCHE
 Denotes the appearance of cyclic vaginal bleeding in
children in the absence of other signs of secondary sexual
development.
 It could be related to increased end-organ sensitivity of the
endometrium to low prepubertal levels of estrogens.
 Diagnosis is formulated by exclusion following investigation
of other causes of vaginal bleeding and confirmed when the
cyclic nature of the bleeding becomes apparent.

LEA THERESE R. PACIS 11