Pediatric Gynecology

M. Thamrin Tanjung, Prof.Dr.dr.Sp.OG(K)

M. Rusda Harahap, dr.Sp.OG(K)
Gynecological care
begins in the delivery room as part
of the newborn examination with
palpation of the breast buds and
examination of the external
genitalia
 Gynecological care
 Evaluation of the external genitalia continues
through routine well-child examinations,
permitting early detection of infections,
labial adhesions, congenital anomalies,
and even genital tumors.

 A complete gynecologic examination is

indicated when a child has symptoms or
signs of a genital disorder.
Specially designed equipment
To prevent undue discomfort and
consequent anxiety about future
examinations.
 vaginoscope,
 virginal vaginal speculum
 The first few weeks of life.

 During the first few weeks of life, residual maternal

sex hormones may produce physiologic effects on
the newborn.
 Breast budding occurs in nearly all female infant
born at term.
 In some cases, breast enlargement
 May be fluid discharge from the nipple.
 No treatment is indicated.
The first few weeks of life (Cont.)
 The labia majora are bulbous, and the labia minora are
thick and protruding
 The clitoris is relatively large, with a normal index
of 0.6 cm2 or less.
 The hymen initially is turgid,
 Vaginal discharge covering is common, comprised
mainly of cervical mucus and exfoliated vaginal cells.
 The uterus is enlarged (4 cm in length) and without
axial flexion; the ratio between the cervix and the
corpus is 3: 1.
 Vaginal bleeding may occur as estrogen levels
decline following birth and the stimulated endometrial
lining is shed. Such bleeding usually stops within 7-10
days.
Early childhood (0-6 years)
 The female genital organs receive little
estrogen stimulation.

 Thelabia majora flatten and the labia

minora and hymen become thin

 The clitoris remains relatively small,

although the clitoral index is unchanged.

 The vagina, lined with atrophic mucosa

with relatively few rugae, offers very little
resistance to trauma and infection.
 Since vaginal fornices do not develop until
puberty,
the cervix in childhood is flush with the vaginal
vault, its opening appearing as a small slit.

 Theuterus regresses in size, regaining the size

present at birth at around age 6.

 Asthe child matures, the ovaries begin to

enlarge and descend into the true pelvis.

 The number and size of ovarian follicles

increase. They may attain significant size and
then regress.
 Late childhood (age 7-10 year)
The external genitalia again show signs of
estrogen stimulation:
 the mons pubis thickens,
 the labia majora fill out, and the labia minora
become rounded.
 The hymen thickens, losing its thin, transparent
character.
Early puberty (age 10-13 years)
 During early puberty (age 10-13 years),
the genitalia cake on adult appearance.
 The major glands (Bartholin's glands) begin to
produce just prior to menarche.
 The vagina reaches adult (10~12 cm) and
becomes more distensible, the mucosa
thickens,vaginal secretions grow more acidic
and lactobacilli reappear.
 With the development of vaginal fornices, the
cervix becomes separated from the vaginal
vault
History & Physical Exam
 Givechild an opportunity to speak with
you alone when appropriate

 Givechild as much control as possible

over situation & get them involved in the
exam if possible

 Bemindful of abuse and be aware of

appropriate steps in suspicious cases
 Never restrain a child (general anesthetic
may be required)
 Have parents sit on table with child
 Use frog leg and knee/chest positions in
younger children
 Inspect hymen carefully for signs of breaks
or trauma as minor external injuries may
hide serious vaginal lesions
 Inspect anal region but do vaginal/rectal
exams only when needed (imaging often
better option)
Instruments
 May need instruments to visualize the
upper 1/3- 1/2 of the vagina
 Office vaginoscope can be tried (0.5
cm in infancy/childhood & 0.8 cm in
premenarcheal girls)
 Water cystoscope allows some
distention of vagina & cleans debris
 Can use urethroscope/laparoscope
 Topical lidocaine to anesthetize vulva

 General Anesthesia if exam not easy

 Huffman-Graves & Pedersen specula should be

used for adolescents

 Saline soaked swabs are used for vaginal

samples in children because this is adequate
given immature lining

 Speculum exam with Cx cultures may be

necessary in adolescent
FA: Calgiswab for obtaining vaginal specimens in the prepubertal
girl. B: Assembled catheter-within-a-catheter, for obtaining
specimens from a prepubertal child. (From Pokorny SF, Stormer
LVN. Atraumatic removal of secretions from the prepubertal
vagina. Am J Obstet Gynecol 1987;156:581; with permission.)
Types of specula (from left to right):
infant, Huffman, Pederson, and Graves.
Otoscope (without a speculum) for visualizing hymen and vagina.
(A) Examination of patient under anesthesia, (B) using a Killian nasal
speculum with fiberoptic light (obtained from Codman and Shurtleff, Inc.,
Pacella Drive, Randolph, MA).
 Methodes of examination
 Placing a child up to 5 years of age on her parent's
lap affords a better opportunity to perform an
adequate examination (Fig 31-4).
 Older children may be placed on the examination table,
but the use of stirrups is not generally necessary if
the patient is asked to flex her knees and abduct her
legs.
 The knee-chest position is useful in visualizing the
upper vagina and cervix.
Positioning the child in the frog-leg position with the aid of her mother. (Courtesy of Dr. Trina
Anglin, Office of Adolescent Health, Health Resources and Services Administration (HRSA),
Washington, DC.)
Positioning the prepubertal child in the frog-leg position. She can
lie horizontally or with the head of the examining table raised.
[Courtesy of Dr. Trina Anglin, Office of Adolescent Health, Health
Resources and Services Administration (HRSA), Washington,
DC.]
Positioning the child in the lithotomy position with the use of
stirrups. (Courtesy of Dr. Trina Anglin, Office of Adolescent Health,
Health Resources and Services Administration (HRSA), Washington,
DC.)
Positioning the child in the lithotomy position with the aid of her
mother. (Courtesy of Dr. Trina Anglin, Office of Adolescent
Health, Health Resources and Services Administration (HRSA),
Washington, DC.)
Examination of the prepubertal child in the knee chest
position.
The Tanner stages of human breast development. (Adapted from Grumbach MM, Styne
DM. Puberty: Ontogeny, neuroendocrinology, physiology and disorders. In: Wilson JD,
Foster DW, eds. Williams textbook of endocrinology, 8th ed., Philadelphia: WB Saunders,
1992; and from Marshall WA, Tanner JM.Variations in pattern of pubertal changes in
girls. Arch Dis Child 1969;44:291.)
The Tanner stages for the development of female pubic hair. (Adapted from Grumbach
MM, Styne DM. Puberty: Ontogeny, neuroendocrinology, physiology and disorders. In:
Wilson JD, Foster DW, eds. Williams textbook of endocrinology, 8th ed., Philadelphia:
WB Saunders, 1992; and from Marshall WA, Tanner JM.Variations in pattern of pubertal
changes in girls. Arch Dis Child 1969;44:291.)
External genitalia of the prepubertal child.
Examination of the vulva, hymen, and anterior vagina by gentle
lateral retraction (A) and gentle gripping of the labia and pulling
anteriorly (B).
Types of hymens (photographed through a colposcope): (A)
crescentic hymen, (B) annular hymen, and (C) redundant hymen
with crescent appearance after retraction.
Types of hymens: (A) normal, (B) imperforate, (C) microperforate,
(D) cribriform, and (E) septate.
Microperforate hymen.
Microperforate septate hymen.
Microperforate septate hymen.
Imperforate hymen.
Septate vagina.
Microperforate hymen. A: Opening difficult to visualize.
B: Opening gently probed.
Hymenal tags.
Child and Adolescent Gynecologic Problem

• Congenital (sex determination)

• Infection (vaginal discharge, pain)
• Precocious puberty and vaginal
Child bleeding
• Traumatic injuries
• Rarely neoplastic lesion

• Puberty, onset of menstruation

• Delayed puberty (1ry amenorrhea)
• Cryptomenorrhea (imperforate hymen)

Adolescent •
•
Vaginal discharge and bleeding
Traumatic injuries
• Rarely neoplastic lesion (germ cell
ovarian tumor)
Examination of the Newborn
Infant
A. GENERAL EXAMINATION
B. CLITORIS
C.VAGINA
D. RECTOABDOMINAL
EXAMINATION
 A. General Examination
 may reveal abnormalities suggesting genital
anomaly eg:
◦ webbed neck,
◦ abdominal mass,
◦ edema of the hands and legs, coarctation of the
aorta
 The external genitalia are inspected and palpated
and evaluated:
◦ Does it appear normal?
◦ Is it in its proper location?
◦ Will it function normally later in life?
 LABIAL ADHESIONS

 Agglutination of the labia minora, termed labial

adhesions or, in the lower half, vulvar
adhesions, occurs primarily in young girls aged
3 months to 6 years
 Labial adhesions are not seen in newborns
because of estrogen effects on the vulva.
 Occasionally, adhesions occur for the first time
after age 6, and adhesions presenting at any age
may persist to the time of puberty.
Labial/vulvar
adhesions with
small opening
below the
clitoris.
 Vulvar irritation may play a role in causing the
formation of the adhesions or the progression
from an initially small posterior adhesion to a
near-total fusion.
 The vaginal orifice may be completely covered,
causing poor drainage of vaginal secretions.
 Parents often become alarmed because the
vagina appear absent
 The diagnosis of labial adhesions is made by
visual inspection of the vulva.
 The treatment of labial adhesions remains
controversial.
 Spontaneous separation may occur,
particularly with small vulvar adhesions at the
posterior fourchette and with estrogenization
at puberty.
 If the opening in the agglutination is large
enough for good vaginal and urinary drainage,
lubrication of the labia with a bland ointment
and gentle separation applied by the mother
over several weeks, may be helpful.
 For adhesions that impair vaginal or urinary
drainage, the most effective treatment is the
application of an estrogen-containing cream

 Estrogen-containing cream (e.g., Premarin)

twice daily for 3 weeks and then at bedtime
for another 2 to 3 weeks. Approximately half
of adhesions will resolve in 2 to 3 weeks (105),
and therapy can then be changed to ointment.
 After separation has occurred, the labia should
be maintained apart by daily baths, good
hygiene, and the application of a bland
ointment at bedtime for 6 to 12 months.

 Forceful separation is contraindicated because

it is traumatic for the child and may cause the
adhesions to form again.
Labial Adhesion (Summary)
 Common in prepubertal children
 Secondary to low estrogen levels
 Local irritation denudes labia causing
adherence in the midline and
reepithelialization
 Most children are asymptomatic but may
have urinary symptoms
 Treatment includes estrogen cream bid
for 7-10 days
 Surgical separation may be necessary
 Recurrence common
Labial abscess.
Vulvovaginitis
Vulvovaginitis
 Most common gyn complaint of children
 Children are susceptible to pruritus & vaginal
discharge from irritation/infection as the
vulva is thin without labial fat pads and pubic
hair, closer to the anus, unestrogenized vagina
is atrophic, pH is excellent for bacterial
growth, & perineal hygiene is suboptimal
 Itch/scratch cycle and subsequent
inflammation & bleeding
Vulvovaginitis
 Sand boxes, wet clothes, etc contribute
 May have large extension onto thighs
 Consider other derm
conditions/lesions and whether there
are signs of abuse
 Wet mount may show numerous leuks
 Cultures & evaluation of vaginal
secretions as appropriate
 Most cases resolve by removing
inciting agent
 Foreign Bodies
 Common
 Present with vulvovaginitis, pain, bleeding or abnormal
discharge
 Often fragments of toilet paper but may be toys etc
which child may not remember or admit to
 If within lower 1/3 vagina – flush with warm saline
irrigation
 Vaginoscopy may be required
Trauma
 Straddle injuries most common cause of genitalia
trauma in young girls
 Seasonal peak in spring with bikes
 Contusions generally require no treatment
 Hematomas are generally controlled with pressure &
an ice pack although an enlarging hematoma may need
operative intervention
 Consider vaginal packing
 Catheter if hematoma blocking urethra
 Pelvic X-ray & Antibiotics as appropriate
 Must rule out more severe injury (eg above hymenal
ring)
Abuse
 Many victims are not seen immediately
 Vigilance is key!
 Know who to call & be sure of evidence
collection
 Recognize and treat all injuries, good
perineal care, screen for STI
 Pregnancy testing
 Counselling & support is key
Lipoma of labia in an 8-year-old girl who had
had a labial mass for 1 year.
B. Clitoris
 The clitoris deserves particular attention,
because:
◦ Enlargement : almost always associated with
congenital adrenal hyperplasia.
◦ Other causes : true hermaphroditism, male
pseudohermaphroditism.
Enlargement of
Clitories
Two newborn girls with virilization and salt-losing congenital
adrenocortical hyperplasia: (A) and (B) patient S.C., (C) patient M.T
 C.Vagina
 The vaginal orifice
 Labia are separated or retracted.
 If it is not, it can be found by gently inserting a small,
well lubricated pediatric feeding tube
 When an opening cannot be found, the infant most
likely has an imperforate hymen or vaginal
agenesis.
 Infrequently, associated inguinal hernias suggest the
possibility that the child is a genetic male, particularly
when there is a mass in the hernial sac.
 If the vaginal orifice cannot be located, further
investigation is warranted.
Imperforate hymen in a baby.
Imperforate Hymen
 D. Rectoabdominal Examination
 To complete the primary evaluation, a
rectoabdominal examination is performed.
 Usually, the uterus and adnexa in the newborn
cannot be palpated on rectal examination.
 Occasionally, a small central mass representing the
uterine cervix can be felt on examination.
 When an ovary is palpable, it denotes a marked
enlargement and warrants further investigation (eg,
ultrasonography) to rule out the presence of an
ovarian tumor. Negative findings are valuable because
they generally exclude a pelvic tumor.
 Rectal examination also confirms patency of the
anorectal canal.
 Examination of the premenarcheal
child
 Focus on the main symptoms identified in this
population: pruritus, dysuria, skin color changes,
and discharge.
 Placing a child up to 5 years of age on her parent's lap
 Older children may be placed on the examination table,
but the use of stirrups is not generally necessary if the
patient is asked to flex her knees and abduct her legs.
 The knee-chest position is useful in visualizing the
upper vagina and cervix.
Examination of the
premenarcheal child

A. PHYSICAL EXAMINATION
1. General inspection.
2. Breasts
3. Abdomen
4. Genitalia.

B.Vaginoscopy
CONGENITAL ANOMALIES

VAGINA
UTERUS
OVARIUM
URETHRA
ANUS
ANOMALIES OF THE VAGINA
1. IMPERFORATE
2. TRANSVERSE VAGINAL SEPTUM
2. LONGITUDINAL VAGINAL
SEPTUM
3. VAGINAL AGENESIS
4. PARTIAL VAGINAL AGENESIS
ANOMALIES OF THE
UTERUS
1. RUDIMENTARY UTERINE HORN
2. UNICORNUATE UTERUS
WITH PARAMESONEPHRIC
CYST
Unicornuate Uterus
 Single horned uterus with corresponding
fallopian tube & round ligament
 Results from agenesis of 1 mullerian duct
with absence of structures on 1 side
 If other hemiuterus present, a small
rudimentary horn is created
 If this horn does not communicate with
other cavity or vagina, may develop
dysmenorrhea and hematometra
 Higher risk preterm labor, infertility,
endometriosis, & malpresentation
Uterine Didelphys
 Failure of fusion of the mullerian duct may
result in 2 separate uterine bodies
 Generally good reproductive outcomes
 Vaginal septae may require resection if
causing difficulty with intercourse, vaginal
delivery, or pain from obstructed
menstruation
Bicornuate Uterus
 Results from partial fusion of the
mullerian ducts which leads to varying
degrees of separation of the uterine
horns
 Reproductive function is generally good
 Septate Uterus
 Results from failure of canalization or
resorption of the midline septa between
the 2 mullerian ducts
 Higher risk of miscarriage with increasing
length of septa
 Hysteroscopic resection may be needed
 ANOMALIS OF THE OVARIUM
 Drawn by the round ligament into the inguinal canal or the
labium majus.
 A firm inguinal mass should alert the examiner to the possible
presence of an aberrant gonad, possibly containing testicular
elements, even though the external genitalia are female.
 A karyotype should be obtained when a girl presents with an
inguinal gonad.
 At the time of hernia repair, the gonad should be biopsied. If it
proves to be an ovary, it should be returned to the peritoneal
cavity and the hernia repaired. If a testis is identified, the gonad
should be removed.
 Pediatric Ovarian Masses
 Fetal/Neonatal
◦ Can be maternal hormone derived follicular cysts
that often regress, rarely enlarge and torse
◦ If not a follicular cyst, the differential is broad. Utilize
imaging and labs!
 Prepubertal
◦ Torsion and hemorrhagic infarction #1
◦ Malignancy exceedingly rare
 Postpubertal
◦ Majority: functional ovarian cysts
◦ Germ cell tumors are #1 neoplasm
 Most are mature teratomas and are benign
 Immature teratomas are rare and show good
response to chemotherapy
 Sarcoma botryoides
 =botryoid rhabdomyosarcoma
One of rare mesenchymal tumors, grows in the
form of polypoid grapelike masses and derives
its name from this gross appearance
 Clinical characteristics
The most common clinical finding is vaginal
bleeding. They may appear as a polypoid mass,
somewhat yellow in color and are friable: thus,
they (possibly) may break off, leading to vaginal
bleeding or infections.
Sarcoma Botryoides
Sarcoma Botryoides

Strap cell
 Epidemiology
Sarcoma botryoides normally is found in children
under 8 years of age. Onset of symptoms occurs at
age 3 years (38.3 months) on average. Cases of older
women with this condition have also been reported.
 Treatment and prognosis
The disease used to be uniformly fatal, with a 5-year
survival rate between 10 to 35%. As a result,
treatment was radical surgery. New multidrug
chemotherapy regimens with or without radiation
therapy are now used in combination with less radical
surgery with good results, although outcome data are
not yet available.
 General Prevention Considerations
 Pap smear surveillance beginning at 21
years of age by current ACOG guidelines.
 Gardasil vaccination 11-26 years of age. 3
vaccine visits two months apart.
 STI and contraceptive counselling
 Summary
 Good gynecologic care begins in the delivery room.
 Use knee-to-chest or frog-leg positioning for genital
exam.
 The most common ovarian mass is a torsed ovary.
 Mature teratomas are the most common pediatric
ovarian neoplasm.
 Judicious use of serum lab evaluation, pelvic imaging
and karyotyping aids in the diagnosis of endocrine and
upper genital tract abnormalities
 Screen for potential abuse.
 Incorporate a preventive care strategy that includes;
STI and contraceptive counselling, HPV vaccination and
current pap smear guidelines.