Your pediatrician will describe each step of the exam. Your doctor checks your vulva, vagina, cervix . Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. Past medical history should include information about congenital anomalies,systemic disorders with dermatologic manifestations, and growth and development.Congenital anomalies, and particularly renal anomalies, may be associatedwith gynecologic anatomic abnormalities. It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation (discomfort/pruritus) or discharge ( Table 12.1 ) ( ). EMANS is Chief, Adolescent Division, Children's Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston. Employee communication. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. An organized stepwise approach in a nonthreatening environment is more likely to result in a successful evaluation of the genitalia. Different positions for performing a gynecologic examination on a child. She provides an overview of the physiology and evaluation of AUB, including recommendations on when to consider referring patients to our Spots and Dots Clinic. Non-sexually acquired genital ulcers (NSGUs) in adolescent females are uncommon, painful skin lesions on the mucous membranes of the vulva and vaginal structures, unrelated to sexual activity. Your First Pelvic Exam - Texas Children's Hospital The Pelvic Exam. Physical examination of newborn infant newborn examination checklist apgar score assessment. She also explains why it is important to check ferritin levels for iron deficiency and discusses the etiology of abnormal uterine bleeding, with most heavy menstrual bleeding in adolescents and young adults due to ovulatory dysfunction or inherited bleeding disorders. Vulvarskin disorders are common, and often easily recognizable on exam. If necessary, small amounts of daily topical estrogen to the labia may be used for treatment. The classic symptom of pinworms is nocturnal vulvar and perianal itching. Most such traumas involve straddle injuries. One method is to use the knee-chest position (see Fig. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. A history of trauma--whetheraccidental, intentional (for example, scratching due to pinworm infection)or caused by sexual abuse--also should be elicited. If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. Emans SJ, Lanfer MR, Goldstein DP: Pediatric and Adolescent Gynecology,4th ed. This chapter considers gynecologic diseases of children from infancy through adolescence. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . The exam can be done even if you have never had sexual intercourse, because the opening to your vagina is large enough to allow for the exam. Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing (bathing suits) are common culprits. Many adolescent girls do not want their mother, guardian, or other observers in the examining room, and in many adolescent gynecology visits, a full pelvic examination is unnecessary ( ). Sometimes doctors do pelvic exams if they think there's a problem. Local anesthesia of the vestibule may be obtained with 2% topical viscous lidocaine (Xylocaine) or longer-acting products such as lidocaine/prilocaine cream. 5 Minute Pelvic Exam Video. Am J Obstet Gynecol 1987;156:581. A pelvic exam is where a doctor or nurse practitioner looks at a girl's reproductive organs (both outside and internally). Historically, these masses were surgically removed, often involving removal of the entire ovary. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus. Exam Videos - IAFN - forensic nurses The prepubertal vagina is also narrower, thinner, and lacks the ability to distend like that of the vagina of a reproductively mature woman. A successful gynecologic examination of a child demands that the physician employ an exam pace that conveys both gentleness and patience with the time spent, without seeming to be hurried or rushed. Videos : Exams. From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. The child is told to have her abdomen sag into the table. This is to help girls understand that there is a doctor dedicated to their reproductive health. The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. In girls with persistent, purulent, or recurrent vaginal discharge, orthose with a suspicion of sexual abuse, obtain a wet preparation and culturesfor bacterial pathogens, C trachomatis, and N gonorrhoeae. Heavy menstrual bleeding is common in adolescents, with about 15% to 40% of teens experiencing heavy bleeding, but many teens dont recognize that their bleeding is abnormal. Diagnose this skin lesion with newest Stanford 25 video and topic. A vaginal discharge that is both bloody and foul-smelling strongly suggests the presence of a foreign body. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. This includes the process for diagnosis and considerations for work-up, evaluation and treatment, such as support and counseling. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. Inspect the child's breasts and palpate themfor signs of puberty. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. In addition, while obtaining a history, an opportunity exists to educate the child on vocabulary to describe the genital area. Thus, a positivevaginal culture should be considered evidence of sexual abuse in the child.Likewise, C trachomatis rarely persists beyond age 2 to 3 years, and mostinfants and toddlers have been treated since birth with an antibiotic thatwould treat Chlamydia. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse. Change gloves, lubricate the rectum, and then gently . A gentle, patient approach is important when examining a prepubertal girl. So this is the scariest picture weve got! A helpful technique is to place the childs hand on top of the physicians hand as the abdominal examination is being performed and to give her some choices, such as having a doll, an electronic tablet, or a toy with her. The Stanford Medicine 25 program for bedside medicine at the Stanford School of Medicine aims to promote the culture of bedside medicine to make current and . A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Persistent vaginal bleeding is an extremely rare symptom in a preadolescent girl. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . Pediatric Head-to-Toe Physical Exam - video Dailymotion In this. In noncooperative children, treatment should not be withheld if a specimen cannot be collected and empiric treatment may be started., many techniques have been described for attempting to collect a specimen, including the use of a very slim urethral Dacron swab moistened with nonbacteriostatic saline (used for collection of male urethral cultures). Below is a collection of all our Stanford 25-generated videos also found throughout the website. Using a hand mirror can be usefulto promote education, distract a child, and allow her to participate moreactivelyin the examination. How To do a Pediatric Physical Exam - YouTube Emphasize setting the stage to make the examinationa positive experience for your young patient. Before puberty, the girls reproductive organs are in a resting, dormant state. Gidwani GP. Stanford 25 Skills Symposium 2016 Announced! Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). The history is critical in terms of making a diagnosis, but it also providestime for you to establish rapport with the patient and elicit her understandingof her symptoms and expectationsof the visit. Learn more about patient ratings and reviews. If a child is scheduled to be seen in the middle of a busy clinic, the staff needs to be alerted that the pace and general routine will be different during her visit. Newborns will exhibit maternal estrogen effects:the labia majora, labia minora, and clitoris will be relatively large, theepithelium a dull pink color, and the hymen often thick and redundant. The prepubertal vagina is neutral or slightly alkaline. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Uterine bleeding that is coming more often than every three weeks, lasting longer than seven days in a row, or resulting in excessive product use and frequent bleeding through clothes should be evaluated. Stanford 25 YouTube Channel Abdominal Examination Examination of the Spleen (Stanford Medicine 25) Percussion of the Spleen (Stanford Medicine 25) Diagnosis Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) with Carnett's Sign - Abdominal Pain Ankle Brachial Index Ankle Brachial Index (ABI) Test: How to Perform Venous Testing Bedside Ultrasound Group A streptococciand Shigella are the most common causes. Pokorny SF. Sarah's Physical Exam with Pelvic Exam - YouTube Allowing the patient to see and touch the instruments also may assist in demystifying the examination and allow it to flow more smoothly. Pediatric Gynecology Videos | Children's Hospital Colorado How to Perform a Vaginal Self-Exam - Verywell Health A foreign object and the cervix may be visualized using this technique. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . When alone withan examiner, a child may disclose abuse or other concerns, and allowingher to be interviewed or examined alone may give her a greater sense ofcontrol and responsibility for her own health. The typical location is the anterior vaginalwall near the cervix. A complete vaginal evaluation should never be performed under duress or by force; to avoid this, sedation can be used when performing this examination on children. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. In determining the diagnosis, it may be helpfulto inquire about persistently wet underwear, recurrent fevers, unexplainedUTI, and abdominal or lower back pain. A gentle, patient approach is important when examininga prepubertal girl. A visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help. Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating. McCann J, Wells R, Simon M, et al: Genital findings in prepubertalgirls selected for nonabuse: A descriptive study. These procedures are usually performed under anesthesia. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation. Providers can counsel patients that they will inform them of each step in the process and then ask the teen if she is ready before performing each step. There will also be an extra sheet you can use to cover yourself. Related collections for "Pelvic Exam Variations" on Vimeo Gynecologic Examination for Adolescents in the Pediatric Office Setting One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics(Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies). 3 simple steps. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Vaginoscopy is a diagnostic procedure that can be used to evaluate the inside of the vagina and is recommended for girls who are too young for a speculum exam or cannot tolerate one. Macleod's Physical Examination - Head, Eyes and Ears Examination - OSCE Guide 2017. The majority of cases of persistent or recurrent nonspecific vulvovaginitis respond to improved hygiene and treatment of irritation resulting from trauma or irritating substances. Here we cover each aspect of the pelvic exam and demonstrate both in text and in our video how this done. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine. Dr. Baldeep Singh filming for a new set of "Approach to Low Back Pain" & "Approach for Hip Pain" videos. What will bedside manner look like for new data-driven physicians? Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs. Watch the gynecology medical education videos below for protocols and research from our experts to help improve the care of your patients. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body. Your first pelvic exam is usually after you become sexually active or when you turn 21, whichever comes first. Thus the office visit and the gynecologic physical examination are performed differently in a prepubertal child compared with an adolescent girl or a mature reproductive-age woman. From Pierce AM, Hart CA. Philadelphia, PA, WB Saunders, 1981, 5. After your examination is complete, congratulate the child for her cooperationand bravery. Instructing patients to use nonmedicated, nonscented wipes rather than toilet paper may prevent the self-inoculation of the vagina with small pieces of toilet paper, which can initiate a chronic discharge. Referral to a gynecologistis warranted if a child has an acute urinary retention or persistent completeadhesions not responding to office therapies. It can also present as a chronic colonization (diaper rash) in patients using diapers. Teens with complex medical issues, including developmental and physical disabilities, may have concerns about their periods. The work-up for vaginal bleeding includes a careful inspection of thevulva and vagina, wet preparation and bacterial cultures, and cultures forsexually transmitted infections if indicated. Patient has this new skin finding, what should you worry about? If thechild is anxious, you may need to leave the room and return when she feelsready to be examined; in some cases, the procedure may have to be postponedfor several days. However, it is when the pain gets progressively worse and occurs outside the menstrual cycle, that it might be time to consider a pathological cause, such as endometriosis.
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