Pediatric and Adolescent Gynecology

1. What every clinician should know

When is an exam indicated in a young child or adolescent?

The American College of Obstetricians and Gynecologists recommends that young women aged 13-15 undergo a dedicated reproductive health visit. The purpose of this visit is for education, prevention, and anticipatory guidance and should be tailored to the individual patient. It generally does not include pelvic exam, which can be emotionally traumatic for women in this age group, but allows young women an opportunity to establish a relationship with a gynecologist in a nonthreatening environment. In general, asymptomatic women do not require pelvic exam until Pap smear or screening for sexually transmitted infection is indicated.

Routine cervical cancer screening via Pap smear should begin at age 21. Screening for sexually transmitted infection should be done annually (more often if indicated by symptom or risk) once an adolescent becomes sexually active. Many children and young adolescents will present to their physician with symptoms or concerns that merit exam.

Indications for exam include but are not limited to:

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  • Pelvic pain

  • Vulvovaginal irritation

  • Vaginal discharge and/or odor

  • Vaginal bleeding

  • Urinary symptoms

  • Suspected abuse

  • Anatomic concerns

What findings are normal in a young child?

It is important that providers understand vulvar and vaginal physiology in young patients and can distinguish normal from abnormal findings. Normally, female infants can demonstrate evidence of estrogenization secondary to maternal hormone exposure. Within the first week of life, they may even experience vaginal bleeding in response to estrogen withdrawal. Other normal findings can include physiologic leukorrhea (white, milky discharge), enlarged labia majora, thickened and redundant hymenal tissue, and breast development. All of these symptoms typically abate over the first few months of life as maternal estrogen is cleared.

By approximately one year of life, female children move into a phase of relative hypoestrogenism that will essentially last until puberty. As this change occurs, the labia become less prominent and there is little subcutaneous fat on the vulva. The hymen and vaginal mucosa become thin, smooth, and atrophic appearing. Normal hymenal anatomy can vary from crescentic (most common) to annular (see below). The distance between the anus and the vestibule is short. The vestibule (area just outside of the hymen) is densely vascular and can appear quite erythematous.

The pediatric vulva is uniquely vulnerable to trauma, irritation, and inflammation due to lack of estrogenization and anatomic features that leave the vestibule relatively exposed.

What techniques are helpful in examining a young child or an adolescent?

A gynecologic exam in a child can be quite challenging for both the provider and the patient. It is helpful to keep parent(s) in the room, start with general exam and do not rush; if the child is very uneasy, consider deferring exam to later visit if possible. Using mirrors or a video colposcope may place a nervous patient at ease, and positioning options include examining a young children in their parent’s lap, frog leg, lithotomy, supine with knees flexed to chest, or a knee-chest position.

Sample collection

In the event that sample collection is required (such as wet mount or bacterial culture), it is often beneficial to ask the child to collect this herself. With proper instruction, most children can accomplish adequate collection while being reassured by the sense of control. Alternatively, the child may prefer to hold her own labia separate while allowing her mother to collect the swab.

Culture and wet mount should be collected from above the hymenal ring using a cotton-tipped applicator moistened with saline. Care should be taken to avoid touching the hymen itself as this causes pain.

2. Diagnosis and differential diagnosis

Common pediatric gynecologic disorders

Vaginal discharge and vulvovaginal irritation are common complaints in prepubertal girls and account for 70% of gynecologic visits in a pediatric population. Concerns about abnormal anatomy are other common issues among patients and their parents.

The differential diagnosis for these conditions is broad and requires a comprehensive history detailing medical history, hygiene practices, personal care products, exposures to pets, and current medications. In many cases, the physical exam can be limited to the vulva and lower vagina and will not require full visualization of the upper vagina and cervix. In performing the exam, one should pay particular attention to the color of the vulvar tissue, the texture of the skin, the presence or absence of discharge, the presence or absence of odor, any evidence of trauma, evidence of excoriation, and the presence or absence of skin lesions such as ulcerations. It is important to remember that vulvar and vaginal issues can occur in isolation or in combination, and clarification of anatomic involvement is helpful to diagnosis and treatment.

Differential diagnosis

Noninfectious vulvovaginitis

Contact dermatitis (or nonspecific vulvovaginitis) accounts for 75% of all cases of noninfectious vulvovaginitis. The skin of the pediatric vulva is quite sensitive to chemical products, and relatively mundane exposures such bath soaps and laundry detergents can produce pronounced irritation. It is often difficult to identify the offending agent. Typically, contact dermatitis of the vulva appears as a generalized erythema, but can become severe enough to result in vesicles and skin breakdown.

Another common cause of external vulvar irritation in a prepubertal child is poor perineal hygiene and fecal contamination. In this scenario, exam usually reveals generalized redness and swelling of the labia. Often, there is residual smegma or even flecks of stool present on the vulva. In more extreme cases, there can be excoriations or skin breakdown that leads to secondary bacterial infection. In general, culture is not indicated for diagnostic purposes in hygiene-related irritation.

Lichen sclerosis is relatively rare in the pediatric population (estimated 1:900), but it often presents with itching, irritation, and soreness. In some cases, there will be bleeding, dysuria, and pain with defecation. The characteristic finding of lichen sclerosis is a loss of pigmentation with a white, parchment paper-like appearance of the skin. If the perianal skin is involved, there is an hourglass-shaped appearance to the affected area. The introitus becomes narrowed, and there is loss of architecture of the vulvar anatomy. Fissuring and subepithelial hemorrhages may be present. Diagnosis is usually made by physical exam alone, but vulvar biopsy is confirmatory if there is uncertainty.

Foreign bodies inside the vagina produce symptoms of foul-smelling and sometimes blood-tinged, purulent vaginal discharge. Vulvar irritation, if present, is usually the result of chronic exposure to the vaginal discharge and is therefore a secondary feature. Although young children have been known to place objects such as marbles in their vagina, it is actually more common for the foreign body to be an inadvertently retained object such as a fragment of toilet paper.

Infectious vulvovaginitis

Unfortunately, children are vulnerable to the same sexually transmitted infections that adults carry. Needless to say, any amount of vulvar or vaginal trauma should raise suspicion for the possibility of abuse. Similarly, if a workup for vulvovaginal irritation or discharge reveals the presence of a sexually transmitted infection, then abuse should be presumed and appropriate steps should be taken ensure that child’s safety.

Children who have suffered abuse, or who are having symptoms consistent with possible sexually transmitted infection, should be evaluated for N. gonorrheae, C. trachomatis, T. pallidum, Trichomonas vaginalis, human papillomavirus (HPV), HIV, and herpes simplex virus. It is important to note that vertical transmission of both Chlamydia and HPV has been demonstrated. In children under the age of 3 with vulvar condyloma, vertical transmission from vaginal birth is a likely source. In many cases of vertical transmission, the mother has no known history of HPV and no recognized active disease at the time of delivery.

Autoinoculation can lead to bacterial infection of the vulva and vagina with respiratory and skin pathogens. The vulva can become quite red, inflamed, and tender. Symptoms include a vaginal discharge that can ranges from yellow to green. Wet mount reveals the presence of abundant white blood cells. A history of recent or ongoing upper respiratory infection or otitis media may be a clue to this diagnosis.Vaginal culture will be positive for a pathogen in approximately 25% of children with vulvovaginitis; therefore, a culture can be helpful in identifying the pathogen. Common pathogens include Group A Streptococcus, Neisseria meningitidis, Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pneumoniae.

Pinworms are transmitted via the fecal-oral route; the adult female worm exits the rectum nocturnally and lays eggs on the skin, causing perianal and vulvar irritation. At times, they can also live in the vagina and cause a vaginal discharge and irritation. The intense itching associated with pinworms can lead to excoriation and in turn secondary bacterial infections of the skin. Pinworms are diagnosed via the “Scotch tape” test, where Scotch tape is applied to the perianal skin and the worm eggs adhere to the tape. It is also reasonable to consider empiric therapy in a high-risk situation where symptoms of perianal itching are pronounced.

Although commonly suspected, Candida is rarely the cause of vulvovaginitis in a prepubertal girl. The hypoestrogenic environment leads to low cellular glycogen content and ultimately a nonhospitable environment for yeast. Immunosuppression and recent antibiotic use increase the likelihood that yeast is the etiology in vulvovaginitis. Common symptoms include intense itching, beefy red erythema of the vulva with irregular borders to the lesion, and satellite skin lesions. Severe cases can even lead to skin weeping and ulceration. The vagina is rarely involved in the prepubertal girl, but the presence of a thick, white discharge would suggest a vaginal infection as well. Yeast culture can be confirmatory if the diagnosis is unclear.

Anatomic concerns

A common complaint among young patients (and parents of young girls) is that something looks abnormal on the vulva. It is often difficult for them to further qualify this statement, so careful examination is important in response to this complaint.

Labial agglutination is an acquired condition wherein the labia minora fuse together in the midline. This is a relatively common condition that is often asymptomatic and likely to resolve with no intervention within a year. It is postulated that labial adhesions form as a consequence of topical irritants that cause inflammation and denuding of the labial skin; as the skin reepithelializes, the two labia become joined by an avascular bridge. The connection between the two labia appears as a white, midline raphe and helps to distinguish this finding from imperforate hymen, ambiguous genitalia, or congenital absence of the vagina. Labial adhesions are most common in children between the ages of 6 months and 6 years. If symptomatic, children may experience discomfort with activity, abnormal urinary stream, postvoid dribbling, or recurrent UTI.

Imperforate hymen is the most common obstructive lesion of the female reproductive tract. This occurs as a result of ineffective apoptosis and degeneration of the central portion of the hymenal membrane during development. Imperforate hymens are most commonly detected either at birth due to a bulging mucocolpos or at puberty due to a hematocolpos that results from menstrual blood being trapped behind the membrane. Other variations on hymenal anatomy are quite common, including microperforate, cribiform, or septate hymens. These are often asymptomatic as they do not completely obstruct menstrual flow. Many are detected due to difficulty with tampon placement or intercourse.

Urethral prolapse often appears as a flowery, red, fleshy mass inside the vaginal opening. The urethral mucosa protrudes past the urethral meatus and becomes quite engorged and even friable. This can be mistaken for a tumor or evidence of trauma. Symptoms often include bleeding, dysuria and urinary hesitancy. Urethral prolapse is more common among African American than Caucasian children and is often related to an underlying cause of frequent valsalva such as cough or constipation.

Although very rare, there are primary tumors of the vagina that present during childhood. If a mass is noted in the vagina, it may be a sarcoma botryoides. These tumors have a classically grape-like appearance and typically occur in girls ages 2 to 5. Sarcoma botryoides can involve the anterior vaginal wall, the urethra and the hymenal ring.

3. Management

Noninfectious vulvovaginitis

If contact dermatitis or poor hygiene is suspected, then treatment should focus on removing the irritant. Patients and parents should be educated about proper hygiene (wiping front to back, etc.). An effort should be made to transition to products that are hypoallergenic and lack artificial dyes and scents. Dove and Aveno bath soap and Dreft laundry detergent are examples of hypoallergenic options. Cotton undergarments are ideal. Daily warm water sitz baths can be helpful. For short-term symptom relief, a topical barrier cream such as Desitin can be used. With severe inflammation a topical steroid cream such as 1% hydrocortisone may provide symptom relief and facilitate healing. Symptoms should begin to resolve within a few days of instituting these steps.

The mainstay of treatment for lichen sclerosis is topical corticosteroid. Often, initial therapy requires a potent steroid such as clobetasol 0.05% which is applied twice daily for 4-6 weeks. Thereafter, most patients can be tapered to a less potent steroid such as triamcinolone and ultimately weaned entirely. Recurrence rates are high and most patients will require repeated courses of therapy. For some young patients, symptoms will abate with the onset of menarche.

Foreign bodies require removal, and at times IV sedation will be required to accomplish this. Given that children will not tolerate a speculum exam, irrigating the vagina with warm normal saline will often flush the foreign body and obviate need for a more invasive procedure. A pediatric red rubber catheter can be attached to a large bulb syringe; with care to avoiding touching the hymenal tissue, the tip of the catheter can be painlessly inserted into the vaginal opening for irrigation. If the child cannot tolerate this procedure, then exam under anesthesia with or without vaginoscopy may be needed. Removal of the foreign body is adequate treatment and antibiotics are not required.

Infectious vulvovaginitis

Sexually transmitted infections should be treated in accordance with adult treatment guidelines, modified to the size and age of the pediatric patient. Vulvar and vaginal infections with bacterial respiratory and skin pathogens are best treated with an appropriate spectrum antibiotic. Amoxicillin or ampicillin are common therapies.

Pinworms are typically treated with mebendazole 100 mg. Single dose therapy is adequate for most patients, but a second dose given after 1-2 weeks improves cure rates. Empiric therapy of other household members is indicated and patients should be educated to clean bed linens and institute strict hand washing precautions to prevent re-infections. Vulvar candidiasis is best treated with topical antifungals such as mycolog or nystatin. If vaginal infection is suspected, then systemic therapy with oral diflucan is indicated.

Anatomic abnormalities

Treatment is indicated for severe labial adhesions or for symptomatic patients. Medical therapy with topical estrogen cream applied twice daily for 2 weeks is highly successful. Parents must understand that a gentle amount of lateral traction on the labia while applying the estrogen cream will facilitate separation. If medical therapy fails, manual separation can be accomplished quickly and safely under conscious sedation.

Correction of an imperforate hymen requires surgical excision. If recognized during childhood, the optimal timing of surgery is after the onset of puberty (tissues are estrogenized) but before the onset of menses (prevents hematocolpos). First-line treatment for urethral prolapse is medical therapy with topical estrogen cream applied nightly for 2-3 weeks. Sitz baths may help with symptoms. It is also important to address any underlying predispositions such as constipation. If the patient does not respond to medical therapy then referral to urology for surgical excision of the prolapsed mucosa can be considered. If sarcoma is suspected, referral to a specialist for biopsy is warranted.

4. Complications

Contact dermatitis and irritation from poor hygiene can lead to skin breakdown, which in turn places the patient at risk for bacterial suprainfection. If there is concern for bacterial infection, culture can be informative and help guide therapy. Recurrence rates for lichen sclerosis are high and most patients will require repeated courses of therapy.

If not removed, foreign bodies could lead to vaginal erosions, injury, and infection. Sexually transmitted infections in children can lead to the same spectrum of complications seen in adults, including vulvar and vaginal dysplasias, upper reproductive tract infection, and infertility. Recurrence of labial adhesions occurs in up to 40% of patients. Good hygiene and reduction of exposure to topical irritants will help to prevent recurrence. If manual separation is required, postoperative estrogen cream may help prevent immediate recurrence.

Unrecognized and untreated imperforate hymens can lead to hematocolpos after a child enters puberty and begins menstruating. Hematocolpos is often associated with pain, and on occasion this obstructed blood can be a host for infection.

5. Prognosis and Outcomes

For most causes of vulvovaginitis in the young patient, appropriate and targeted therapy is curative. Lichen sclerosis tends to wax and wane over time, and most young women diagnosed with this condition will have recurrent episodes. In some fortunate women, the onset of puberty may herald an end to exacerbations of lichen sclerosis.

Labial adhesions are at risk for recurrence after either medical or surgical therapy. Once systemic estrogen levels increase associated with puberty, it is unlikely for labial adhesions to persist or recur. Urethral prolapse is typically corrected with a combination of medical therapy and elimination of causative factors such as chronic constipation. If this conservative approach is not successful, surgical correction is definitive therapy. Surgical correction of abnormalities of the hymen is definitive therapy.

6. What is the evidence for specific management and treatment recommendations

“Committee opinion No. 460: The initial reproductive health visit”. Obstet Gynecol. vol. 116. 2010. pp. 240-243. (Guidelines for preventative gynecologic care in the adolescent patient, including recommendations for timing of visits, indications for exams, and information for coding and billing these visits.)

Emans, SJH, Laufer, MR, Goldstein, DP. “Pediatric and adolescent gynecology.”. 1998. (A comprehensive textbook including chapters addressing vulvovaginitis as well anatomic abnormalities in young patients.)

Zitelli, BJ, Davis, HW. “Atlas of pediatric physical diagnosis”. 2002. (A comprehensive pediatric photo atlas with a chapter dedicated to pediatric gynecology.)

Carpenter, SEK, Rock, JA. “Pediatric and adolescent gynecology”. 2000. (A comprehensive textbook including chapters addressing vulvovaginitis as well anatomic abnormalities in young patients.)

Van Eyk, N, Allen, L, Giesbrecht, E. “Pediatric vulvovaginal disorders: a diagnostic approach and review of the literature”. J Obstet Gynaecol Can. vol. 31. 2009. pp. 850-862. (Excellent review of the differential diagnosis of vulvovaginal disorders in young patients, with discussion of both diagnostic and treatment approaches.)

Jamieson, MA. “A photo album of pediatric and adolescent gynecology”. Obstet Gynecol Clin North Am. vol. 36. 2009. pp. 1-24. (Informative photo atlas that provides visual diagnostic cues for common diagnoses in pediatric and adolescent gynecology patients.)

Goldfarb, A. “Clinical Problems in Pediatric and Adolescent Gynecology”. Chapman and Hall;. 1996. (Comprehensive manuscript addressing common gynecologic disorders in young patients. Includes guidance for both diagnosis and treatment.)

Garden, AS. “Vulvovaginitis and other common childhood gynaecological conditions”. Arch Dis Child Educ Pract Ed. vol. 96. 2011. pp. 73-8.. (Excellent review of common gynecologic disorders in pediatric patients. Includes helpful pictures and tips and diagnosis and treatment.)

Mroueh, J, Muram, D. “Common problems in pediatric gynecology: new developments”. Curr Opin Obstet Gynecol. vol. 11. 1999. pp. 463-466. (General review of diagnosis and management of common pediatric gynecologic disorders.)