History and Physical Examination

Published on 22/03/2015 by admin

Filed under Pediatrics

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1390 times

Chapter 542 History and Physical Examination

Kerith Lucco, Diane F. Merritt

History

With a preverbal or very young patient, clinicians obtain the majority of the history from a parent or caregiver, although even for the very young patient, developmentally appropriate social questions to the patient can put her at ease and help to develop cooperation and rapport that will facilitate a subsequent examination. Specific patient, caregiver, or provider concerns about vaginal discharge or bleeding, pruritus, external genital lesions, or abnormalities should direct a problem-focused history. In a patient presenting with vaginal bleeding, questions focus on recent growth and development, signs of puberty, trauma, vaginal discharge, medication exposure, and any history of foreign objects in the vagina. For complaints of vulvovaginal irritation, pruritus, or discharge, questions concentrate on perineal hygiene, the onset and duration of symptoms, the presence and quality of discharge, exposure to skin irritants, recent antibiotics, travel, presence of infections or medical conditions in the patient or family members, and other systemic illness or skin conditions. Clinicians may ask the patient about what has bothered her, any genital contact, and, if the complaint warrants, whether she ever placed something into her vagina. The patient should be encouraged to ask her own questions. Occasionally the child is brought to the clinician because she or her parents have concerns about anatomic findings, developmental changes, or congenital anomalies. It helps to understand the family’s concerns and if a specific reason, event, or family history raised the issue.

Gynecologic Examination

Neonates

The delivering obstetrician should briefly examine the external genitals of female infants to confirm the patency of the vagina and assess the presence of any obvious genital anomalies. The pediatrician’s newborn examination should note any abnormal findings such as ambiguous genitals, imperforate hymen, urogenital abnormalities, abdominal mass, or inguinal hernia that might herald a gynecologic problem.

Placing the infant in the supine position with thighs flexed against the abdomen allows visualization of the neonate’s external genitals. Estrogenic effects commonly apparent include prominence of the labia majora and a white vaginal discharge. The labia minora and hymen may protrude slightly from the vestibule. The hymen should be evaluated for patency. A small amount of neonatal vaginal bleeding due to endometrial sloughing, following maternal hormone withdrawal, might occur. Bleeding that is excessive or persistent beyond 1 mo of life requires additional evaluation. Breast buds may be palpable and regress in the first months of life; occasionally nipple discharge occurs.

The vaginal orifice may be difficult to see. Gentle lateral traction on the labia majora usually allows complete visualization of the hymen and vaginal orifice. Most hymenal variations—imperforate, microperforate, septate—do not require treatment during the neonatal period. Variations should be noted and readdressed in subsequent visits. The hymen originates from the urogenital sinus, in contrast to the uterus and vagina, which originate from müllerian ducts. The concomitant renal malformations seen with müllerian anomalies are not associated with hymenal anomalies. Hymenal polyps seen in newborns typically regress in size as the maternal estrogen effects subside. Cervicovaginal mucus secretions can accumulate behind the blocked outflow tract of an imperforate hymen and manifest as a mucocolpos. Correction of imperforate hymen in the neonatal period is indicated if urinary obstruction occurs.

The clitoris may appear large in proportion to the other genital structures, especially in premature infants. If the clitoris appears enlarged, the clitoral width should be measured; values >6 mm in a newborn indicate a need for further evaluation. If clitoromegaly and ambiguous genitals are present, the immediate concerns of the obstetrician and pediatrician are to obtain expert consultation for the infant and to counsel the parents. Congenital adrenal hyperplasia is the most common cause of ambiguous genitals (accounting for >90% of cases), and salt-wasting forms can lead to rapid dehydration and fluid and electrolyte imbalance (Chapter 570). Delay of diagnosis and treatment of congenital adrenal hyperplasia may be life-threatening.

In the neonate, the ovaries are <1 cm in diameter and average 1 cm3 in volume. Antenatal or postnatal abdominopelvic ultrasound might reveal small simple ovarian cysts (normal follicles). Because of the abdominal location of ovaries in the neonate, ovarian enlargement can manifest as a palpable abdominal mass. Large cysts (>4-5 cm) or those of a complex nature might signify neonatal ovarian torsion, hemorrhage into the cyst, or, uncommonly, an ovarian tumor. A nonresolving or enlarging neonatal ovarian cyst warrants expert consultation. If the mass causes respiratory compromise or gastrointestinal obstruction, decompression is usually performed. Cyst aspiration can give temporary relief, but the cyst wall should be surgically removed to prevent reaccumulation of fluid and provide a pathologic diagnosis. Preservation of normal ovarian tissue is recommended for all benign lesions, and salpingo-oophorectomy should not be performed unless clinically indicated.

Infants and Prepubertal Girls

As the maternal estrogen effect subsides, the genitals of the female infant change in appearance. The labia begin to flatten. The hymenal membrane loses its redundancy and becomes translucent. The hypoestrogenic prepubertal vaginal epithelium appears thin, red, and sensitive to the touch. The vaginal mucosa of young children can have longitudinal ridges running along the axis of the vagina at 3 o’clock, 6 o’clock, and 9 o’clock, which can cause small protrusions on the hymen at these locations. The cervix usually appears flat and flush with the vaginal vault. During infancy, the uterus regresses in size and does not return to its birth size until the 5th or 6th year. The prepubertal cervix:fundus ratio is 2 : 1.

As puberty approaches, the child experiences increasing endocrine activity of the hypothalamus, pituitary gland, adrenal gland, and ovaries (Chapter 555). The labia majora begin to fill out and the labia minora thicken and elongate as a result of increased estrogen levels. The hymen thickens and becomes more redundant. Clear or white physiologic secretions may be present. Breast buds begin to appear, initially with one side first, or as a pair.

Indications for Genital Examination

Genitourinary complaints or suspected genitourinary pathology warrant assessment of the external and internal genitals of pediatric patients in cases of vaginal bleeding, vaginal discharge, vulvar trauma, perineal or pelvic masses, vulvovaginal ulcerative or inflammatory lesions, congenital anomalies, or sexual abuse.

Preparation

The genital examination in prepubertal girls requires a gentle, patient approach to maximize cooperation and minimize fear or embarrassment. Clear, simple explanation of what the exam involves can facilitate the child’s comfort and cooperation. The presence of a parent or caregiver during the examination provides reassurance for most children. For the older prepubertal patient, the physician may discuss whether the patient wishes to have a family member present during the examination. Even in the presence of the caregiver, the examiner should speak directly to the child and verify that the caregiver has given permission for the examination. This provides an opportunity to explain to the child the privacy of body parts and who may examine or touch those areas. It is useful to educate the patient and caregiver about the basic anatomy and hygiene of the external genital area. Before each step of the examination, the physician should explain what will occur. Allowing an older child the option of watching her examination with a hand-held mirror may contribute to her comfort and understanding. Forcible restraint is never indicated; if optimal evaluation is not possible, the clinician must assess the acuity of the complaint and pathology and determine the potential need for a multivisit examination or an exam under anesthesia.

Positioning

A variety of techniques and positions can facilitate the genital examination in prepubertal patients. Children <4 yr can be placed on the parent’s lap with the child’s legs straddling the parent’s thighs. If the child permits, she may be positioned on the table in the supine position with the hips fully abducted and the feet together in the frog-leg (diamond or butterfly) position. Older children may prefer to use stirrups. When the child is supine, grasping the labia majora along the inferior portion between the thumb and index finger and gently pulling outward and posteriorly (labial traction) allows visualization of the vaginal introitus. Alternatively, the child may be placed in the knee-chest position with elevation of the buttocks and hips. This position provides exposure of the inferior portion of the hymen, the lower vagina, and possibly the upper vagina and cervix, but has the disadvantage of having the child face away from the examiner.

Some extremely cooperative children tolerate a vaginoscopic examination in an outpatient office setting for better intravaginal assessment. The endoscope (either a cystoscope or a hysteroscope) is placed in the vagina and the labia are gently opposed, allowing the vagina to distend with water. This technique permits visualization of the vagina and cervix, allowing evaluation of an injury, lesion, anatomic variant, or presence of a foreign body. Application of 2% lidocaine gel at the introitus makes the insertion easier. If a more complete examination is indicated, or if the child is too young, frightened, or unable to cooperate, an examination under anesthesia is recommended.

Documentation

Clinicians should thoroughly and accurately document genital exam findings in the medical record, reserving conclusions and diagnostic terms for the impression and plan portion of the documentation rather than in the description of exam findings. Each structure visualized should be noted (e.g., clitoris, labia majora, labia minora, urethra, vestibule, and rectum), as should the configuration of the hymen (e.g., annular, crescentic). Describing any findings or lesions using a clock-face method provides a consistent reference point; a sketch or magnified photograph may also be helpful. Future examiners will rely on this documentation as a record with which they compare their findings and note any variances. Changes should be noted in any follow-up examinations.

Adolescents

Some teens prefer to initially meet and discuss the reason for their visit with the provider without their parent or guardian, and this request should be honored (Chapter 106). Most of the time, obtaining a history from an adolescent begins with meeting the patient and her parent or caregiver together to review her history and the reason for the visit and to explain the concepts of confidentiality and privacy. Familiarity with local laws governing limitations to confidential services should guide the protection of teens’ and parents’ rights to information access and privacy. The Guttmacher Institute provides an up-to-date listing of state and federal laws in the USA affecting confidentiality (http://www.guttmacher.org/statecenter/spibs/index.html). Brief discussions of normal pubertal development and menstruation can reassure both patients and parents or guardians and provide valuable education on appropriate menstrual flow, menstrual hygiene, and the duration and frequency of bleeding. Introducing the menstrual diary as an invaluable tool for the teen can help patients, parents, and clinicians identify abnormal bleeding patterns that might require further evaluation.

After the initial interview with the teen and her parent or caregiver, the confidential and sensitive portion of the history, particularly sexual history and alcohol, tobacco, and drug use, is taken with the teen alone. Such a request could be phrased as follows: “I would like to give your daughter an opportunity to ask any questions she might have privately, so would you mind stepping out of the room for a moment?” Concerns for the presence of vaginal discharge, the potential for sexually transmitted infections, pregnancy, or menstrual aberration should be explored. Teens and their parents should be informed of the proper use and accessibility of condoms, all contraceptive methods, and emergency contraception.

A number of resources for educating adolescents regarding their first pelvic examination and in-depth sexual history and psychosocial screening tools are available. These include the North American Society for Pediatric and Adolescent Gynecology (http://www.naspag.org), the Society for Adolescent Health and Medicine (http://www.adolescent.health.org), the Association of Reproductive Health Professionals (http://www.arhp.org), and GYN101. The “Tool Kit for Teen Care, 2nd edition” is available through the American College of Obstetricians and Gynecologists; it includes information on how to establish an office-friendly environment for the adolescent gynecologic evaluation, tools for adolescent assessment, suggestions about how to talk with teens, handouts for adolescents, and a number of resources for health care professionals (http://www.acog.org/departments/adolescentHealthCare/TeenCareToolKit/generalBrochure.pdf, http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=4798).

Pelvic Examination

Indications for the first pelvic examination in adolescents are presented in Table 542-1: abnormal uterine bleeding, vulvovaginitis, severe dysmenorrhea, or abdominal pain. If an adolescent does not meet one of the criteria listed in Table 548-1, ACOG recommends that the first “gynecologic encounter” occur between the ages of 13 and 15 yr (Table 542-2). Patients should undergo screening for sexually transmitted infection (STI) with each new sexual partner, but with the availability of urine and vaginal swab nucleic acid amplification testing for chlamydia and gonorrhea, STI screening does not necessitate a speculum exam.

Table 542-1 SUGGESTED INDICATIONS FOR PELVIC EXAMINATION IN ADOLESCENTS

Age 21 yr
Menstrual irregularities, acute phase
Severe dysmenorrhea
Unexplained abdominal pain
Unexplained dysuria
Abnormal vaginal discharge

Modified from American College of Obstetricians and Gynecologists: Committee opinion no. 460: the initial reproductive health visit, Obstet Gynecol 116:240–243, 2010.

Table 542-2 RECOMMENDATIONS FOR FIRST GYNECOLOGIC EVALUATION

Between 13 and 15 yr of age
First gynecologic encounter is not necessarily a pelvic examination
First pelvic examination with Pap smear at 21 yr of age

Data from American College of Obstetricians and Gynecologists Committee on Gynecologic Practice: ACOG Committee Opinion No. 483: Primary and preventive care: periodic assessments, Obstet Gynecol 117:1008–1015, 2011.

At the initial gynecologic exam, the physician should explain the process in understandable terms. A thorough evaluation begins with an assessment of body mass index (BMI), blood pressure, thyroid, lymph nodes, breast development, and skin. The external genitals should be examined with the patient in the dorsal lithotomy position while communication is maintained between the physician and patient. Elevating the head of the examination table allows the teen and her examiner to make eye contact. The teen can hold a mirror to follow along with the exam, and she should be encouraged to ask questions. Inspection of the vulva is followed by inspection of the Bartholin, urethral, and Skene glands. The clitoris, normally 2-4 mm wide, is then assessed; a clitoris wider than 10 mm, especially in the presence of other signs of virilization, suggests a need for further evaluation. The hymenal anatomy should also be evaluated.

Because the initial Papanicolaou (Pap) smear is deferred until age 21 yr and cultures for STIs can be obtained from urine or vaginal swabs, the need for a speculum exam is decreasing in this age group. If a speculum exam is indicated, use an appropriate teen-sized speculum, such as the Huffman (image in wide × 4 in long) or Pedersen (image in wide v 4 in long). Shorter speculums will not allow visualization of the entire vaginal canal. The adolescent patient should be reassured that the exam may be uncomfortable but should not be painful and that her request to stop or wait will be honored. Encouraging the patient to watch with a hand-held mirror facilitates patient education and can be empowering. She may be told before the insertion of the speculum that she will experience a pressure sensation. Before touching the introitus, it may be useful to touch the inner thigh with the speculum. One should avoid compression of the urethra. Gentle pressure with a finger or displacement of the fourchette posteriorly further facilitates proper speculum placement. After visualization of the vagina and cervix, specimens can be obtained as indicated. A bimanual examination, sometimes with a single digit, allows palpation of the vaginal walls and cervix and bimanual assessment of the uterus and the adnexa.

Following the examination, meeting again with the teen and her parent or caregiver allows a review of the exam findings and collaborative discussion of the management plan. Encouraging adolescents to participate in decision making empowers them to appropriate responsibility for their health care and an appreciation of their bodies and minds.

Bibliography

Allen L, Fleming NA, Strickland J. Adnexal masses in the neonate, child, and adolescent. In: Sanfilippo JS, Lara-Torre E, Edmonds K, Templeman C, editors. Clinical Pediatric and Adolescent Gynecology. New York: Informa Healthcare; 2009:417-426.

American College of Obstetricians and Gynecologists. Breast concerns in the adolescent. ACOG Committee on Adolescent Health Care opinion no. 350. Obstet Gynecol. 2006;108:1329-1366.

American College of Obstetricians and Gynecologists. The initial reproductive health visit. ACOG Committee Opinion No. 335. Obstet Gynecol. 2006;107:745-747.

American College of Obstetricians and Gynecologists. Tool kit for teen care, ed 2. Atlanta: American College of Obstetricians and Gynecologists; 2009.

Braverman PK, Breech L. The Committee on Adolescence: Clinical report—gynecologic examination for adolescents in the pediatric office setting. Pediatrics. 2010;126(3):583-590.

Emans SJ. Office evaluation of the child and adolescent. In: Emans SJ, Laufer MR, Goldstein DP, editors. Pediatric and adolescent gynecology. ed 5. Philadelphia: Lippincott Williams & Wilkins; 2005:1-48.

Jamieson MA. Vaginal discharge and genital bleeding in childhood. In: Sanfilippo JS, Lara-Torre E, Edmonds K, et al, editors. Clinical pediatric and adolescent gynecology. New York: Informa Healthcare; 2009:147-148.

Lara-Torre E. The physical examination in pediatric and adolescent patients. Clin Obstet Gynec. 2008;51:205-213.

Lin-Su K, Neu ML. Diagnosis and management of congenital adrenal hyperplasia. In: Altchek A, Deligdisch L, editors. Pediatric and adolescent gynecology. Oxford, England: Wiley Blackwell; 2009:29-30.

Merritt DF. Genital trauma in children and adolescents. Clin Obstet Gynecol. 2008;51:237-248.

Related posts:

Disorders of the Lacrimal System Cutaneous Defects Ascariasis (Ascaris lumbricoides) Anesthesia, Perioperative Care, and Sedation Goiter Default ThumbnailGynecologic Care for Girls with Special Needs