Paediatric and adolescent gynaecological disorders

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 15 Paediatric and adolescent gynaecological disorders

Yasmin Jayasinghe

Gynaecological problems encountered in children and adolescents are unique to these age groups and involve sensitivity and skills differing from those utilised for adults.

Paediatric disorders

• normal genital anatomy in the prepubertal child
• maternal oestrogenisation wanes by 6 months
• hypooestrogenisation causes labia to be atrophic, and hymen to appear erythematous
• hymen may be crescentic, annular (circumferential), microperforate or cribriform
• cervix is often flush with the vaginal vault or protrudes slightly
• uterus may be so small that it may be difficult to identify on ultrasound in inexperienced hands

Examination of a prepubertal child

• examine only with parental consent, and once the child and parent are comfortable with you
• start with a general examination
• appropriate explanation to child and parent is important: it will not involve internal examinations, it should not hurt, there is no use of force, listen to the child if she wants you to stop
• with appropriate rapport and explanation, these examinations are usually tolerated very well; if very resistant, consider deferring examination or performing an examination under anaesthesia (EUA) depending on urgency
• frog-leg position on mother’s lap if more comfortable
• genital inspection then lateral and outward traction on labia majora will enable hymen to open; ask child to cough while inspecting lower vagina

Vulvovaginal abnormalities

Vulvovaginitis

• symptoms: pruritis, dysuria, soreness of the vulval area, vaginal discharge, occasionally vaginal bleeding
• usually non-specific inflammation with no identifiable pathogen (80% of cases)
• specific pathogens: group A beta-haemolytic streptococci and Haemophilus influenzae, from the upper respiratory tract, are the most common

Causes

• underlying factors: hypo-oestrogenism causing overgrowth of normal flora, close proximity of vagina to anus, alkaline vaginal pH
• moisture: synthetic fibre underwear, obesity
• irritants (bubble baths, irritant soaps)

Differential diagnosis

• threadworms, vulval dermatoses, foreign body, sexual abuse, ectopic ureter, Crohn’s disease

Investigation

• only take introital swab if moderate to severe offensive discharge, or bloody discharge

Management

• perineal hygiene (vinegar baths: ½ cup white vinegar in shallow bath as required)
• cotton underwear and change soon after sport
• barrier cream
• antibiotics if severe symptoms, including bloody discharge; if symptoms do not promptly settle, EUA
• treat empirically for Enterobius vermicularis (pinworms) if persistent significant pruritis
• reassurance, as symptoms settle with age

Vaginal bleeding

• pathological and warrants further investigation
• consider the following:

Vaginitis

• commonest cause
• if suspected, may treat with antibiotics alone initially, but if recurrent bleeding do EUA to exclude another cause

Foreign body

• commonly toilet paper
• EUA and removal of the object

Sarcoma botryoides (embryonal rhabdomyosarcoma)

• presents with lower abdominal mass and vaginal bleeding
• may sometimes see grape-like lesions at introitus

Genital trauma

• Straddle injuries may cause haematomas and genital lacerations (usually involving labia or fourchette) and associated with bruising of labia or thigh. A consistent history is important.
• Labial fat pads generally protect the hymen and vagina. Hymenal, vaginal or perianal lacerations, without labial or thigh bruising, is suspicious for non-accidental penetrating injury. Note that most children who have been sexually abused have normal clinical findings (<5% have abnormal findings). Any concerns regarding sexual abuse should be immediately referred to a skilled professional in the field so that appropriate investigation, documentation and follow-up can be organised.

Management

• ensure voiding is possible, sitz baths
• EUA if ongoing bleeding expanding haematoma, concerns about anatomical integrity

Urethral prolapse

• precipitants: hypo-oestrogenisation, chronic straining
• treat with oestrogen cream nocte and sitz baths; regression seen over days to weeks
• if persists and symptomatic, may require surgical excision

Other anatomical causes

• vascular lesions
• Crohn’s disease

Precocious puberty

• bone age, follicle-stimulating hormone (FSH), luteinising hormone (LH), oestradiol, pelvic ultrasound to look for ovarian activity

Labial adhesions

• labia adherent in mid-line, mid-line raphe seen
• present in 0.6%–3% of prepubertal girls
• usually present 6 months to 6 years, not seen in the newborn
• often asymptomatic, but may cause urinary dribbling due to narrow vaginal opening, vulvitis, and rarely urinary tract infections

Due to hypooestrogenisation

• differential diagnosis: imperforate hymen or disorder of sexual differentiation, where no mid-line raphe will be seen

Management

• reassurance, vinegar baths and barrier cream for symptoms
• manual separation not indicated in hypo-oestrogenised child: 40% recurrence rate
• oestrogen creams may cause breast budding and are also associated with recurrence after cessation of use
• adhesions usually resolve with age and increasing oestrogen levels

Lichen sclerosus

• commonest age of presentation in premenarcheal girls is 5–7 years
• symptoms: pruritus, papules, fissures, erosions, bleeding
• 75% improvement in symptoms after menarche
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