Paediatric gynaecology

Published on 23/06/2015 by admin

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15.1 Paediatric gynaecology

Pamela Rosengarten, Sonia Grover

Essentials

Prepubescent girls

1 Vaginal examination is inappropriate in paediatric patients and usually provides little information. Ultrasound may provide further information or, if necessary, an examination under anaesthesia (EUA) is more appropriate.
2 Vulvovaginitis is the most common gynaecological problem in prepubertal girls and in most cases a specific infectious cause cannot be identified.
3 Vaginal bleeding in the prepubertal female is abnormal after 3–4 weeks of age.

Adolescents

1 Laboratory confirmation is required to make an accurate diagnosis of a vaginal discharge.
2 Pregnancy-related conditions need to be considered for all adolescents with pelvic pain or abnormal vaginal bleeding.
3 Abnormal vaginal bleeding may be secondary to an underlying haematological condition.

Prepubescent gynaecology

Vaginal discharge

Introduction

Vaginal discharge in neonates and prepubertal girls can be physiological. In neonates, a white mucoid vaginal discharge is present in most baby girls and is due to the effects of maternal oestrogens; it disappears by about 3 months of age. The second period where physiological discharge may occur is at the time ovarian activity commences with the onset of puberty.

Other conditions that cause vaginal discharge in the prepubertal girl include vulvovaginitis, lichen sclerosis, foreign body, eczema and pinworms.

Vulvovaginitis

This is the most common gynaecological problem in childhood, usually occurring in girls aged between 2 years and prior to the onset of puberty.1,2 Most vulvovaginitis in this age group is non-infectious in origin and results from irritation of the vaginal and vulval skin, particularly where there is contact between the labial surfaces.2,3 Factors that contribute to genital inflammation include the vaginal and vulval skin of children being thin and atrophic due to low oestrogens and therefore easily irritated. In addition, lack of protective labial hair and fat pads as well as moisture from wet swimming costumes, obesity and poor hygiene may play a role.2–4 Additionally, the presence of bowel flora, which is the normal flora in the atrophic vagina, may contribute to skin irritation and the other related common symptom of offensive smell.

Infectious vulvovaginitis is less common and is due to an overgrowth of one organism, for example Group A Streptococcus, Staphylococcus, enterococci and Escherichia coli. In this instance, profuse discharge is usually present with marked skin inflammation, often beyond the contact surfaces of the labia.3 Isolation of an organism that has strong sexual transmission, such as Neisseria gonorrhoeae or Chlamydia trachomatis, generally indicates sexual abuse or sexual activity and therefore warrants further investigation.3,4

Lichen sclerosis is an uncommon condition of unknown aetiology. It may present in childhood with vulval irritation, pruritus, dysuria or bleeding.1,2 Examination reveals pale atrophic patches on the labia and perineum. The patches can be extensive and coalesce, and with scratching lead to chronic inflammation and purpuric haemorrhage into the skin. The condition usually persists with intermittent exacerbations. Most resolve before puberty although some may continue to have problems into adult life.5

Eczema may contribute to the symptoms of vulvovaginitis with the addition of itch. In these cases eczema is usually present elsewhere on the body and can be superimposed on the irritation due to the discharge.

Foreign bodies are a potential cause for a persistent, unresolving, often bloodstained offensive discharge.

Candida is very uncommon in the prepubertal girl unless there has been significant antibiotic use or they are still in nappies.2,4 (Thrush thrives in an oestrogenised environment, not in the atrophic setting.) In this age group, recurrent or unexplained candida requires exclusion of diabetes mellitus or other causes of diminished immune function.

History

The child or parent/caregiver usually describe:

• an offensive vaginal discharge;
• erythema (redness)/irritation of the labia and perineal skin;
• itch, dysuria and urinary frequency may also be present.

These symptoms often fluctuate in severity.

A general medical history is required, with specific history of the symptoms and their duration including nature of discharge as well as any previous treatments. Also important is past history of urinary tract infection, encopresis, constipation, enuresis, the presence of skin disorders, and any other illness, including antibiotic use in the previous 4 weeks. Although a history of perineal hygiene (e.g. wipe front to back, frequency of bathing, type of underwear/clothes, specific irritants, such as bubble baths or use of feminine hygiene sprays in the adolescent population, etc.) should also be established, there is limited evidence to support the role of this in the pathogenesis of vulvovaginitis.3 Where itch is the dominant symptom, pinworms should be considered and questions asked about family symptoms.

Although uncommon, the possibility of sexual abuse should always be considered in a child that presents with genital symptoms, and check for other signs that may be present including alterations in behaviour such as phobias, eating or sleeping disorders.

Examination

A general examination including sexual development is required. Perineal, vulval and introital examination may be required for the above conditions. Attempts must be made to ensure it is not a traumatic event for the child. The perineum is best examined either with the girl supine with heels together and knees flexed and hips abducted or in the lateral position with knees drawn up to the chest.6 Vaginal examination is inappropriate in paediatric patients and usually provides little further information. Specific external examination of the perineum usually reveals mucoid discharge and reddened introitus, particularly on the contact surfaces between the labia.

The presence of a profuse discharge or marked skin inflammation, especially if it extends beyond the contact surfaces of the labia, suggests an infectious cause. An offensive discharge can occur with vulvovaginitis or foreign body. A bloody discharge can occur with vulvovaginitis (particularly with Shigella or Group A streptococci).6 The presence of perianal excoriation suggests pinworm.

Investigations

Swabs are generally not required. If taken in mild cases, they usually reveal a growth of mixed coliforms.3 If discharge is visible or profuse or marked erythema is present, introital swabs should be taken for culture. Vaginal swabs are painful and distressing and are not required.

If urinary symptoms are present, the urine (midstream urine; MSU) should be checked to exclude urinary tract infection. A pinworm test should be taken if itch is a prominent symptom. This requires briefly placing clear sticky tape on the perianal skin in the morning and viewing under a microscope for eggs. Otherwise worms may be seen in the perianal region at night.

Ultrasound may provide further information, especially if there is a possibility of foreign body, or if necessary an EUA may be more appropriate.

Management

Vulvovaginitis

Management consists of:

Explanation and reassurance.
Toileting/hygiene advice:

• avoidance of potential irritants such as soaps and bubble baths and other causal factors, such as tight/synthetic clothing and wet bathers;
• vinegar (add one cup white vinegar in a shallow bath and soak) or the use of a simple barrier cream to the labial area (e.g. zinc-castor oil or nappy rash cream) or both.

Rarely, if the problem persists, further action may be required. The natural history of vulvovaginitis is for recurrences to occur up until the age when oestrogenisation begins. If a primary bacterial cause is suspected, cultures should be taken and treatment commenced with the appropriate antibiotics, e.g. initial amoxicillin, and adjusted when culture results are available.

Where itch is a dominant symptom consider:

• Pinworms, especially if perianal excoriation is present, and treat the child and their family with pyrantel 10 mg kg-1 (maximum 500 mg) orally or mebendazole 50 mg (<10 kg), 100 mg(> 10 kg) orally (contraindicated in pregnancy and <6 months of age) as a stat. dose and repeat 2 weeks later.7
• Lichen sclerosis in the asymptomatic patient does not require treatment other than
• reassurance. In symptomatic patients, avoidance of irritants, improved hygiene, reduced trauma and barrier ointments, e.g. nappy rash creams. In more severe cases, a brief course of topical steroid (1% hydrocortisone) and referral to a dermatologist or paediatric gynaecologist is required.
• Eczema, especially if skin disease is present elsewhere. Combined treatment of the vulvovaginitis (as above) and hydrocortisone or Diprosone may be indicated.

Foreign body

If foreign body is suspected then an examination under anaesthesia with vaginoscopy is usually required. If the presence of a foreign body is questionable then an ultrasound may be beneficial to visualise the object. The most common foreign bodies are tiny pieces of tissue paper. The possibility of sexual abuse should be borne in mind.

Vaginal bleeding

Introduction

Vaginal bleeding in the prepubertal child is abnormal after 3–4 weeks of age.6

Causes of vaginal bleeding in the prepubertal girl can be classed as hormonal and non-hormonal.

Hormonal causes

Neonates

A withdrawal bleed from maternal oestrogens is common and does not require investigation or treatment. This will cease after approximately 4 weeks of age.

Onset of menstruation

Consider as premature (precocious puberty) if this occurs at less than 8 years of age.7

Non-hormonal causes

Vulvovaginitis

In prepubescent girls, vaginal bleeding in this age group is most commonly due to more severe vulvovaginitis (the most common pathogens are Shigella or Group A β-haemolytic streptococci).6 The discharge is brown and often offensive (see above under vaginal discharge, vulvovaginitis).

Trauma

Accidental injury usually results from straddle injuries where the girl falls on a narrow object (e.g. bicycle cross bar, jungle gym). Non-accidental injury/sexual abuse should be considered in trauma, especially where there is a hymenal tear without a history of accidental penetrating injury.

Foreign body

Vaginal foreign body may also result in bloodstained discharge and should be considered if no infectious cause is identified or there is failure to respond to appropriate treatment. In bleeding secondary to excoriation from pinworms, lichen sclerosis or eczema, examination should demonstrate eczema and lichen sclerosis. The presence of anal and perineal excoriation suggests pinworms and treatment as previously described under vulvovaginitis.

Tumours

Although rare, the possibility of a genital tumour should be considered when there is chronic genital ulceration, non-traumatic swelling, tissue protruding from the vagina or foul smelling, bloody, vaginal discharge. Vaginal bleeding associated with genital enlargement, premature sexual maturation or virilisation may be associated with hormonally active ovarian or adrenal tumour.

Non-vaginal causes of bleeding

Haematuria may stain the underwear or nappy and be reported as vaginal bleeding. This will become evident upon urinalysis. Urethral prolapse often presents with bleeding thought to be vaginal in origin. The peak age is 5–8 years. Bleeding disorders are an uncommon cause of vaginal bleeding but should be considered when there are other systemic signs of a bleeding tendency, e.g. bruising and petechiae.

History

A general medical history including family and past history should be taken.

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