Epidemiology

Gynecologic concerns are common but nonetheless anxiety producing in prepubertal girls. Vulvovaginitis is the most common gynecologic problem affecting prepubertal girls and is responsible for the largest number of health care visits. Pediatric sexual abuse affects more than 100,000 children a year, and many of these girls will be taken to the emergency department (ED) for initial evaluation. Many parents going to the ED have spoken or unspoken concerns about sexual abuse that need to be addressed.

Pathophysiology

Pediatric gynecologic problems differ from those of adult women chiefly because the vaginal mucosa is thin, dry, and easily irritated in the absence of estrogen. This makes prepubertal girls more sensitive to a variety of chemical, physical, and microbiologic irritants. The normal hymen looks thin, with an average opening of about 4 mm. However, there is great variability in normal hymenal shape, ranging from imperforate to multiple small fenestrations to oval, round, or stellate openings (Fig. 21.1). Abnormal findings that may correlate with vaginal penetration include lacerations of the hymen or a thickened hymen with rolled edges. These findings are extremely difficult to differentiate from normal variations, and photos should always be taken if sexual abuse is suspected. Neonates have swollen labia and thick, moist vaginal epithelium for several weeks after birth, but most prepubertal girls have smooth pink vaginal mucosa and a pale vulva that barely covers the clitoris.

Fig. 21.1 Types of hymens in prepubertal girls.

A, Posterior rim of a crescentic hymen. B, Fimbriated or redundant hymen. C, Imperforate hymen.

(From Pokorny SF. Configuration of the prepubertal hymen. Am J Obstet Gynecol 1987;157:950.)

Presenting Signs and Symptoms

The chief complaints of children with gynecologic problems include vaginal discharge or bleeding, itching or rubbing of the genitals, dysuria or refusal to void, or a foul genital odor noted by caregivers. The initial differential diagnosis can be guided by the predominant complaints (Box 21.1).

A calm, professional, thoughtful approach is essential to allow parents to discuss their concerns, enable a physical examination, and appropriately treat the patient. Vulvovaginitis, for example, can cause vaginal discharge or bleeding, itching or pain, urinary retention, abnormal appearance noted by caregivers, and concerns about possible sexual abuse.

The approach to pediatric gynecologic problems must take into account the developmental and psychologic state of the patient. Children zealously guard autonomy over their bodies. In addition, little girls are socialized to hide their genitals and will resist examination for various reasons throughout developmental stages—it is important to help them overcome their fear, embarrassment, or anxiety. It is helpful, when attempting to make the child comfortable with the examination, to speak directly to the child in language appropriate for her age (see the Tips and Tricks box). In teaching hospitals, try to coordinate care so that the examination is performed only once.

Sexual Abuse

ED evaluation of possible sexual abuse should focus on identifying patients who require urgent treatment, urgent collection of evidence, or protective custody (Fig. 21.2). Open-ended questions by the emergency practitioner (EP) will allow the parents to voice their concerns about possible molestation (this should be done away from the child). When interviewing the patient, history taking should be limited to open-ended questions phrased in child-appropriate language, such as “How did you get this ouchie?” Do not make suggestions that the child may follow in an attempt to please. Do not direct, lead, or ask questions with embedded information because such information can appear in the child’s later responses. Formal interviewing and complete examination are best minimized in the ED and instead carried out by trained personnel. ED providers should be aware of local resources and if possible refer children to a designated child sexual abuse evaluation center.

Fig. 21.2 Algorithm showing the critical pathway for evaluation of pediatric sexual abuse.

HIV, Human immunodeficiency virus.

If abuse is alleged within the past 72 hours, collection of evidence should be undertaken as soon as possible. In studies of forensic evidence collection in prepubertal sexual assault cases, the majority of usable evidence is found on clothing and linen. In one large study of prepubertal sexual assault victims, no swabs were positive for blood after 13 hours or for semen or sperm after 9 hours.¹

A brief physical examination of the vulva, vagina, and anal area should be undertaken, as described previously. The chief purpose of the initial physical examination is to discover injuries in need of urgent treatment (vaginal lacerations, anal tears) or injuries that may change over a short period and require documentation. Bruises or petechiae may fade quickly, and the ED description of the fresh injuries may be important evidence in legal proceedings. If possible, photographs should taken for legal evidence. Areas of perineal erythema, abrasion, lacerations, bruising, and petechiae, as well as the shape or tears of the hymen, should be described in writing and pictured in drawings.

However, most children who have been molested have no physical findings related to abuse. The absence of physical findings should not be used to negate any statement or suspicions. All concerns must be thoroughly, supportively, and objectively explored by a trained interviewer.

Genital Examination

Infants and young toddlers can usually be examined easily if positioned supine in the frog leg position (Fig. 21.3