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Examining pediatric and adolescent gynecology patients
J Pediatr Adolesc Gynecol (2003) 16:257–258
In-Training Section Examining Pediatric and Adolescent Gynecology Patients Editor: Julie Strickland, MD Truman Medical Center, Kansas City, Missouri, USA
Author: G. Hewitt, MD Assistant Professor, Pediatrics and Obstetrics/Gynecology at the Ohio State University College of Medicine and School of Public Health, Section Head of OB/GYN at Columbus Children’s Hospital, Columbus, Ohio. Stoneridge Obstetric and Gynecological Practice, Columbus, Ohio
Introduction Successfully completing a gynecologic examination in pediatric and young adolescent patients can be challenging for all parties involved: the patient, the caregiver, and the clinician. Experiential learning is invaluable in obtaining the skills required to perform the pediatric gynecologic exam. The following outline can be used as a guide to teach medical students and residents some basic fundamentals to either prepare them for their initial patient encounter or augment their current fund of knowledge. Slides referenced throughout the outline are from the PediGYN Teaching Slide Set developed by the North American Society of Pediatric and Adolescent Gynecology.
Premenarchal Patients The patient should be told in developmentally appropriate language that only parents, guardians, caregivers, or clinicians can touch or examine the genital area and that the examination has been “sanctioned” by the parents. Parent/caregivers may participate in the examination to help comfort the patient. The patient should be instructed on the use of a gown or drape to reinforce that the exam has special meaning specific to a medical surrounding. The examination should be geared to the patient’s complaint. Many of the problems encountered in the prepubertal patient are vulvar and lower vagina in origin; not all pediatric gynecologic patients will require visualization of their upper vagina and cervix. Address reprint request to: Dr. G. Hewitt, Stoneridge Ob-Gyn Practice, 4053 Dublin-Granville Rd., Columbus, OH 43017
쑖 2003 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
Most patients should be in the supine position at the edge of the exam table with legs frog-legged or in stirrups, or in the caregiver’s lap with patient’s legs draped over the caregiver’s legs. It is helpful to keep the patient’s head elevated so that she can maintain eye contact with the examiner and watch what he/she is doing. The patient can be given a hand-held mirror to watch as well. The patient may be able to participate in the examination with separating the labia, pointing to areas of concern, etc. “Lateral spread technique” can be used to visualize the external genitalia, hymen, and distal vagina. The examiner places his/her index fingers on the posterior aspect of the labia and gently applies downward and lateral traction. The patient then “valsalvas” to aid in the visualization of the distal portion of the vagina. See slide 7. Normal findings commonly identified include hymenal tags and periurethral grooves. See slides 9 and 19. Some of the more common lower tract abnormalities identified in this age group include: hymenal and vaginal cysts (see slides 12 and 13), urethral prolapse (see slide 14), labial agglutination (see slide 32), vaginitis (see slide 43), foreign objects (see slide 38), imperforate hymen (see slide 65), and lichen sclerosis (see slide 102). Knee chest position can be used to try to visualize the upper vagina and cervix. The patient kneels on the examination table resting on her elbows and with her cheek placed on one of her hands. If the labia and buttocks are spread and the patient “blows” often the examination can be successful without instrumentation. Alternatively, the examiner can then use a nasal speculum or otoscope to visualize the upper vagina and cervix. Again, viscous lidocaine placed at the introitus can be helpful. Common complaints requiring 1083-3188/03/$22.00 doi:10.1016/S1083-3188(03)00130-X
258
Hewitt: Pediatric and Adolescent Gynecologic Exam
visualization of the upper vagina and cervix include vaginal bleeding, persistent vaginal discharge, suspected foreign object, and trauma. Examination under anesthesia and/or vaginoscopy may be required in select cases to complete the evaluation of the upper vagina and cervix. Vaginoscopy requires a light source, irrigation, and either a hysteroscope or pediatric cystoscope. The procedure can be performed in the operating room with anesthesia or in the office setting if tolerated by the patient. Vaginoscopy allows for direct visualization of the entire vagina and cervix. Foreign objects may be “flushed” out of the vagina during the procedure. Bimanual examination is rarely indicated in the pediatric patient. Ovarian masses can be palpated abdominally due to their location and the presence of a uterus can be confirmed with a gentle rectal examination. Specimens should be obtained, if necessary, at the end of the exam. Premenarchal vaginal mucosa is atrophic and obtaining specimens with dry cotton tip swabs can be painful and cause bleeding. Therefore swabs moistened with saline should be used. Calgi swabs can be moistened and wrapped together so that in one “pass” specimens can be collected for gonorrhea, general bacterial culture, chlamydia, wet mount, and maturation index as indicated. “Catheter inside a catheter technique” is another approach that can be used to collect samples. The proximal four inches of an IV catheter is placed inside the distal four inches of a red rubber catheter. The red rubber catheter is then placed into the vagina. A syringe is attached to the catheter and 2-3 cc of saline is flushed into the vagina. Exudate can then be collected for cytology, wet mount, and cultures. Retained foreign objects may also be “flushed” from the vagina with this technique. Viscous lidocaine jelly can be placed at the introitus if necessary for anesthesia. Magnification can be important to carefully examine the small genital structures. Otoscopes with the truncated ear canal piece removed, hand held magnifying glasses, and colposcopes can all be used for this purpose.
Peripubertal Patients Adolescents should be given an opportunity to speak privately with their physician without parental involvement at some time during the visit. While parental
involvement should be respected and encouraged, this must be balanced with the patient’s right to privacy and confidentiality. These issues should be reviewed with both the patient and the parents. A thorough explanation of the pelvic examination with the use of diagrams should precede the examination. A bimanual examination is indicated in adolescents with gynecologic complaints or unexplained abdominal or pelvic pain. A vaginal examination with the use of a speculum is indicated with irregular bleeding, menorrhagia, vaginal discharge, and suspected sexually transmitted diseases. A speculum examination can be considered in this age group due to estrogenization of the genital tissues. The vaginal introitus is more elastic allowing for accommodation of the speculum and the walls of the vagina are much less likely to be traumatized. The size of the hymenal opening should be considered when chosing the speculum. For patients who have smaller hymenal openings the Huffman speculum (1/2 × 4 inches works well). Pediatric speculums (3 inches long) are often too short to allow visualization of the cervix. In patients who are sexually active the Pederson speculum (7/8 × 4 inches) is a good choice. The Graves speculum (1 × 3 inches) should be reserved for adolescents who are post partum. Sexually active adolescents require testing for N. gonorrhoeae and C. trachomatis as well as a Pap smear. Additional Reading Emans SJ: Office evaluation of the child and adolescent. In: Pediatric and Adolescent Gynecology. Edited by SJ Emans, MR Laufer, DP Goldstein. Philadelphia, Lippincott-Raven, 1998, pp. 1–48 Mendiratta V: Office gynecologic evaluation of the pediatric patient: indications, examination, and procedures. Operative Techniques in Gynecologic Surgery 1999; 4:164 PediGYN teaching slide set by NASPAG (North American Society of Pediatric and Adolescent Gynecology.) The slide set can be purchased online at www.naspag.org Pokorny SF: Genital examination of prepubertal and peripubertal females. In: Pediatric and Adolescent Gynecology. Edited by JS Sanfilippo, D Muram, P Lee, J Dewhurst. Philadelphia, W.B. Saunders, 1994, pp. 170–186
In-Training Section Examining Pediatric and Adolescent Gynecology Patients Editor: Julie Strickland, MD Truman Medical Center, Kansas City, Missouri, USA
Author: G. Hewitt, MD Assistant Professor, Pediatrics and Obstetrics/Gynecology at the Ohio State University College of Medicine and School of Public Health, Section Head of OB/GYN at Columbus Children’s Hospital, Columbus, Ohio. Stoneridge Obstetric and Gynecological Practice, Columbus, Ohio
Introduction Successfully completing a gynecologic examination in pediatric and young adolescent patients can be challenging for all parties involved: the patient, the caregiver, and the clinician. Experiential learning is invaluable in obtaining the skills required to perform the pediatric gynecologic exam. The following outline can be used as a guide to teach medical students and residents some basic fundamentals to either prepare them for their initial patient encounter or augment their current fund of knowledge. Slides referenced throughout the outline are from the PediGYN Teaching Slide Set developed by the North American Society of Pediatric and Adolescent Gynecology.
Premenarchal Patients The patient should be told in developmentally appropriate language that only parents, guardians, caregivers, or clinicians can touch or examine the genital area and that the examination has been “sanctioned” by the parents. Parent/caregivers may participate in the examination to help comfort the patient. The patient should be instructed on the use of a gown or drape to reinforce that the exam has special meaning specific to a medical surrounding. The examination should be geared to the patient’s complaint. Many of the problems encountered in the prepubertal patient are vulvar and lower vagina in origin; not all pediatric gynecologic patients will require visualization of their upper vagina and cervix. Address reprint request to: Dr. G. Hewitt, Stoneridge Ob-Gyn Practice, 4053 Dublin-Granville Rd., Columbus, OH 43017
쑖 2003 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
Most patients should be in the supine position at the edge of the exam table with legs frog-legged or in stirrups, or in the caregiver’s lap with patient’s legs draped over the caregiver’s legs. It is helpful to keep the patient’s head elevated so that she can maintain eye contact with the examiner and watch what he/she is doing. The patient can be given a hand-held mirror to watch as well. The patient may be able to participate in the examination with separating the labia, pointing to areas of concern, etc. “Lateral spread technique” can be used to visualize the external genitalia, hymen, and distal vagina. The examiner places his/her index fingers on the posterior aspect of the labia and gently applies downward and lateral traction. The patient then “valsalvas” to aid in the visualization of the distal portion of the vagina. See slide 7. Normal findings commonly identified include hymenal tags and periurethral grooves. See slides 9 and 19. Some of the more common lower tract abnormalities identified in this age group include: hymenal and vaginal cysts (see slides 12 and 13), urethral prolapse (see slide 14), labial agglutination (see slide 32), vaginitis (see slide 43), foreign objects (see slide 38), imperforate hymen (see slide 65), and lichen sclerosis (see slide 102). Knee chest position can be used to try to visualize the upper vagina and cervix. The patient kneels on the examination table resting on her elbows and with her cheek placed on one of her hands. If the labia and buttocks are spread and the patient “blows” often the examination can be successful without instrumentation. Alternatively, the examiner can then use a nasal speculum or otoscope to visualize the upper vagina and cervix. Again, viscous lidocaine placed at the introitus can be helpful. Common complaints requiring 1083-3188/03/$22.00 doi:10.1016/S1083-3188(03)00130-X
258
Hewitt: Pediatric and Adolescent Gynecologic Exam
visualization of the upper vagina and cervix include vaginal bleeding, persistent vaginal discharge, suspected foreign object, and trauma. Examination under anesthesia and/or vaginoscopy may be required in select cases to complete the evaluation of the upper vagina and cervix. Vaginoscopy requires a light source, irrigation, and either a hysteroscope or pediatric cystoscope. The procedure can be performed in the operating room with anesthesia or in the office setting if tolerated by the patient. Vaginoscopy allows for direct visualization of the entire vagina and cervix. Foreign objects may be “flushed” out of the vagina during the procedure. Bimanual examination is rarely indicated in the pediatric patient. Ovarian masses can be palpated abdominally due to their location and the presence of a uterus can be confirmed with a gentle rectal examination. Specimens should be obtained, if necessary, at the end of the exam. Premenarchal vaginal mucosa is atrophic and obtaining specimens with dry cotton tip swabs can be painful and cause bleeding. Therefore swabs moistened with saline should be used. Calgi swabs can be moistened and wrapped together so that in one “pass” specimens can be collected for gonorrhea, general bacterial culture, chlamydia, wet mount, and maturation index as indicated. “Catheter inside a catheter technique” is another approach that can be used to collect samples. The proximal four inches of an IV catheter is placed inside the distal four inches of a red rubber catheter. The red rubber catheter is then placed into the vagina. A syringe is attached to the catheter and 2-3 cc of saline is flushed into the vagina. Exudate can then be collected for cytology, wet mount, and cultures. Retained foreign objects may also be “flushed” from the vagina with this technique. Viscous lidocaine jelly can be placed at the introitus if necessary for anesthesia. Magnification can be important to carefully examine the small genital structures. Otoscopes with the truncated ear canal piece removed, hand held magnifying glasses, and colposcopes can all be used for this purpose.
Peripubertal Patients Adolescents should be given an opportunity to speak privately with their physician without parental involvement at some time during the visit. While parental
involvement should be respected and encouraged, this must be balanced with the patient’s right to privacy and confidentiality. These issues should be reviewed with both the patient and the parents. A thorough explanation of the pelvic examination with the use of diagrams should precede the examination. A bimanual examination is indicated in adolescents with gynecologic complaints or unexplained abdominal or pelvic pain. A vaginal examination with the use of a speculum is indicated with irregular bleeding, menorrhagia, vaginal discharge, and suspected sexually transmitted diseases. A speculum examination can be considered in this age group due to estrogenization of the genital tissues. The vaginal introitus is more elastic allowing for accommodation of the speculum and the walls of the vagina are much less likely to be traumatized. The size of the hymenal opening should be considered when chosing the speculum. For patients who have smaller hymenal openings the Huffman speculum (1/2 × 4 inches works well). Pediatric speculums (3 inches long) are often too short to allow visualization of the cervix. In patients who are sexually active the Pederson speculum (7/8 × 4 inches) is a good choice. The Graves speculum (1 × 3 inches) should be reserved for adolescents who are post partum. Sexually active adolescents require testing for N. gonorrhoeae and C. trachomatis as well as a Pap smear. Additional Reading Emans SJ: Office evaluation of the child and adolescent. In: Pediatric and Adolescent Gynecology. Edited by SJ Emans, MR Laufer, DP Goldstein. Philadelphia, Lippincott-Raven, 1998, pp. 1–48 Mendiratta V: Office gynecologic evaluation of the pediatric patient: indications, examination, and procedures. Operative Techniques in Gynecologic Surgery 1999; 4:164 PediGYN teaching slide set by NASPAG (North American Society of Pediatric and Adolescent Gynecology.) The slide set can be purchased online at www.naspag.org Pokorny SF: Genital examination of prepubertal and peripubertal females. In: Pediatric and Adolescent Gynecology. Edited by JS Sanfilippo, D Muram, P Lee, J Dewhurst. Philadelphia, W.B. Saunders, 1994, pp. 170–186