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OBJECTIVES
1.
Describe prepubertal genital examination preparation and techniques.
2.
Discuss normal prepubertal hymenal variants.
3.
Identify hymenal variants requiring referral to pediatric gynecology.
4.
Discuss common prepubertal gynecologic problems.
5.
Identify genital examination findings concerning for abuse/trauma.
Posttest Questions
Contact hours: 1.0
Passing score: 70%
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INTRODUCTION
The gynecologic assessment in prepubertal children is an essential element of a thorough physical examination. It is not unusual for pediatric health care providers, including pediatric nurse practitioners (PNPs), to feel challenged by assessing for gynecologic signs and symptoms and performing a physical examination of the external genitalia in prepubertal girls (
). The benefits of routine genital examinations have been discussed in the literature, including increasing patient and caregiver comfort with an examination, improved health care provider skill and confidence with examination and diagnostic assessment, providing a baseline for future examinations, and documentation of previously undiscovered anomalies (
). This continuing education article will discuss genital examination preparation and techniques, normal prepubertal hymenal variants, common prepubertal gynecologic problems, and genital examination findings concerning abuse.
GENITAL EXAMINATION PREPARATION AND TECHNIQUES
Gathering a focused gynecologic history from birth to present should include the standard health care queries, including a history of congenital abnormalities, subsequent genital complaints, infections, especially sexually transmitted infections, lesions, rashes, discharge, pain/discomfort, bleeding, or injuries (
). There is additional information that should be gathered. Explore genital care practices with caregivers. See Box 1 for questions to elicit information regarding genital care practices. The PNP must then determine if the practices are age-appropriate or indicate an inappropriate emphasis on genital care (
). Inappropriate genital care can result in negative psychological and even physical consequences for children; they can be a form of medical child abuse (
). Anticipatory guidance should also address any caregiver concerns regarding sexual behaviors. Sexual behaviors in prepubertal children that are considered normal/age-appropriate sexual behaviors versus problematic sexualized behaviors are discussed in Box 2. Finally, explore if the caregiver has any concerns about sexual abuse, including previous concerning statements made by the child, family history of sexual abuse, or exposure to a known sexual abuse perpetrator (
Questions to elicit information about genital care practices
1
Is your child independent with toileting, or are you involved with some aspect of their toileting needs?
2
Is your child independent with bathing, or do you regularly perform some aspects of care during the bath or shower?
3
Describe how you bathe your child's genitals?
4
Do you ever need to inspect your child's genitals? Why?
5
Describe how you inspect your child's genitals.
6
Do you ever use medications or creams on your child's genital? If yes, why and how frequently? Do you consult with a health care provider before using the medications or creams?
Each PNP develops a method to progress efficiently and confidently through the genital examination. However, basic principles exist to guide the genital examination in prepubertal females. First, caregiver understanding and assent are vital as anxiety on their part is easily transferred to the child. It is important that the child be relaxed during the examination; distracting conversation, use of toys or books, or bubbles are often helpful. A genital examination requiring physical or psychological force should be avoided as such force can develop fear and anxiety in both child and caregiver (
). The genital examination begins with a simple matter-of-fact explanation of the examination to the caregiver and child. Explain that the child should be checked head to toe to ensure that they are healthy and growing as they should, so now their private parts will be examined. This provides an excellent opportunity to educate both child and caregiver regarding the concept of private parts and sexual abuse (Box 3). Discuss with caregivers the importance of teaching their children the correct anatomical names for their private parts. Inform the caregiver that this is to help ensure that children who experience sexual abuse can disclose victimization in words that can be understood by any adult (
Explain to the child that everyone has private parts—parts of their body that no one should touch, kiss, tickle, hurt, or put anything in
2
What are your private parts? Have the child verbally tell you or point to their private parts
3
What should you do if anyone bothers or tries to bother your private parts?
4
Do you tell or keep it a secret?
5
Who could you tell if anyone bothered your private parts? Ensure the child can name at least two adults
6
You could also tell your teacher, nurse practitioner (doctor, nurse, etc.), or a policeman
7
Has anyone ever touched, tickled, kissed, or hurt your private parts?
8
Who is allowed to help you with your private parts if you need help?
An adequate light source and knowledge of normal prepubertal genital anatomy are necessary to perform an accurate genital examination (Figure 1). The child should be relaxed, lying supine in the frog-leg or butterfly position. Stirrups can also be used. If the young child is anxious or reluctant, the caregiver could sit on the examination table with the child supine on their lap. The child should always be offered the presence of a supportive caregiver for the anogenital examination. There may be instances when the accompanying caregiver, such as the father, is not comfortable being in the examination room for the genital examination. It is best practice to use a staff chaperone, such as a medical assistant or nurse, during the anogenital examination. Chaperones play an important role in assuring the safety of both patient and provider (
). The PNP must understand that the appearance of normal female genital anatomy is influenced by the presence of estrogen in both adolescents and infants. Note Figure 2 for changes to female genitalia occurring with puberty. As the female enters puberty, estrogen is released, resulting in increased elasticity of the hymen and other genital structures, hymenal thickening, and redundancy, increased moisture, and loss of sensitivity/pain to touch (
). These estrogen changes can occur before menarche. Newborn females are also affected by maternal estrogen. The hymen is thickened, redundant, and elastic. This estrogen effect typically wanes by 2-years-old, but girls aged 7–8 years may still have persistent estrogen effects (
Visualization of the hymenal opening is an important element of the examination. Achieving the opening of the hymen can be challenging, especially if the child is tense. Separation of the labia majora will allow visualization of the clitoris, labia minora, urethra, and posterior fourchette. Occasionally, the mere separation of the labia majora will allow visualization of the hymenal opening. However, a combination of separation and labial traction is often required. Labial traction refers to the examiner grasping the labia majora bilaterally with the thumb and forefinger and pulling the labia toward the examiner while simultaneously separating the labia. There are times when it is necessary to release traction and reapply to achieve the opening of the hymen. The hymen can also be floated with a few drops of normal saline or water to achieve floating the hymen to allow for visualization of the opening. The prepubertal hymen should never be touched with a cotton swab or any object to achieve opening as the prepubertal hymen is very sensitive/painful to touch.
NORMAL PREPUBERTAL HYMENAL VARIANTS
The vulvar vestibule is between the labia minora and the hymenal/vaginal opening (
). The face of a clock should be used when describing examination findings related to all structures within the vulvar vestibule, including the hymen (
). Variations in normal hymen morphology exist. These variations have been present since birth and do not indicate trauma or sexual abuse. The hymen may be described as annular with hymenal tissue present 360° around the opening from 12 o'clock to 12 o'clock (Figure 3) or crescentic with areas of missing hymen above 3 o'clock and 9 o'clock (Figure 4). Another less common variation in normal hymenal morphology is the redundant or sleeve-like hymenal opening (Figure 5).
Figure 3Annular hymen.
(This figure appears in color online at www.jpedhc.org.)
There are also hymenal morphologies since birth, again not concerning for trauma or sexual abuse, requiring further examination to determine if medical intervention is indicated. One such morphology is the septate hymen (Figure 6). Most commonly, hymenal septa are vertical (longitudinal); however, a horizontal septum can be noted on examination. Patients with a horizontal hymenal septum require referral to pediatric gynecology (
). When a vertical septate hymenal is noted, it is crucial that the PNP determine that a cotton swab can be passed behind the septum. This ensures that the septum does not extend into the vagina, running the length of the vaginal canal, thus creating duplicate vaginas (
). If cotton swab passage is not possible, referral to pediatric gynecology is indicated. Other normal hymenal morphologies requiring referral to pediatric gynecology are microperforated, with a very small hymenal opening (Figure 7); imperforate, with no hymenal opening (Figure 8); and cribriform, with multiple small hymenal openings. These children may require a hymenectomy to remove the extra hymenal tissue to ensure that the vaginal opening is adequate for menstruation, tampon use, and vaginal intercourse (
). When a girl reaches menarche, an imperforate hymen prevents the exit of menstrual blood and normal vaginal secretions from the vagina, known as hematocolpos, often resulting in cyclic pelvic/abdominal pain or difficulty urinating (
). In addition, girls with microperforated and imperforated hymenal morphology are prone to recurrent urinary tract infections, vulvovaginitis, and ascending pelvic infections (
). There are also instances when a hymenectomy is indicated for children with septate hymens that are not associated with vaginal septa if the extra hymenal tissue is yielding difficulties with tampon use or sexual intercourse once they have entered puberty (
). Although an imperforated, microperforated, or septated hymen can be diagnosed at birth, and the American Academy of Pediatrics recommends that a genital examination be completed at every well-child visit (
). Also, hymenal notches or clefts of any depth may be noted above 3 o'clock or 9 o'clock (anterior hymenal rim) and shallow notches or clefts not extending to the base of the hymen at or below 3 o'clock and 9 o'clock (posterior hymenal rim) may be present. Tags of tissue may also extend from anywhere on the hymenal rim. These findings are all normal variants with no clinical significance (
Incomplete fusion of the perineum can occur during embryonic development resulting in a defect known as a failure of midline fusion or perineal groove (
). This defect has no clinical significance or known complications. Failure of midline fusion (Figure 9) appears as a wedge of visible submucosa in the perineum near the anus or the posterior fourchette. The defect can be mistaken for an acute wound; however, the finding is symmetrical with no signs of healing and no pain on palpation. Reexamination in 1-week can confirm that an acute wound is indeed not present, and thus, the lesion is a failure of midline fusion.
Figure 9Failure of midline fusion.
(This figure appears in color online at www.jpedhc.org.)
One of the most common gynecologic conditions noted in prepubertal females is labial adhesions, occurring in approximately 22% of girls aged 3 months to 6 years (
). The labia fuse starts at the posterior introitus and can be minimal with no clinical significance or extensive blocking of the entire introitus (Figure 10). Most labial adhesions are asymptomatic. However, symptoms can develop as the result of the accumulation of urine behind the partially fused labia and include urinary tract infections, vulvovaginitis, pain, and postvoid dripping of urine (
). Treatment is only recommended for symptomatic individuals. Treatment involves lightly applying topical estrogen cream to the adhesions twice daily for 2 weeks and then once daily for 2 weeks (
). Caregivers should be advised that side effects such as breast bud development or vaginal bleeding can develop, which resolve on cessation of treatment.
Figure 10Labial adhesions.
(This figure appears in color online at www.jpedhc.org.)
). Most children with vulvovaginitis, 70% to 80%, have nonspecific physical or chemical irritant vulvovaginitis requiring only reassurance and anticipatory guidance (Box 4) (
). Bacterial infections can also cause vulvovaginitis. β-hemolytic streptococcus is the most common pathogen and causes bright red, well-demarcated dermatitis of the vulva or perianal tissues (
). Treatment involves a course of oral amoxicillin. Gastrointestinal pathogens such as Escherichia coli, Salmonella, and Shigella may also cause vulvovaginitis (
). Candida is a common cause of diaper dermatitis, but it is an uncommon cause of vulvovaginitis in prepubertal girls unless they have recently received oral antibiotics (
). Sexually transmitted infections are rarely the cause of vulvovaginitis in the prepubertal child. However, gonorrhea, chlamydia, and trichomonas are more frequently diagnosed in children presenting for vaginal discharge than those presenting because of a concern of sexual abuse (
). Sexually transmitted infections must be included in the differential diagnosis when a child presents for vulvovaginitis, and a dirty urine specimen should be collected for chlamydia, gonorrhea, and trichomonas nucleic-acid amplification test. Positive chlamydia, gonorrhea, or trichomonas result in a prepubertal child for whom perinatal transmission can be eliminated requires a referral to Child Protective Services because of deep concerns for sexual abuse (
Pinworms can also be the cause of vulvovaginitis in the prepubertal child. The primary symptom of pinworms is significant nighttime vaginal and/or anal pruritis (
). The caregiver may note the actual pinworm, “thin-white threads,” in the vaginal or anal areas. Diagnosis typically requires a tape test in which tape is placed on the anal skin the first thing in the morning, and then ova are noted on examination under the microscope (
). Retained toilet tissue is the most common retained vaginal foreign body, but a variety of small objects can be found. It is normal sexual behavior for children to explore their bodies and place objects in their vaginas; this should not raise concerns about sexual abuse (
). A thorough external genital examination can reveal a foreign body; however, most retained foreign bodies cannot be visualized on external examination (
). There is typically a significant delay in diagnosing the vaginal foreign body, and a bacterial infection can develop. Children with persistent vaginal discharge refractive to antibiotic treatment should be referred to pediatric gynecology for further evaluation and examination for a possible retained foreign body.
Prepubertal girls may present for care because of concerns of vaginal bleeding. The differential diagnosis must include trauma, structural defects, infection, inflammation, neoplasm, and endocrine disorders (
). To assess a complaint of vaginal bleeding in the prepuberal female, a thorough genital examination that includes an inspection of the anus and urethra is necessary. Bleeding from the anus, urethra, or perineal skin conditions can be mistaken for vaginal bleeding (
). Trauma can be accidental or nonaccidental (sexual abuse). Examination findings concerning sexual abuse will be discussed later. Accidental injuries, such as straddle injuries, result from blunt force trauma (
). Typically, the child falls straddling an object such as a chair edge or playground equipment, with the impact of the fall involving the genitalia. The impact site is often to the anterior genitalia, usually external to the hymen, and injury is most often unilateral. However, penetrating trauma to the hymen and other genital structures can occur (
). Obtaining a thorough injury history is crucial when determining accidental versus nonaccidental trauma. See Figure 11 for an example of genital bleeding with acute accidental genital trauma in an 18 months old resulting from a fall in the bathtub onto an inverted funnel.
Figure 11Acute accidental genital trauma.
(This figure appears in color online at www.jpedhc.org.)
). On examination, a vascular ring of congested, friable, edematous tissue with a donut-like appearance is noted. The prolapsed mucosa may appear red, purple, black, or even necrotic in some areas (
). Warm sitz baths can also be efficacious. Constipation exacerbates the prolapse; therefore, stool softeners may be helpful. Referral to urology is indicated, especially when conservative treatment fails or the child has difficulty urinating (
Children with lichen sclerosus (LS) can also present with a concern of vaginal bleeding (Figure 13). LS is more common in females than males with two peak age groups: prepubertal girls and postmenopausal women (
). The exact cause of LS is unknown; however, an autoimmune association is suspected. Examination reveals hypopigmented atrophic skin in a figure-eight pattern from the vulva to the anus (
). The atrophic skin does not extend inside the introitus. Subepithelial hemorrhages result from the mild trauma of scratching, wiping, or rubbing clothing (
). Treatment involves using high potency topical steroid cream; referral to pediatric gynecology or dermatology is typically indicated for management (
Early signs of puberty may be noted on examination of the young child. The development of coarse, curly pubic hair, axillary hair, and body odor in a girl aged younger than 8 years in the absence of breast tissue development or vaginal discharge suggests premature adrenarche (
). Diagnostic workup includes obtaining a dehydroepiandrosterone blood test, bone age films, and consultation/referral to a pediatric endocrinologist (
). Girls with precocious puberty present with progressive breast development over 4–6 months and rapid growth (> 6–7 cm/year) between the ages of 6- and 8-years-old (
). The primary concern regarding precocious puberty is the potential for the premature fusion of the growth plates resulting in significantly lower-height attainment than the child's genetic target height (
). Referral to a pediatric endocrinologist is indicated. Caregivers should be reassured that most girls with puberty onset aged between 7 and 9 years require monitoring, but treatment is not indicated (
). Thus, children are rarely examined acutely, meaning within 1–2 weeks following the sexual abuse incident. Any trauma, acute or nonacute, to the genitalia, should raise concern for possible sexual abuse, even if the child has made no disclosure of abuse (
). A thorough history of injury must be obtained from both caregiver and child, when possible, to determine if the history given is consistent with the injury and the developmental level of the child. A history of surgical intervention given to explain the traumatic finding should be verified with a medical record review (
Acute genital injuries are typically easily apparent on thorough physical examination. Acute bruising or laceration to the genital tissues, including labia, perineum, vulva, vestibule, posterior fourchette, or vagina, are diagnostic of trauma (
). Acute hymenal injuries, including bruising, petechiae, abrasions, or lacerations/transections of any depth (partial or complete) located anywhere along the hymenal rim from 12 o'clock to 12 o'clock are diagnostic of trauma (
). Any acute genital injuries without a clear and consistent history of accidental trauma, even if the child denies sexual abuse, are highly concerning for sexual abuse and must be reported to Child Protective Services and law enforcement.
Nonacute/residual genital trauma can be more of a diagnostic challenge. If a nonacute genital finding is noted in one position, such as supine, the child should be examined in another position, such as knee-chest, to confirm that the finding is present. Referral to a child abuse specialist can be valuable in confirming any nonacute genital examination finding. A scar of the posterior fourchette is caused by trauma; this finding is rare and difficult to diagnose unless an acute injury was previously documented in the same area (
). A white linear vertical finding at 6 o'clock of the posterior fourchette is most likely a normal finding known as linea vestibularis (formed from the two halves of the body coming together in utero) and can be mistaken for a scar. A nonacute hymenal transection (Figure 14) can be difficult to diagnose and confirm (Figure 15). A healed/nonacute hymenal transection located below 3 o'clock and 9 o'clock and extending entirely through the hymen with no visible hymenal tissue at the site is concerning for trauma. Nonacute genital injuries without a clear history of accidental trauma are also highly concerning for sexual abuse, and a report to Child Protective Services and law enforcement is indicated.
Figure 14Nonacute hymenal transection.
(This figure appears in color online at www.jpedhc.org.)
A thorough gynecologic assessment and examination are essential elements of a pediatric physical examination. Consistent performance of the genital examination will increase child and caregiver comfort with the examination and increase PNP comfort and competence with performing the examination and addressing common prepubertal gynecologic complaints. The genital examination provides an opportunity for timely identification of anatomical variants or trauma requiring further subspecialty intervention. The genital examination also provides the PNP an appropriate occasion to educate both children and caregivers regarding sexual abuse. Genital examinations need no longer be an uncomfortable, neglected component of the well-child examination.
References
Adams J.A.
Farst K.J.
Kellogg N.D.
Interpretation of medical findings in suspected child sexual abuse: An update for 2018.
Journal of Pediatric and Adolescent Gynecology.2018; 31: 225-231
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