1. Gynecological disorders in childhood Dr Hayder Al Shamma’a

2. objectives The student should be familiar with the gynecological disorders affecting girls at different age during childhood The student can describe the pathophysiology of these disorder The student can diagnose and manage these conditions The student should be able to counsel the parents about the line of treatment

3. Objectives continue……… The student should be able to detect symptoms and signs suggestive of sexual abuse The student should be familial with all aspects of managements of these cases both scientifically and legally and be able to record forensic evidences notification of authorities

4. Gynecological disorders are not common during childhood but this doesn't mean they are not important Examination and investigations are more difficult Emotional and psychological upset of patients and parents

5. Neonatal period Due to high estrogen during the intrauterine life there is passive estrogenic stimulation when estrogen crosses the placenta, this disappear in neonatal period The uterus is relatively large Cx/body= 1/1 The vaginal lining is stratified squamous epithelium of many layers rich in glycogen

6. 1 Breast enlargement and discharge Variable amount of breast enlargement affect most neonates Some times with nipple discharge (witches’ milk ) It is transient, no treatment needed avoid squeezing the nipples.

7. 2 Vaginal discharge Due to estrogen there is cervical mucous discharge the vulva appear wet in the neonatal period ( not seen in childhood) It is transient need no treatment pH 5 ( acidic due glycogen)

8. 3 Vaginal bleeding It is a sort of withdrawal bleeding (decrease of estrogen and progesterone from the placenta) the endometrium may shed off and a blood stained discharge may be noticed Affect 10 – 15 % of neonates in first week of life It may cause a great deal of concern to the parents No treatment required

9. 4 Hydrocolpus It occurs when the vaginal end is occluded by a membrane (misnomer :- imperforated hymen) There is accumulation of mucus inside the vagina (few cc –quite considerable amount ) Few cc completely asymptomatic and diagnosed at puberty when there is amenorrhea + hematocolpus Large volume which distend the vagina, press on the bladder neck, rectum

10. hydrocolpus Symptoms and signs 1.There is abdominal pain, 2. suprapubic mass, 3. retention of urine, 4.constipation, 5. bulging membrane at the site of hymen, 6. if the membrane thick it may not seen bulging and dx is more difficult

11. hydrocolpus Investigations U/S, MRI, +- Treatment Catheterization + surgical incision of the membrane for drainage If it is a thick septum treatment is more difficult

12. Hydrocolpus 8 days old

13. Hydrocolpus bulging membrane

14. Childhood disorders Very low E2 &P4 Very low FSH, LH Hypotrophic uterus Cx/body = 2/1 No uterine secretions No Cx secretions Thin vaginal lining few layers without glycogen pH 7 ( loss of protective acidity )

15. 1 Non specific vulvovaginitis The commonest gynecological disorder in childhood Causes usually low virulence micro-organisms 1.loss of protective acidity 2.Vaginal opening is less protected by fat 3.Anus is anatomically close to the vagina 4.Child slides on the floor 5.Pinworms (Entrobius vermicularis ) 6.Foreign bodies *(severe persistent discharge usually blood stained or frank bleeding) 7.Sexual abuse*(specific STD as gonorrhoea )

16. Symptoms of vulvovaginitis 1.Vulvar itching (pruritis vulvae)* 2.Vulvar soreness (pain)* 3.Discharge 4.Blood stained discharge * variable severity

17. Examenation Inspection reveal red swollen vulva Gentle separation of labia show discharge Treatment Vulvar hygiene Avoid antiseptics Cleaning after defecation Drying after baths Change underwear Antibiotics ???? Local estrogen cream 2wks Usually improves as puberty approached

19. 2 lichen sclerosis Atrophic changes of the vulvar skin (hyperkeratosis + flattened rate pegs +hyaline degeneration of collagen ) The vulva appear red and flat Soreness and itching are variable ? Autoimmune disorder Improves at puberty Rx vulvar hygiene +- topical steroids 2wks

20. Lichen sclerosis

21. 3 labial adhesion Seen in childhood It is not uncommon* Adherent labia minor Usually start posteriorly and moving anteriorly leaving small orifice through which urine passes The line of adhesion is thin and translucent at the beginning but becomes firmer and thicker with timeThe child is asymptomatic The problem is this may be mistaken as absent vagina

22. Causes of labial adhesion Low E2 Bad hygiene Treatment Vulvar hygiene Separation of labia minor manually Or by surgery E2 cream locally 2wks.→spontaneous separation It may recur again (( The primary reason of treatment is to reassure the parents ))

23. Labial adhesion

24. 4 Butryoid tumor It is a rare sarcoma of the vagina and cervix Affect children at their first decade of life Could be related to exposure to synthetic estrogen in utero (estrogen treatment during pregnancy ) Polypoidal mass in the vagina, it may come out through the vaginal orifice It causes vaginal discharge It causes vaginal bleeding in childhood

25. Treatment Chemotherapy Then hysterectomy + vaginectomy Some times pelvic exenteration Prognosis is bad

26. 5 Urethral prolaps It is a rare condition It is a prolaps of urethral mucosa through the urethral orifice and form a congested mass which may bleeds easily It may occur following dehydration or weight loss It may be mistaken as botryoid tumor ( sarcoma botyroides of the vagina )**** Examination under anesthesia may reveal the conditon

27. 6 Sexual abuse May occur in childhood at any age More common in low social class Strict religious community doesn’t prevent it completely Penetration of child genitalia cause tears of the hymen and often vulvo-vaginal tears and lacerations

28. It may be non penetration sexual abuse Other injuries depends on many factors 1.Age of child and body size 2.Age of the abuser 3.Resistance by the child 4.Degree of violence and others

29. Other findings Perineal lacerations Contusions and bruises on other part of the body Severe psychological trauma ( need special psychiatric care )

30. Absence of physical trauma doesn’t exclude sexual abuse Presence of STD without evidence of trauma may suggest non penetration sexual abuse

31. Management include Notifying the authorities Physical treatment of injuries Prevention of STDs Emergency contraception ( if the child at puberty age ) Psychiatric treatment and support Social care Care for the parents

32. Thank you