1. PRACTICAL APPROACH TO PEDIATRICS GYNECOLOGICAL PROBLEMS
PRESENTED BY:
NABEEL S. BONDAGJI
MD, FRCSC, FACOG
Assistant Prof., KAUH
Chairman, Department of OB/GYN
KFSH&RC-Jeddah

2. Discharge
Itching
Pain
Bleeding
Redness

3. Causes : Vaginal Discharge
Primary irritants
poor hygiene
Foreign body (recurrent smelly discharge) mostly toilet tissue) .
Bacterial infection group A beta-hemolytic Streptococcus and enteric pathogens, such as Escherichia coli or Shigella organisms causes vaginitis with genital erythema.

4. Cont. - Vaginal Discharge
STD can cause Vaginitis in prepubertal girls, including Neisseria gonorrhea and Chlamydia trachomatis ELISA a very high rate of false-positive.
Child sexual abuse.
Urethra prolaps.
Genital warts.

5. Physical Examination A careful genital inspection:
A clinician who has time, knowledge, and skill with children and children behaviors.
A relaxed or distracted child (books read by the mother).
A good light source

6. Cont. - Physical Examination
A careful genital inspection:
The best position for the patient is lying on her back on the examination table in the supine frog-leg position with her knees bent and the soles of her feet touching.
The labia majora are then gently spread laterally using separation or grasped and pulled forward toward the examiner using labial traction.
Prone knee-chest position.

7. Physical Examination Vaginal discharge.
Culture with uretheral swab. (Routine culture + culture for GC & chlamydia).
Inspect the hymen. (Common type crescentic).
In tears, mainly posteriorly
Inspect skin of the top labia.
Eczema, psoriasis and scaling

11. Cont. - Vaginal Discharge
If a child has persistent vaginal discharge with negative culture results, examination by with the patient under anesthesia is indicated.
The vagina can be irrigated and examined with the smallest Pedersen speculum or sometimes a hysteroscope or cystoscope, and the vagina can be thoroughly explored for the presence of a foreign body.

15. Vaginal Itching Causes
Irritant vulvitis lichen sclerosis atrophicus sharply demarcated area of hypopigmentation, around the vulva and the perianal area .
Pinworms can hatch in the anus, travel to the vagina, and cause genital itching. The child scratch at either the genital or the anal area, especially at night.
Chronic irritation.
Allergies
poor hygiene.

16. Itching History Duration Site: more attention to the anal area.
Nature: scratching or rubbing
Associated symptoms:
Allergic rhinitis
Upper R.T.I.
Diarrhea or discharge blood

17. Itching
Cont. - History
Urinary symptoms:
Dribbling
Retention

18. Is Child Toilet Trained? If Not.
Type of Diapers?
No. of Diapers Changed / day?

19. If Yes Does the baby shower or bath? Bath: After bathing:
Does she use bubble bath or shampoo?
What kind of soap?
After bathing:
Does the mother scrub the area?

20. Does the child wear cotton or nylon Underwear? Tight clothing or not
Child toilet train:
Does the mother find sticky of stool on the underwear?
Does she noticed bad odor or discharge on the panties?

21. Physical Examination A careful genital inspection:
A clinician who has time, knowledge, and skill with children and children behaviors.
A relaxed or distracted child (books read by the mother).
A good light source

22. Cont. - Physical Examination
A careful genital inspection:
The best position for the patient is lying on her back on the examination table in the supine frog-leg position with her knees bent and the soles of her feet touching.
The labia majora are then gently spread laterally using separation or grasped and pulled forward toward the examiner using labial traction.
Prone knee-chest position.

23. The standard recommendations for treatment of presumed irritant vulvitis are as follows:
Have the child take a sits bath in plain warm water with no soap of any kind for 20 minutes daily.
Use only white cotton underwear and white unscented toilet tissue.
Stop all bubble baths.
Proper hygiene after the child has a bowel movement.

26. Repeated Vulvitis
Most cause labial adhesion.

27. Adhesion of the labia is a common disorder in the female pediatric population.
Asymptotic and is first noticed during a routine physical examination.

28. Etiology of labial adhesions relates to vaginal inflammation or irritation.

30. Frequency
In the US: 1 – 2% of females aged 3 months to 6 years.

31. Morbidity
Labial adhesions occasionally cause outflow obstruction, leading to vaginal reflux of urine and subsequent vaginal leaking when the child stands after voiding.

32. Physical
Thin, pale, semitranslucent membranes cover the vaginal os between the labia minora.

33. Causes
Labial adhesions probably are caused by vaginal inflammation or irritation, which, in some cases, could be the result of sexual abuse.

34. Medical Treatment Observe
if treatment is necessary or requested, prescribe estrogen cream application. Once the labia separate, apply lubricant or antibiotic ointment for several more weeks to allow complete healing.
Dienestrol 0.01% cream .

35. Cont. - Medical Treatment
Once the labial adhesions separate, either treatment, apply antibiotic ointment for several weeks to allow the labial edges to heal without repeat adhesion formation.

36. Complications
Estrogen cream application often causes temporary hyperpigmentation of the skin in the area of application.

37. Prognosis
The prognosis for girls with labial adhesions is excellent. If left untreated, the condition usually resolves spontaneously at puberty.

38. Vaginal Bleeding Foreign bodies Bacterial vaginitis Lichen scleroses
Child sexual abuse
Urethral prolapse.
Condyloma acuminatum, or genital warts, often present with bleeding.
Application of topical estrogen cream.

39. Cont. - Vaginal Bleeding
Endocrine disorders.
Malignancy (Sarcoma Botryoides)
Bleeding disorders.
Acute lacerations of the posterior fourchette, hymen, or anus seen by even the inexperienced examiner.

43. Genital Pain
Urinary tract infections, vaginal infections, vaginal irritation
Herpes simplex lesions
Primary varicella or varicella zoster lesions
Syphilis
Ulcerative vulvitis of bacterial origin
Aphthous ulcers
Behcet disease
Crohn disease
Bacterial infection (especially Streptococcus)

44. Cont. - Genital Pain
Culture the lesions for virus and draw serum for syphilis serology before any routine bacterial culture.
Improved hygiene and oral antibiotics.

47. The neonate with imperforate hymen typically presents with a bulging membrane between the labia.
In severe cases, lower abdominal midline mass may be evident on physical examination.

51. Thank You…