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

Discharge Itching Pain Bleeding Redness

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.

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.

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

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.

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

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.

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.

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

Itching Cont. - History Urinary symptoms: Dribbling Retention

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

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?

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?

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

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.

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.

Repeated Vulvitis Most cause labial adhesion.

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

Etiology of labial adhesions relates to vaginal inflammation or irritation.

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

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

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

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

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 .

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.

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

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

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.

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.

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)

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

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.

Thank You…