Pediatric gynaecology

Pediatric gynaecology

System	Female reproductive system
Significant diseases	Gynaecological cancers, Menstrual bleeding
Specialist	Pediatric gynaecologist

Pediatric gynaecology or pediatric gynecology is the medical practice dealing with the health of the vagina, vulva, uterus, and ovaries of infants, children, and adolescents. Its counterpart is pediatric andrology, which deals with medical issues specific to the penis and testes.

Etymology

The word "gynaecology" comes from the Greek γυνή gyne. "woman" and -logia, "study."

Examination

Assessment of the external genitalia and breast development are often part of routine physical examinations. Physicians also can advise pediatric gynecology patients on anatomy and sexuality. Assessment can include an examination of the vulva, and rarely involve the introduction of instruments into the vagina. Many young patients prefer to have a parent, usually a mother, in the examination room. Two main positions for examination can be used, depending on the patient's preference and the specific examination being performed, including the frog-leg position (with the head of the examination table raised or lowered), the lithotomy position with stirrups, or either of these with a parent holding the child. A hand mirror can be provided to allow the child to participate and to educate the child about their anatomy. Anesthesia or sedation should only be used when the examination is being performed in an emergency situation; otherwise it is recommended that the clinician see a reluctant child with a gynecologic complaint over several visits to foster trust.

Examination of the external genitalia should be done by gently moving the labia minora to either side, or gently moving them towards the anterior (front) side of the body to expose the vaginal introitus. Routine physical examinations by a pediatrician typically include a visual examination of breasts and vulva; more extensive examinations may be performed by a pediatrician in response to a specific complaint. Rarely, an internal examination may be necessary, and may need to be conducted under anesthesia. Cases where an internal examination may be necessary include vaginal bleeding, retained foreign bodies, and potential tumors.

Diseases and conditions

There are a number of common pediatric gynecologic conditions and complaints, both pathological and benign.

Hernias

Main article: Hernia

Intersex conditions

Main article: Intersex

A pediatric gynecologist can care for children with a number of intersex conditions, including Swyer syndrome (46,XY karyotype).

Amenorrhea

Main article: Amenorrhea

Amenorrhea, the lack of a menstrual period, may indicate a congenital anomaly of the reproductive tract. Typically obvious on an external visual examination of a child's vulva, imperforate hymen is the presence of a hymen that completely covers the introitus. Other anomalies that can cause amenorrhea include Mullerian agenesis affecting the uterus, cervix, and/or vagina; obstructed uterine horn; OHVIRA syndrome; and the presence of a transverse vaginal septum. OHVIRA and uterine horn obstruction can also cause increasingly painful menstruation (dysmenorrhea) in the months following menarche.

Abnormal vaginal bleeding

Main article: Vaginal bleeding

Vulvitis

Main article: Vulvitis

Vulvitis, inflammation of the vulva, can have a variety of etiologies in children and adolescents, including allergic dermatitis, contact dermatitis, lichen sclerosus, and infections with bacteria, fungi, and parasites. Dermatitis in infants is commonly caused by a soiled diaper being left on for an extended period of time. Increasing the frequency of diaper changes and topical application of emollients are sufficient to resolve most cases. Dermatitis of the vulva in older children is usually caused by exposure to an irritant (e.g. scented products that come into contact with the vulva, laundry detergent, soaps, etc.) and is treated with preventing exposure and encouraging sitz baths with baking soda as the vulvar skin heals. Other treatment options for vulvar dermatitis include oral hydroxyzine hydrochloride or topical hydrocortisone.

Lichen sclerosus is another common cause of vulvitis in children, and it often affects an hourglass or figure eight-shaped area of skin around the anus and vulva. Symptoms of a mild case include skin fissures, loss of skin pigment (hypopigmentation), skin atrophy, a parchment-like texture to the skin, dysuria, itching, discomfort, and excoriation. In more severe cases, the vulva may become discolored, developing dark purple bruising (ecchymosis), bleeding, scarring, attenuation of the labia minora, and fissures and bleeding affecting the posterior fourchette. Its cause is unknown, but likely genetic or autoimmune, and it is unconnected to malignancy in children. If the skin changes are not obvious on visual inspection, a biopsy of the skin may be performed to acquire an exact diagnosis. Treatment for vulvar lichen sclerosis may consist of topical hydrocortisone in mild cases, or stronger topical steroids (e.g. clobetasol propionate). Preliminary studies show that 75% of cases do not resolve with puberty.

Organisms responsible for vulvitis in children include pinworms (Enterobius vermicularis), Candida yeast, and group A hemolytic Streptococcus.

STIs

Main article: Sexually transmitted infection

Contraception

Main article: Contraception

Pregnancy

Main article: Adolescent pregnancy

Precocious puberty

Main article: Precocious puberty

Precocious puberty occurs when children younger than 8 experience changes indicative of puberty, including development of breast buds (thelarche), pubic hair, and a growth spurt.

Labial adhesion

Main article: Labial adhesion

Labial adhesion is a fusion between the labia minora that may be small and posterior - and generally asymptomatic - or may involve the entire labia and seal off the vaginal introitus entirely. It is generally only treated when it causes urinary symptoms; otherwise it normally resolves when the vaginal mucosa becomes estrogenized at the onset of puberty. Treatments include topical application of estrogens or betamethasone with gentle traction on the labia, followed with vitamin A, vitamin D, and/or petroleum jelly to prevent re-adhesion. The labia may be separated manually with local anesthesia or surgically under general anesthesia (in a procedure called introitoplasty) if topical treatment is unsuccessful. This is followed with estrogen treatment to prevent recurrence.

Complaints

Common pediatric gynecologic complaints include vaginal discharge, pre-menarche bleeding, itching, and accounts of sexual abuse.

A mass in the inguinal area may be a hernia or may be a testis in an intersex child.

Prepubertal anatomy

The vaginal mucosa in prepubertal children is markedly different from that of postpubertal adolescents; it is thin and red colored.

In neonates, the uterus is spade-shaped, contains fluid 25% of the time, and often has a visible endometrial stripe. This is normal and due to the hormones that have passed to the neonate across the placenta. The shape of the uterus is influenced by the anteroposterior diameter of the cervix, which is larger than the fundus at this age. By premenarchal age, the uterus is tubular, because the fundus and the cervix are the same diameter. The ovaries are small in neonates and grow throughout childhood to a volume of 2-4 cubic centimeters. On vaginoscopy, the prepubertal cervix is usually level with the proximal vagina.

Puberty

During puberty, the vaginal mucosa becomes estrogenized and becomes a dull pink color and gains moisture. Secondary sex characteristics develop under the influence of estrogen on the hypothalamic-pituitary-gonadal axis, typically between the ages of 8 and 13. These characteristics include breast buds, pubic hair, and accelerated growth. Higher body mass index is correlated with earlier puberty.