EXAMINATION OF THE PEDIATRIC PATIENT
Preparing Pediatric Patient for Examination
While performing pediatric gynecologic examination (Figs 1.1 to 1.3), it is important to gain the confidence of the child and make the process as pain-free as possible. The environment in which a child receives health care should be inviting and the medical staff child friendly in order to facilitate the examination process and make the child's first gynecologic encounter nontraumatic.
INSTRUMENTS AND SUPPLIES FOR THE PREPUBERTAL EXAMINATION
Different instruments and supplies are used for the prepubertal examination and are shown in the Figures 1.4 to 1.6.
Fig. 1.1: The child in the examination area made comfortable with the toys and familiar cartoon characters
Fig. 1.3: Pediatric gynecology exam starts with general examination; starting with records of the height, weight, vital signs and physical examination with emphasis on the gynecologic examination
Fig. 1.5: Use of a nasal speculum to visualize the vagina of an 8-year-old child patient. It is preferable to do vaginal examination with instrumentation under anesthesia
Fig. 1.6: Vaginal speculum is used to visualize the vagina and cervix in a nonvirgin adolescent. Speculum is lubricated, patient is asked to relax their pelvic diaphragm and the speculum inserted slowly with blades closed and pointed posterior toward the coccyx
DIFFERENT TECHNIQUES OF POSITIONING
There are different techniques of positioning in pediatric gynecologic examination, which are shown in the Figures 1.7 to 1.10.
Fig. 1.7: A 3-year-old child patient in a frog leg position. Supine, with hips flexed and the soles of the feet must be meeting together. Draping the child's lower body leaves an impression that the genitalia is a special part of the body
Fig. 1.8: A 3-year-old child patient is in supine position sitting on parent's lap with the legs spread out across the parent's thighs. The parent embraces and reassures the child
Fig. 1. 9: A 9-year-old child patient in a knee chest position. The child is in prone position with the chest resting on a pillow, back slightly swayed and the knees on the table. In this position, gravity causes the lower edge of the hymen to roll outward
Fig. 1.10: A 15-year-old adolescent. Dorsal lithotomic position stirrups (for the older, co-operative child and the adolescent). The patient's buttocks are on the edge of the table, knee flexed and legs rest on stirrups
DIFFERENT TECHNIQUES OF VISUALIZING THE VESTIBULE
There are different methods that a doctor can use to visualize the vestibule as shown in the Figures 1.11 and 1.12.
Fig. 1.11: Supine lateral spread method. The index finger of both hands is placed in the labia majora, lateral to the vestibule and slightly posterior to the vaginal orifice; the labia majora are then spread laterally and posteriorly, enough to visualize the vestibule
Fig. 1.12: Supine lateral traction method. The labia majora are grasped gently in the same location used for the lateral spread method, followed by gentle traction of the tissue toward the examiner and slightly posterior and lateral
OBTAINING SAMPLES
The techniques to obtain sample from the external genitalia are shown in the Figures 1.13 to 1.15.
Fig. 1.13: A cotton tip applicator held near the vaginal opening while the child patient is instructed to cough out to allow vaginal fluid to egress
Fig. 1.14: Cervico-vaginal discharge of a 15-year-old adolescent patient is visualized by using vaginal speculum. Sample of discharge is obtained with a cotton tip swab
Fig. 1.16: A 6-year-old child patient undergoing recto-abdominal examination (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
RECTO-ABDOMINAL EXAMINATION
Recto-abdominal examination of a child (Figs 1.16 and 1.17): Before performing a recto-abdominal examination to a child, the first thing to do is to ask permission and explain the examination procedure. It is important to maintain eye contact and communication while doing the examination. Wear gloves, lubricate the index finger of right hand with KY Jelly or oil then, gently insert the index finger into the rectum while the left hand is used to depress the hypogastric area. With the left hand, gently palpate for the uterus that feels like a small button.
Fig. 1.18: Normal external genitalia of prepubertal child (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
NORMAL EXTERNAL GENITALIA OF A CHILD
Normal external genitalia (Figs 1.18 and 1.19): There are differences in the normal external genitalia of a prepubertal child and a neonate. In the neonate the effect of intrauterine transfer of estrogen of the mother to the fetus usually last up to two years then it gradually wanes out. As a result, estrogenized external genitalia is seen among neonates. As the child approaches the prepubertal years, estrogen effect becomes totally absent, hence the external genitalia will show an unestrogenized features such as the a thin labia majora, thin and small labia minora, a vestibule that is reddish due to the prominence of blood vessels, a hymen that is thin and inelastic, and a dry vaginal canal.
Fig. 1.19: Neonatal vulva–estrogenized, from maternal transfer in utero (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
DIFFERENT HYMENAL CONFIGURATIONS
Different hymenal configurations (Figs 1.20 to 1.23): The hymen is a thin mucosal membrane with abundant blood vessels and lines the vaginal opening. There are variation in shapes and size of the hymen, the one in this atlas are those commonly seen in our day to day practice.
Fig. 1.20: Annular hymen—also known as circular, lunar or moon-shaped hymen (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
Fig. 1.21: Redundant hymen—has several folds of tissues; spread laterally to reveal the opening (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
Fig. 1.22: Crescentric hymen—half moon shaped hymen (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
Fig. 1.23: Imperforate hymen. Vaginal opening completely closed (Photo was taken by the author from own patient, taken with permission from patient, with permission to be used for educational/reference purposes)
BIBLIOGRAPHY
- Bhatnagar K. Embryology and normal anatomy. In: Sanfilippo J, et al (Eds). Pediatric and Adolescent Gynecology, 2nd edn. WB Saunders Company 2001; Philadelphia: pp. 2-17.
- Carson S. Gynecologic examination of the adolescent. In: Carpenter S, et al (Eds). Pediatric and Adolescent Gynecology. Raven Press Ltd New York; 1992; pp. 67-76.
- Pokorny S. Genital examination of prepubertal child and peripubertal females. In: Sanfilippo J, et al (Eds). Pediatric and Adolescent Gynecology, 2nd edn. WB Saunders Company Philadelphia: 2001; pp.182-98.
- Wilson M. Vaginal discharge and vaginal bleeding in Childhood. In: Carpenter S, et al (Eds). Pediatric and Adolescent Gynecology. Raven Press Ltd New York: 1992;139-51.