";s:4:"text";s:5172:"Investing in education before the examination process will pay appropriate dividends with respect to patient cooperation and overall assessment of the problem at hand. The subspecialized area of pediatric and adolescent gynecology is an integral part of gynecologic care. A hand-held mirror can be used so that the patient can be further involved in the examination process. A wet preparation is useful in assessing vaginal discharge.A speculum is rarely if ever necessary in assessing the pediatric patient. The “show and tell” concept is often helpful in achieving an adequate evaluation. When sexual abuse is discovered, referral to a child abuse specialist in the community should be made to ensure proper and complete care, especially because the collection of evidence may vary from the office guidelines. The Pap test is performed before obtaining the endocervical swab for STI testing.Cervical specimens should be obtained for gonorrhea and chlamydia testing by using an NAAT, culture, or DNA probe (nonamplified DNA testing). Pediatrics 65: 758, 1980 Rau FJ, Muram D: Vulvovaginitis. The legs are placed in a “frog-leg” position. Cleaning agents should never be applied with a washcloth, which can exacerbate areas of irritation or transfer infectious organisms to that area. Pediatrics 83: 146, 1989 Emans S, Goldstein D: The gynecologic examination of the prepubertal child with vulvovaginitis: Use of the knee-chest position. St. Louis, CV Mosby, 1987 Pokorny SP: Configuration of the prepubertal hymen.
Patients with urethral prolapse usually present with blood staining on their underwear. Pediatr Clin North Am 26: 91, 1979 Reindollar R, Tho S, McDonough P: Abnormalities of sexual differentiation: Evaluation and management.
Chicago, Harper & Row, 1984 Lee PA, Houk CP, Ahmed SF, Hughes IA; International Consensus Conference on Intersex organized by the Lawson Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology. The physical presence of an assistant (i.e., medical assistant or nurse) must be emphasized.The overall assessment should be approached as for any physical examination; that is, the skin should be assessed and the presence of any lesions or disfigurements noted. Some of the NAATs for gonorrhea and chlamydia have also been approved for vaginal swab specimens. Often only inspection of the vulvovaginal area is adequate. Genital infection with Bacterial vaginosis can be associated with sexual abuse but has been reported in “control” subjects.Herpes simplex virus (HSV) produces vesicular lesions with a resultant ulcerative vulvovaginitis and usually includes inguinal lymphadenopathy and systemic symptoms. Surgical correction is necessary for this condition.Patients with vesicovaginal fistulas also usually have a history of a constantly wet perineum and show nonspecific vulvovaginitis and excoriation on physical examination as a result of the continuous presence of urine. At a minimum, examination of the external genitalia should be included as part of the annual comprehensive physical examination of children and adolescents of all ages. Often only inspection of the vulvovaginal area is adequate.
Exacerbations and recurrences allow for only limited success with most treatment plans, which primarily involve topical and intralesional corticosteroid administration as well as antihistamines. With chronic exposure, the vulva may develop cracks or fissures and eventually a lichenified appearance. They should also know their local mandated reporting laws and should perform a thorough physical examination as well as an extensive psychosocial history. Therapy consists of cryotherapy, serial applications of TCA, podophyllin or imiquimod cream. The key idea is to develop rapport and communication; it is extremely important for the patient to develop trust in the healthcare provider. It is most common in African-American children younger than 10 years of age.Vaginal discharge is a more prominent finding associated with infectious causes of vulvovaginitis than with noninfectious causes. When the vulva is involved, pruritus is common, as is an increased chance of secondary infections with bacteria, most commonly GAS, or with fungus.Treatment starts with environmental control of possible offending allergic agents, such as food or environmental allergens.