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Rukset Attar, MD, PhD
Obstetrics and Gynecology

Pediatric & Adolescent Gynecology

Gynecologic care begins in the delivery room, with

inspection of the external genitalia during routine
newborn examination.
Evaluation of the external genitalia continues through
routine well-child examinations, permitting early
detection of infections, labial adhesions, congenital
anomalies, and even genital tumors.
A complete gynecologic examination is indicated when a
child has symptoms or signs of a genital disorder

Common Gynecologic Disorders

Newborn Infants
During the first few weeks of life, residual maternal sex
hormones may produce physiologic effects on the

Breast budding occurs in nearly all female infants born at term.

In some cases, breast enlargement is marked, and there may be
fluid discharge from the nipples - No treatment is indicated.
The labia majora are bulbous, and the labia minora are thick and
Vaginal bleeding may occur
Vaginal discharge is common, composed mainly of cervical
mucus and exfoliated vaginal cells.

Common Gynecologic Disorders

Congenital Anomalies of the Female Genital


Anomalies of the Vulva & Labia

Anomalies of Clitoris
Anomalies of the Hymen
Anomalies of the Uterus
Anomalies of the Ovaries
Anomalies of the Urethra and Anus

Common Gynecologic Disorders

Labial Adhesions

estrogen deficiency and inflammation
applying estrogen cream to the fine thin raphe twice a
day for 2 weeks followed by once daily application for
2 weeks.
parents are asked to repeat the course of treatment in
6-month to 1-year intervals if recurrence occurs.

Common Gynecologic Disorders

estrogen cream can be systemically absorbed, parents

may notice transient breast development
Forceful manual separation is not advised

as this is often painful and traumatic to the child

recurrence is much more common.

Surgical separation is rarely justified and only applicable

if urinary problems result and estrogen therapy has

Common Gynecologic Disorders

Imperforate Hymen

A mucocolpos or hematocolpos can develop

is apparent as a bulging thin membrane at the
introitus with the Valsalva maneuver or crying

Surgical incision

Common Gynecologic Disorders


vulvar discomfort or itching

The first step is to take a careful history in regards to
any possible irritants
the level of hygiene,
urinary incontinence,
frequency of diaper changes, and
bathing habits.
Diaper dermatitis

Common Gynecologic Disorders

Common organisms causing prepubertal vulvitis are

usu. under the age of 2
may follow a course of antibiotics in the infant
underlying factors such as juvenile onset
diabetes or immunosuppression
antifungal creams such as clotrimazole,
miconazole, or butaconazole applied twice a
day to the affected area for 10 to 14 days or
until rash is cleared

Common Gynecologic Disorders

Pinworms (Enterobius vermicularis)

Diagnosis is made by
inspecting at night with a flashlight to observe worms
exiting the anus
a morning inspection with "Scotch tape" to the anal
region can identify the eggs.
Treatment consists of mebendazole (Vermox) 100 mg
orally once and repeated in 1 week.
It is advised to treat the entire family to prevent reinfection

Group A -hemolytic streptococcus

appropriate antibiotic for 2 weeks and occasionally for

longer periods of time (up to 4 weeks)

Common Gynecologic Disorders

Contact or allergic vulvitis

Treatment may consist of removing the irritant

if itching is severe
providing an oral medication, such as hydroxyzine
hydrochloride (Atarax), 2 mg/kg/d divided into four
application of topical hydrocortisone cream 2.5% twice a
day for a week and then discontinuing.

Common Gynecologic Disorders

Lichen Sclerosus

itching, irritation, soreness, bleeding, and dysuria.

The vulva is characteristically white, atrophic, with
parchmentlike skin and occasionally evidence of
subepithelial hemorrhages, excoriations, fissures, and
Treatment consists of clobetasol (Temovate) cream 0.05%
applied nightly to the affected area for 6 weeks.
Follow-up should be scheduled at that time and if there is
significant improvement the dose is tapered progressively
until it is being used only one time weekly at bedtime.

Common Gynecologic Disorders

Nonspecific Vulvovaginitis

is the most common gynecological disorder of prepubertal girls

(accounts for over 50% of visits)

Poor hygiene practices at home or daycare program

Inadequate front-to-back wiping

Smaller labia minora, which are less protective of the vestibule,

with a short distance from the anus to vagina

Vulvovaginal epithelium that is not well estrogenized and thus

thinner and more prone to irritation

Foreign body such as toilet paper, small toys, or pieces of cloth,

which may be inadvertently inserted in the vagina by the child

Chemical irritants such as bubble baths, shampoos, or bath oils,

and certain deodorant soaps

Dermatologic conditions such as eczema and seborrhea

Chronic disease and altered immune status

Sexual abuse

Common Gynecologic Disorders

The pathogenesis of vulvovaginitis is not well defined

may be associated with an alteration of the vaginal flora with
an overgrowth of fecal aerobes or an overabundance of
anaerobes contributing to the symptoms of odor and
Cultures performed indicate a variety of organisms
considered normal vaginal flora such as diphtheroids,
enterococci, coliforms, and lactobacillus.
Escherichia coli is often found on vaginal culture, suggesting
poor hygiene; contamination with bowel flora may contribute
to the problem.

Common Gynecologic Disorders

Infectious Vulvovaginitis

Hemophilus influenzae, Staphylococcus aureus, group A hemolytic streptococci, and Streptococcus pneumoniae causing
a yellowish to greenish purulent vaginal discharge (S.
pneumoniae infection and group (amoxicillin 40 mg/kg divided
three times a day for 10 days)
Shigella flexneri, an enteric pathogen, can cause a
mucopurulent, sometimes bloody discharge following an episode
of diarrhea in some young girls(trimethoprim (TMP)sulfamethoxazole (Bactrim) 6 to 10 mg/kg/d TMP by mouth,
divided every 12 hours. Treatment may require more than 10 to
14 days of medication.)

Common Gynecologic Disorders

Physiologic Discharge

resulting from maternal estrogen exposure in utero

may appear as clear mucous, whitish in color or clear
On occasion, a bloody discharge is noted and results from
exposure to maternal estrogens in utero, causing transient
endometrial shedding.
This will most often resolve within a few hours to days.

Common Gynecologic Disorders

Condyloma Acuminata
in children less than 2 years of age, the mode of
transmission is vertical from mother to child during
After age 2, sexual abuse is a primary concern in
children presenting with condylomatous lesions (in
approximately one third of cases)

Common Gynecologic Disorders


trichloroacetic acid
CO2 laser vaporization therapy
more recently the advent of imiquimod cream (Aldara), an
immune response modifier supplied in a cream base, has
eased and revolutionized therapy for external genital warts (A
thin layer of cream is applied to the wart(s) at bedtime and left
on for 6 to 10 hours, after which it is washed off. Therapy is
for 3 days a week (i.e., Monday, Wednesday, and Friday) and
continued until the warts are completely gone, or up to 16
week )

Common Gynecologic Disorders

Urethral Prolapse

usually presents with unexplained bleeding, often thought to be

coming from the vagina.
The child experiences no pain and has no recent history of
vulvar trauma.
On physical examination a bright red, friable annular mass is
noted just above the hymen surrounding the urethral opening
Treatment consists of estrogen cream to the area nightly for 1 to
2 weeks.

Common Gynecologic Disorders

Foreign Bodies

The vaginal discharge is often dark brownish in color

occurs daily, requiring the use of a panty liner by the child.
The discharge is often malodorous

Common Gynecologic Disorders

Sexual Abuse
Genital infection with Neisseria gonorrhoeae is
associated with a purulent thick yellow discharge
along with vulvar erythema and edema.
Chlamydia trachomatis may present with
vulvovaginitis, pruritis, and discharge. Infants born to
mothers with chlamydia may carry the organism for
up to 18 months

Common Gynecologic Disorders

Anomalies of sexual development and puberty

Vaginal Bleeding
Bleeding disorders
Juvenile Pregnancy


Physical examination
Specimen collection

Collection of Specimens

Vaginal cultures are easily collected by a technique described by

Pokorny using a catheter within a catheter. A 4-inch segment of the
tip of a no. 12 red rubber catheter is placed over the hub end of a
butterfly catheter attached to a 1-mL tuberculin syringe . Sterile
normal saline (0.05 to 1 mL) is instilled slowly and aspirated back to
acquire fluid
Collection of material to evaluate for gonorrhea may be collected by
swabbing visible discharge on the perineum or in a similar manner
as with chlamydia.
Cultures for chlamydia must include material taken directly from the
mucosal surface using a saline-moistened calcium alginate swab
(male urethral swab). The swab is inserted into the vagina as the
child coughs, which makes the hymen gape open and serves as a

Radiological tests may be performed in those children

who are unable to cooperate or have specific problems,
such as suspicion of an abdominal mass, abdominal
pain, or precocious puberty.

Pelvic ultrasound
computed tomography
magnetic resonance imaging (MRI) scan