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.
Cases where an internal examination may be necessary include vaginal bleeding, retained foreign bodies, and potential tumors.
A pediatric gynecologist can care for children with a number of intersex conditions, including Swyer syndrome (46,XY karyotype).
Other anomalies that can cause amenorrhea include Müllerian 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.
Causes of vaginal bleeding in children include trauma, condyloma acuminata, lichen sclerosus, vulvovaginitis, tumors, urethral prolapse, precocious puberty, exogenous hormone exposure, and retained foreign body.
Most causes can be diagnosed with a visual examination of the vulva and a careful medical history, but some may require vaginoscopy or a speculum exam.
Nonspecific vulvovaginitis may be triggered by fecal contamination, sexual abuse, chronic diseases, foreign bodies, nonestrogenized epithelium, chemical irritants, eczema, seborrhea, or immunodeficiency.
[3] Infectious vulvovaginitis can be caused by group A beta-hemolytic Streptococcus (7–20% of cases), Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, Shigella, Yersinia, or common STI organisms (Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, herpes simplex virus, and human papillomavirus).
and is treated with preventing exposure and encouraging sitz baths with baking soda as the vulvar skin heals.
[3] 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.
[3] Organisms responsible for vulvitis in children include pinworms (Enterobius vermicularis), Candida yeast, and group A hemolytic Streptococcus.
Candida infections cause a red raised vulvar rash with satellite lesions and clear borders, and are diagnosed by microscopically examining a sample treated with potassium hydroxide for hyphae.
Streptococcus infections are characterized by a dark red discoloration of the vulva and introitus, and cause pain, itching, bleeding, and dysuria.
Neonates can have small breast buds at birth or white discharge (witches' milk), caused by exposure to transplacental hormones in utero.
The most common cause is low levels of estrogen (hypoestrogenism), which may result from chronic disease, radiation or chemotherapy, Poland syndrome, extreme physical activity, or gonadal dysgenesis.
Fibroadenomas make up 68–94% of all pediatric breast masses, and can be simply observed to ensure their stability, or excised if they are symptomatic, large, and/or enlarging.
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.
Neonatal ovarian cysts usually affect one ovary, do not cause symptoms, are classed as simple, and disappear by the age of 4 months.
Transabdominal ultrasonography can be used to diagnose and image pediatric ovarian cysts, because transvaginal probes are not recommended for use in children.
[3] Common pediatric gynecologic complaints include vaginal discharge, pre-menarche bleeding, itching, and accounts of sexual abuse.
[2] Secondary sex characteristics develop under the influence of estrogen on the hypothalamic-pituitary-gonadal axis, typically between the ages of 8 and 13.