After infancy, the labia majora and minora flatten out, and the hymenal mem- The appearance of pubic hair be-brane becomes thin, translucent, and vascular, with the edges easily identified. fore the age of 7 years should be considered precocious puberty and The genital examination is the same for all ages of children, from late infancy requires evaluation to determine until adolescence. Use a calm, gentle approach, including a developmentally the cause. appropriate explanation as you do the examination. A bright light source is essential. Most children can be examined in the supine, frog-leg position.
If the child seems reluctant, it may be helpful to have the parent sit on the examination table with the child; alternatively, the exam may be performed while the child sits in the parent's lap. Do not use stirrups as these may frighten the child. The following diagram demonstrates a 5-year-old child sitting on her parent's lap with the parent holding her knees outstretched.
Examine the genitalia in an efficient and systematic manner. Inspect the external genitalia for the presence of pubic hair, the size of the clitoris, the color and size of the labia majora, and the presence of rashes, bruises, or other lesions.
Next, visualize the structures by separating the labia with your fingers as A vaginal discharge in early child-shown at the left on the following page. You can also apply gentle traction hood can be due to perineal irrita-by grasping the labia between your thumb and index finger of each hand, tion (e.g., bubble baths or soaps), and separating the labia majora laterally and posteriorly to examine the inner structures, as shown below. Labial adhesions, or fusion of the labia minora, may be noted in prepubertal children and can obscure the vaginal and ure-thral orifices. They may be a normal variant.
foreign body, vaginitis, or a sexually transmitted disease from sexual abuse.
Note the condition of the labia minora, urethra, hymen, and proximal vagina. If you are unable to visualize the edges of the hymen, ask the child to take a deep breath to relax the abdominal muscles. Another useful technique is to position her in the knee-chest position as shown on the right. These maneuvers will often open the hymen. You can also use saline drops to make the edges of the hymen less sticky.
Vaginal bleeding is always concerning. Etiologies include vaginal infection, accidental trauma, sexual abuse, foreign body, and tumors. Precocious puberty from many causes can induce menses in a young girl.
Purulent, profuse, malodorous, or blood-tinged discharge should be evaluated for the presence of infection, foreign body, or trauma.
Abrasions or signs of trauma of the external genitalia can be due to benign causes such as masturbation, irritants, or accidental trauma, but should also raise the possibility of sexual abuse.
The normal hymen in infants and young children can have a variety of configurations, as shown in the following figures.
The physical examination may reveal signs that suggest sexual abuse, and the exam is particularly important if there are suspicious clues in the history. Bear in mind, that even with known abuse, the great majority of examinations will be unremarkable. Mounds, notches, and tags on the hymen may all be normal variants. The size of the orifice can vary with age and the examination technique. If the hymenal edges are smooth and without interruption in the inferior half, then the hymen is probably normal. Certain physical findings, however, suggest the possibility of sexual abuse and require more complete evaluation by an expert in the field.
Avoid touching the hymenal edges as the hymen is exquisitely tender without the protective effects of hormones. Examine for discharge, labial adhesions, lesions, estrogenization (indicating onset of puberty), hymenal variations (such as imperforate or septate hymen, which is rare), and hygiene. A thin, white discharge (leukorrhea) is often present. A speculum examination of the vagina and cervix is not necessary in a prepubertal child unless there is suspicion of severe trauma or foreign body.
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