Gynecologic examination of the newborn and child

INTRODUCTION — Gynecologic evaluation of the prepubertal child is approached by directing attention to the specific complaint, symptom, or question to be addressed [1]. Educating the child and family prior to this examination is important both for their reassurance and for gaining their trust. Inspection of the genital region should follow a focused general examination. Knowledge of typical prepubertal anatomy and use of accurate nomenclature are essential for describing and documenting anatomic findings (figure 1).

Gynecologic examination of newborns and children will be reviewed here. Evaluation of common vulvovaginal complaints in these patients is discussed separately. (See "Overview of vulvovaginal conditions in the prepubertal child".)

INDICATIONS

●External genitalia – Examination of external genitalia, including the vulva, clitoris, labia, and urethral and anal orifices, is a part of the routine physical examination. Examination of the external genitalia is discussed separately. (See "The pediatric physical examination: The perineum", section on 'Female genitourinary system'.)

Assessment of the vulva, hymen, and lower vagina for signs of vulvar rashes, vulvar pigmented/nonpigmented lesions, masses, lichen sclerosis, labial adhesions, and/or vaginal discharge is most commonly performed visually without the use of instruments.

●Internal examination – Internal examination permits visualization of the vagina and cervix and is reserved for children with genitourinary complaints or suspected genitourinary pathology (eg, vaginal bleeding, persistent discharge, assessment for foreign bodies, trauma, acute sexual abuse with a penetrating injury, cystic or solid masses, suspected congenital anomalies).

Visualization of the vagina may be accomplished without instruments if the child is relaxed and placed in the knee-chest position (figure 2 and figure 3). However, examination under anesthesia with a Killian nasal speculum (figure 4), fiberoptic scope, or other instruments may be needed if the complaint cannot be adequately evaluated.

HISTORY AND PHYSICAL EXAMINATION

General guidelines — The medical history is obtained from both the child, if possible, and the parent(s), caregiver(s), or legal guardian(s). Prior to the examination, the child should be told the reason for the office evaluation [2]. A prior traumatic incident or examination can cause girls to become apprehensive and uncooperative. The provider should explain why examination of this area is needed and how the examination will be performed, including whether swabs or lights will be used. Allowing the child to maintain some control of the environment is also important. As an example, they can be offered the opportunity to select the gown that they will wear and to view the light source (otoscope, magnifying glass, or direct light).

The goal of the examination is to obtain the necessary information without traumatizing the child. Younger patients may be examined while sitting in a parent's, caregiver's, or guardian's lap. Older children can be provided choices (eg, whether to climb or be lifted onto the examination table).

Evaluation of the vulva and vagina — Evaluation of the vulva can be done with the child lying supine with the legs in a "frog-leg" or "butterfly" position and, if needed, for complaints requiring visualization of the vagina, in a "knee-chest" position (figure 2), or supine with the knees held by the child against their chest. The vulva, hymen, and anterior vagina can be visualized using gentle lateral retraction and then, if needed, by gently grasping the labia and pulling anteriorly (figure 3).

Examination of the vulva in the child may be facilitated by using a colposcope, especially in cases of sexual abuse. The colposcope magnifies the area being examined and allows photography of areas of interest. However, magnification with an otoscope (without a speculum), hand lens, or 35 mm camera with macro-lens can also be used.

Examiners who are experienced in office assessments and are comfortable with a procedural office evaluation of the vagina, local anesthetic jelly or cream can be applied to the hymenal area and a flexible, narrow lighted scope can be used to visualize the vagina and cervix.

Rarely, an adequate external genital examination cannot be performed in the office setting, and so an examination under anesthesia may be required. This can be done in a procedure unit or an outpatient ambulatory surgical unit with mask general anesthesia or intravenous conscious sedation. (See "Procedural sedation in children: Approach".)

When performing an anesthesia examination, a lighted Killian nasal speculum (figure 4) and a fiberoptic scope (cystoscope, flexible vaginoscope, flexible hysteroscope) are useful for examining the prepubertal vagina. A liquid distention media can be used for vaginoscopy to visualize the whole vagina and cervix. Vaginal cultures should be obtained prior to the vaginoscopy. (See "Vaginoscopy".)

Evaluation of the hymen — Examination of the hymen is an important part of the evaluation of girls who may have been sexually abused. The examiner must be able to distinguish the normal hymen and its normal variants from abnormal hymens [3-5]. However, 90 to 95 percent of girls who are known victims of sexual abuse have a normal genital examination. Anatomic variants sometimes mistaken for signs of sexual abuse include midline sparing (linea vestibularis), lichen sclerosus, failure of midline fusion, urethral prolapse, labial adhesions, pemphigoid, and other dermatologic conditions. (See "Evaluation of sexual abuse in children and adolescents", section on 'Female genitalia' and 'Congenital abnormalities of the hymen' below and "Vulvar lichen sclerosus: Clinical manifestations and diagnosis" and "Overview of vulvovaginal conditions in the prepubertal child", section on 'Labial adhesions'.)

Hymens change with age. Newborns have redundant, estrogenized, thick, elastic hymens, often with a prominent ridge at six o'clock. White discharge due to maternal and fetal/newborn estradiol-stimulated mucus production may appear at the hymenal orifice.

The hymen of prepubertal girls is unestrogenized, thin, and easy to assess in the cooperative child. The hymen may appear as a posterior rim, annular, redundant, and sleeve-like configuration (figure 5). In contrast, pubertal girls have thick, estrogenized, elastic hymens with white discharge.

Descriptions of hymenal tissue — Clinicians should be cautious about making judgments about abnormalities of the hymen in children being evaluated for sexual abuse. Several texts have provided atlases and descriptions of abnormal findings. In prepubertal girls, a complete transection of hymenal tissue between four and eight o'clock (lower half) is highly suspicious for trauma [6]. Accidental trauma usually spares the hymen (except in some injuries falling on objects or the edge of a bathtub or pool), whereas sexual abuse may cause this type of injury in a small number of girls. Measurement of the transverse width of the hymenal opening is not recommended and is not diagnostic of sexual abuse [7]. (See "Evaluation of sexual abuse in children and adolescents", section on 'Female genitalia'.)

Bumps refer to elevations of hymenal tissue that are usually attached to longitudinal intravaginal rugae. They are a normal variant. A hymenal fold at six o'clock may appear as a bump but disappears in the knee-chest position. Rarely, a bump may occur in the lower half (ie, between three and nine o'clock) adjacent to a partial transection.

Thickening of the hymen occurs upon estrogenization but may also develop after trauma. Folding of the hymen may give a false appearance of thickening. This finding should be confirmed in a knee-chest position.

Midline sparing (linea vestibularis) refers to a symmetric, flat avascular area of the posterior vestibule observed in 10 percent of normal newborns. It can sometimes be confused with scarring, which usually occurs on the hymen and posterior fourchette.

Congenital abnormalities of the hymen — Congenital abnormalities of the hymen occur in approximately 3 to 4 percent of the female population. They include imperforate, microperforate, cribriform, and septate hymens (figure 6). Of note, a study of 1131 female newborns did not find any cases of congenital absence of the hymen [8].

Evaluation of pelvic organs — If the child is relaxed, the cervix/uterus and adnexa in the child can be evaluated through examination using a finger placed rectally and the other hand abdominally with the patient lying supine. If a mass is suspected or cannot be excluded or the symptoms are worrisome, then an abdominal pelvic ultrasound is indicated. In the child, the ovaries are higher in the abdomen.

HOW TO OBTAIN CULTURES AND OTHER SPECIMENS FROM CHILDREN — There are some special issues to consider in obtaining cultures from children. If the child is awake, CalgiSwabs moistened with sterile saline can be used to obtain the specimen by gently inserting the swab through the hymenal ring without touching the edges of the hymen. Alternatively, a soft sterile eyedropper or a small feeding tube or urethral catheter with a syringe can be gently inserted through the hymenal opening to aspirate secretions or to obtain a vaginal wash sample. Another method uses saline squirted into the vagina while three swabs are held near the hymenal ring with the labia manually closed over them. The child is then asked to cough to expel the saline from the vagina onto the swabs. Cultures are more useful and more likely to be positive in girls who have vaginal discharge evident at the time of the examination.

If gonorrhea infection is possible, tests include culture and nucleic acid amplification tests (NAATs). A culture for Neisseria gonorrhoeae is done by plating the swab obtained on modified Thayer-Martin-Jembec medium at the time of the examination. A NAAT can be performed on the appropriate swab or a urine sample [9,10]. While culture is sometimes preferred for sexual abuse evaluations, urine NAATs are much more practical for the evaluation of routine vulvovaginitis and most sexual abuse evaluations. The laboratory should be informed that the specimen was obtained from a prepubertal child so that identification of N. gonorrhoeae is precise. Similarly, a positive NAAT should be confirmed by the laboratory. (See "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims'.)

Tests for Chlamydia trachomatis include cultures and NAATs. Cultures for C. trachomatis are rarely obtained; they are much less available and less sensitive than NAATs. For most patients, specimens for NAAT testing are obtained from urine or occasionally a vaginal sample and should be performed in a laboratory with expertise in pediatric testing [11]. (See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Nucleic acid amplification testing (test of choice)'.)

Genital cultures are transported using a CalgiSwab or Culturette II and plated by the laboratory on genitourinary media (eg, blood, MacConkey's, chocolate). A Nickerson Biggy agar or other fungal media can be used for detection of Candida spp if the child has itching. Candida vaginal infections are uncommon in prepubertal girls unless other risk factors (in diapers, recently treated with antibiotics, or diabetic). Thus, itching, mucoid vaginal discharge, or nonspecific erythema of the vulva should not be treated with antifungals without a culture or positive potassium hydroxide prep. A NAAT test can be obtained for Trichomonas to assess for vaginitis in the neonate or in cases of suspected sexual abuse, but Trichomonas infections are rare in the prepubertal child. (See "Candida vulvovaginitis: Clinical manifestations and diagnosis", section on 'Diagnostic approach' and "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)

OTHER TESTS

Microscopy of vaginal secretions — Microscopy is much less useful for evaluating vaginitis in prepubertal girls than adolescents because the etiology is usually nonspecific or a respiratory pathogen such as Streptococcus pyogenes. (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Respiratory and enteric flora' and "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Nonspecific vulvovaginitis'.)

Saline microscopy can be performed to look for Trichomonas but a nucleic acid amplification test is preferred. Signs of bacterial vaginosis include positive whiff (amine) test, defined as the presence of a fishy odor when 10 percent potassium hydroxide (KOH) is added to vaginal discharge samples; clue cells (>20 percent) on saline wet mount; or a homogeneous, grayish-white discharge (not present before puberty), but are rare in prepubertal girls. Vaginal pH, which is an important finding in adolescents and adults, cannot be used in prepubertal girls. The addition of 10 percent KOH is also helpful for diagnosing Candida vaginitis. Culture for Candida may be useful if microscopy is negative. (See "Vaginitis in adults: Initial evaluation".)

Vaginal pH — The vaginal pH in prepubertal girls is 6.5 to 7.5 and in pubertal girls is 3.5 to 4.5. Therefore, vaginal pH is not useful for diagnosis of bacterial vaginosis and vaginal Trichomonas infection in prepubertal girls.

Maturation index — The maturation index is rarely used but provides information about the pathophysiology of estrogen effect on the vaginal mucosa. Girls with precocious pubertal development may rarely (and only if atraumatic) have a vaginal smear obtained as part of their evaluation to determine degree of estrogenization using the maturation index. Vaginal smears for maturation index can be used to evaluate adolescents with amenorrhea if visual inspection does not confirm estrogen effect on the vaginal mucosa. In the Meisel system, 100 cells are counted and scored 0 points for parabasal cells, 1/2 point for intermediate cells, and 1 point for superficial cells.

The sum of points is interpreted as follows:

●60 to 70 points – newborns

●0 to 30 points – prepubertal girl

●31 to 45 points – hypoestrogenic female

●45 to 60 points – pubertal female

●90 to 100 points – hyperestrogenic female

SUMMARY AND RECOMMENDATIONS

●Indications and objectives – Examination of external genitalia, including the vulva, clitoris, labia, and urethral and anal orifices, is part of the routine physical examination of children. Internal examination is reserved for children with genitourinary complaints or suspected genitourinary pathology (eg, vaginal bleeding, persistent discharge, assessment for foreign bodies, trauma, acute sexual abuse with a penetrating injury, cystic or solid masses, suspected congenital anomalies). (See 'Indications' above.)

The goal of the examination is to obtain the necessary information without traumatizing the child. Younger patients may be examined while sitting in a parent's, caregiver's, or guardian's lap. Older children can be provided choices (eg, whether to climb or be lifted onto the examination table). (See 'General guidelines' above.)

●Evaluation of the vulva and vagina – Evaluation of the vulva can be done with the child lying supine, with the legs in a "frog-leg" or "butterfly" position or, if needed to visualize the vagina, in a prone "knee-chest" position (figure 2), or supine with the knees held by the child against their chest. (See 'Evaluation of the vulva and vagina' above.)

●Evaluation of the hymen – The examiner must be able to distinguish a normal hymen (figure 5) and normal variants (figure 6) from abnormal hymens. However, a normal hymen does not exclude the possibility of sexual abuse. (See 'Evaluation of the hymen' above.)

●Evaluation of pelvic organs – Although the cervix/uterus and adnexa can be evaluated bimanually with the finger of one hand in the rectum and the other hand on the abdomen, ultrasonography is more commonly employed. (See 'Evaluation of pelvic organs' above.)

●How to obtain cultures and other specimens – Vaginal cultures and other specimens are obtained without a speculum and require special techniques. (See 'How to obtain cultures and other specimens from children' above.)