Gynecology: Pediatric Gynecology

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1. General: Gynecology of infancy and childhood is often neglected, primarily because problems are uncommon before the onset of puberty; however, when such problems arise, they must be appropriately evaluated. If child abuse is suspected, document the exam carefully and report to the appropriate authorities. Consultation with a specialist in pediatric gynecology may be helpful in cases with legal ramifications.

2. Common Disorders of Infancy and Childhood:
1. Vulvovaginitis. Most common complaint:
1. Symptoms. Soreness, pruritus, discharge, and burning.

2. Exam. Microscopic exam of vaginal secretions, UA, and possible vaginal cultures. Recurrent or refractory infections of foul-smelling, bloody discharge require vaginoscopy to exclude foreign body or tumor.

3. Causes include nonspecific polymicrobial infection secondary to poor hygiene or foreign body, contact irritation from soaps, etc. Primary infections (Candida, Gardnerella, Trichomonas, gonorrhea, syphilis, herpes, etc.), pinworms, lichen sclerosus et atrophicus may also occur. Neoplasms are rare.

4. Treatment:
1. Remove foreign body with warm saline irrigation or bayonet forceps. Obtain vaginal and urine cultures and treat concurrent infection.

2. Treat specific infections. Candidiasis: see previous section in this chapter. Bacterial vaginosis and Trichomonas vulvovaginitis: metronidazole 35 to 50 mg/kg/day up to 750 mg divided TID for 7 days. Gonorrhea: ceftriaxone 125 mg IM x 1 azithromycin 10 mg/kg PO x 1 (max 1 g). UTI: TMP/SMX. Scabies and pediculosis pubis: see Chapter 10. Suspect sexual abuse if BV, trichomonas, gonorrhea, or chlamydia is present.

3. Educate about perineal hygiene.

2. Pinworms (Enterobias vermicularis). May cause vulvovaginitis; rectal itching common; frequently have vaginal pain.

3. Diaper dermatitis (primary contact irritant dermatitis):

1. Caused by irritants in urine, producing red, papulovesicular, shiny rash sparing skin folds; may fissure.

2. Treat with good hygiene and protection with zinc oxide or white petroleum jelly as well as frequent diaper changes allowing skin to dry fully. Treat secondary infections caused by Streptococcus, Staphylococcus, or Candida organisms.

4. Labial adhesions:

1. Related to low estrogen levels, poor hygiene and vulvar irritation. Usually asymptomatic but may interfere with urination leading to dysuria and recurrent vulvar and vaginal infections.

2. Treat with topical estrogen cream BID for 7 to 10 days, which will lyse adhesions. Use surgical intervention only as a last resort.

5. Neonatal vaginal bleeding. May occur at 3 to 5 days, representing withdrawal of transplacental estrogens. No treatment except reassurance of parents.

6. Urethral prolapse:

1. Prolapse of estrogen-dependent distal urethral mucosa forming painful, friable mass at vaginal orifice. Catheter passed through center enters bladder.

2. Treat initially with topical estrogens and antibiotic creams. If urinary retention is present or lesion is large and necrotic, surgical excision may be required.

7. Rare but serious disorders of infancy and childhood

1. Sarcoma botryoides (embryonal carcinoma of vagina):

1. Presents as bloody vaginal discharge most commonly in very young girls (<3 years) with polypoid growth, which may look like a cluster of grapes.

2. Survival rare but improving with use of combination chemotherapy and radical surgery.

2. Ovarian tumors:

1. Symptoms include pain, mass, pressure; may cause vaginal bleeding or the precocious development of secondary sex characteristics if hormonally active. Requires complete evaluation by experienced gynecologist.