16 - The Pediatric Gynecological Exam

Dr. Susan Kaufman, pediatric gynecologist at Virtua Health, is joined by Dr. Tania Dumont, pediatric gynecologist from CHEO and the University of Ottawa, to break down how to perform a pediatric gynecologic exam with empathy, clarity, and evidence, from newborn anatomy to adolescent assessment. We show how language, positioning, and choice reduce fear while improving visualization, diagnosis, and outcomes.

Reference: NASPAG Essentials of Pediatric and Adolescent Gynecology: Chapter 4

What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

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PAG WebEd cases are a great way to review our podcast content.

Transcript

Welcome, Guests, And Goals

SPEAKER_00 0:24

The patient takes strawberry-scented bubble bath. She sleeps in her underwear and often spends hours in a wet bathing suit and her presenting symptoms of our itching. Hello everyone, and welcome to Pag Over Pastries, a 20 to 30 minute podcast covering many topics in pediatric and adolescent gynecology. Today we're going to cover chapter four, how to do a pediatric gynecologic exam, which comes from the NASBAG Essentials book, Pediatric and Adolescent Gynecology. I'm Susan Kaufman. I'm a pediatric and adolescent gynecologist at Virtua Health in South Jersey. I am super excited today to have the author of the chapter with me to do this podcast.

SPEAKER_01 1:09

Thank you for the invitation, Dr. Kaufman. I'm really excited to be here and to share my knowledge with our listeners today. So I am Dr. Tanya Zmo. I'm an associate professor at the University of Ottawa in Ottawa, Canada, as well as the chief of the Division of Pediatric and Adolescent Gynecology at CHIO, which stands for the Children's Hospital of Eastern Ontario. And some of our learners may also know that I am the Fellowship Program Director for Pediatric and Adolescent Gynecology in Ottawa.

SPEAKER_00 1:36

Antonio, what's your favorite pastry?

SPEAKER_01 1:38

Oh, my favorite pastry is La Chocolatine. It's awesome with chocolate inside. If you don't know, it's just sinfully good. I love it.

SPEAKER_00 1:48

Okay. All right. So let's get started, everybody. So, first of all, how is a pediatric gynecologic exam carried out? And why is it different from an adult exam? And how does it differ from an adult exam?

Indications And No-Speculum Approach

SPEAKER_01 2:08

Yes, it's different because it will vary based on the patient's age. If you're examining a newborn versus a toddler versus a preschooler or someone that's getting to be almost a teenager, the exam will vary because the consent will be different. How much you explain to the patient and the care provider will also differ. And then the indications as well will differ. There are very specific indications for the pediatric exam. So one of them is, you know, confirmation of normal anatomy, if the referring provider has some questions about perhaps an imperforate hymen or aplasia of the vagina. Of course, if the patient is having vulvar complaints, that's another indication, as well as abnormal vaginal discharge, if you're suspecting abuse, if there has been trauma to the area. And of course, if they're presenting pre-pubertally with some vaginal bleeding, or there's a worry about precocious puberty as well.

Who Should Perform The Exam

SPEAKER_00 3:03

And just to emphasize, we really rarely, if ever, use speculums in pediatric and adolescent gynecology. Maybe in an older teenager, but not in an infant, in a child, or in a young teenager. We will not use a speculum. We have other instruments, have visualized the vagina, and we'll mention them in a moment. And we don't use very many instruments, if any, in the vagina of our young patients. Who should be performing pediatric gynecologic exams?

Consent, Chaperones, And Control

SPEAKER_01 3:38

Because for a lot of these patients, it's going to be their very first exam. I think we have to set the bar high and the standard high so that they be that they have a good experience the first time around. So I would say the practitioner must be experienced with the pediatric gynecologic exam and really should consider having an assistant there if you need another set of hands or and for sure a chaperone as well. So, you know, asking the child, you know, if they wish to have their parent in the room with them, or maybe if they wish to have the nurse instead. You know, we we never know the history and the potential trauma a patient has been through. So sometimes the parent is not the right person to be there, but most of the time it is. But I think asking that that question open-endedly to the child, you know, of course, depending on the on their age and their ability to communicate with us. And finally, I think it's important to never restrain a child. That's gonna leave, you know, some marking impressions for their future reproductive health and the future exams that they may have as well.

SPEAKER_00 4:38

Another way that the exam differs is it requires a lot more explanation and teaching and time before we even actually get to the genital part of the exam. What should be discussed with the patient and the caregiver before we start an exam? How do you approach that? By the way, I want to mention that when I'm examining anybody, whether it's a newborn to older teenagers, I do a total body exam from head to toe. Now you're ready to do your genital exam. How do you approach that with the parent and the child?

Preparing Families And Tools

SPEAKER_01 5:13

Yeah, so I usually start off by asking them if they've ever had this type of exam before and how their experience was with it. So I know where I'm I'm starting from and where their headspace is at. Yeah, emphasize that it's it's normal that they feel anxious or stressed out about the exam and let them know that they are in control. And so at all times, if they wish to stop or take a break, then they just need to let me know and we'll do that. The other thing is I often will ask if they want to see the instruments or the swabs that we're going to be using. And that really varies. I find the answers from patient to patient. Some of them just want to look at their parents' phone and be distracted. Others absolutely want to know everything you're going to use, everything you're going to do. So I think respecting the child's desires is really important moving forward. And then more to the parents, usually, but is emphasizing that the exam will not change the hymen or the concept of virginity in any shape or form.

SPEAKER_00 6:13

A couple other things that I do is I use a picture of the vulva and I explain all the parts and I show the child where they pee and poop from and where the vaginal opening is and explain using the picture what they're going to feel. I also offer a mirror. Some of them want to look in a mirror while you're examining them. So I might have my medical assistant help them hold the mirror, and then I can also explain some anatomy. It's funny, sometimes they want to hold the mirror and then they end up taking the mirror and just looking at their face. So that's a good distraction sometimes, too.

SPEAKER_01 6:49

We love the mirror as well. I find it's a really great opportunity for education. And I find sometimes even the parents learn about the proper anatomy and the words that we should be using.

Education, Mirrors, And Language

SPEAKER_00 7:00

We can also engage the child in the exam, even a two-year-old, regardless of age, they can help us. So we can use their hands to move their knees apart, we can use their fingers to retract their labia. And sometimes they'll say, Well, you can look, but you can't touch. And I'll say, Well, can I touch with your fingers? And I will hold their fingers and move them around so that I get to see what I need to see, but I'm not really touching them. Like you said, being concerned about their previous experiences, any trauma, any fear that somebody might have put in them by describing what an adult exam is like. We overcome that by giving the child control and helping them to participate in the exam. So, what are we looking for in the newborn exam? What is newborn genital anatomy look like?

SPEAKER_01 7:52

You're going to have some findings that are remnant of the maternal estrogen. So actually, the hymen is going to be thickened, the labia menorah might be elongated, and there might actually even be some breast development. And those will slowly change as the maternal estrogens wear off, and then we'll really find, you know, the prepubertal hymen, which is different. That's when we actually see a really thin hymen that's typically crescentic or annular in shape. The labia menorah are usually much shorter, smaller, and thinner.

SPEAKER_00 8:25

Sometimes the hymen in the newborn, up to six to eight weeks, is so puffy that we can't establish patency. And somebody doing an exam who doesn't have the experience may assume that that's an imperferred hymen or an absent vagina simply because they cannot see patency. So we have to keep in mind that that is normal.

Newborn Anatomy And Estrogen Effects

SPEAKER_01 8:47

I actually had a referral for a prolapped cervix in a newborn just last week. And by the time we saw them, the hymen was completely normal and patent, and we were able to show it to the parents that were there with the child. But exactly like you just described, I think it was from the, you know, the thickened hymen, and someone that's not used to seeing that, I could see how they would think that it would be potentially a you know a cervical prolapse.

SPEAKER_00 9:12

So what positions can we use when we're examining a child's?

SPEAKER_01 9:16

Yeah, I think the most common position is what we call either the butterfly or the frog leg position. And I really describe it in very simple words to the patient. So I just ask them to, you know, lie down on their backs on the table, then I ask them to bend their knees as much as they can. And then I ask them to pretend that their legs are butterfly wings and to show me the beautiful designs and to open the butterfly wings. And then that usually gets them into that position where we need to be able to see. If they're nervous or they're struggling, then I'll usually try and have them do this, but sitting on their parents' lap. And sometimes that's helpful as well. Or I have the parent mimic the position underneath them as well, and then they can copy their parent. And then if if we're struggling with visualization, the other position we'll do is what we call a knee chest position. So that's more when the tummy side is facing the table. So basically they're putting their shoulders on the table with their head turned to one side, their buttocks is in the air, the lower back is lightly arched, and then the knees are wide apart. And sometimes that just with gravity helps us get a better view of the of the hymen as well.

Exam Positions That Work

SPEAKER_00 10:22

I have tried that position on occasion. I find for me personally, it doesn't work particularly well, but it is something to keep in mind if we're having problems with visualization. When we're lying the child down, I always prop the child up on a pillow or prop the back of the bed up enough so that I can keep contact with the child so they can see me at all times. And even if they're not using a mirror to see what I'm doing, they can at least see that, you know, I'm doing what I told them I was going to do.

SPEAKER_01 10:54

I love that.

SPEAKER_00 10:55

So as the child gets a little older, what are we going to be looking for on the genital exam? Say somebody who is starting puberty.

Structured Pubertal Exam Checklist

SPEAKER_01 11:04

Have a structured approach so that you don't forget anything. The first thing if we're at the genital exam is tenor staging of the pubae hair, so from one to five and grading it there. Then next I'll move on to the appearance of the labia and majora and then working my way in. And then I'll want to look at the clitoris, and if I'm at all worried about hypertrophy, I might actually measure. And then I'll also want to check the clitoral hood to make sure that it's mobile and that there's no famosis there. And then I typically will move over to the introitus, looking for patency, any hymenal anomalies, any erythema, vagatal discharge, and whether it looks estrogenized or not. And then if possible, and I can see the lower vagina, I'll look for any bleeding, formed bodies or discharge. And then I keep working my way down. So the perineum, looking for lesions, discolorations, or excoriations. And then finally I end my exam with the anus, looking for kind of the same things, lesions, exoriations, and discolorations, but also pinworms, especially if the child is presenting for paritis.

SPEAKER_00 12:04

And in you mentioned being able to visualize the distal vagina. So there are a couple of techniques that we use for that. One is called labial retraction, where we will gently grasp the labia majora and move them. And I don't like to use the word pull. If I say to a child, I'm going to pull on your tissue, that's not good. So I say I'm going to move them down and out so that the vaginal muscles to relax, it helps the hymen to retract, and we can see into the distal vagina. Sometimes we need to just move them out laterally and sometimes up and out, depending on the anatomy and what we're looking for. But labial retraction really helps us to see a significant amount of anatomy, both of the introitus and the distal vagina.

SPEAKER_01 12:55

Yes, I think it's important to point out the difference between labial separation and retraction. I think I've seen a lot of patients come to me and say, oh, they just, you know, separated them or pulled them apart, but that doesn't give a really good view of the hind. And so as you described, the labial retraction is so important. And if I have a patient that's worried about the feeling of the retraction, sometimes what I'll do is just kind of do it on their thigh so that they can feel the type of pressure and gentle pog that pull that I'm gonna provide on their labia majora. And sometimes that provides some comfort so they know what to expect in terms of that movement.

SPEAKER_00 13:32

That's a great idea. So if you were to see an abnormal discharge, explain where you're gonna take that culture from and how you're gonna do it.

Labial Retraction Versus Separation

SPEAKER_01 13:41

It's really important to teach how to do the swabs properly, both for our, you know, our trainees and other providers that are referring patients to us. Ideally, if we can put the patient through only one swab, the most important thing is having two people in the room. You're gonna need one person to do the labial retraction, as we just talked about. So to really get a good view and having that hymen open up. And then the other person's gonna be the one doing the swab. So who, first of all, you want to use the swab that's gonna be the smallest diameter you have for culture and sensitivity in your institution. If you have access to what we call a calgy swab, those are really thin. Moistening the tip with sterile water or saline can be really helpful as well. And then you're just gonna want to gently pass it through the hymen without touching the hymen and just really getting a sample of the lower third of the vagina.

Swabbing Technique And Comfort

SPEAKER_00 14:29

If the young lady wants to see what the swab looks like, I will hold up a calgy swab and I will hold up a regular Q-tip. And sometimes even the rectal Q-tips, if I have one, and I show them the difference in size, and I say, now which one do you think I should use to get the culture? And of course, they're gonna pick the calgi swab. So again, I'm giving them some control. I'll also use some lidocaine gel around the introital area if they are really nervous. I don't rub it in, I just put a glob of it around the hymenal area and let it sit for a few minutes, and then I can pass the swab over with minimal feeling. So you have a young lady who presents with a brown, persistent, maybe odorous discharge, and you suspect a foreign body. How do you accomplish that in the context of your exam?

SPEAKER_01 15:22

Yeah, so first I'll try to look either in those two positions we talked about. So that, you know, butterfly or frog leg position. And if I'm not getting a view of that lower third of the vagina, I'll try them on that knee chest position, kind of second line, to see if if gravity can help me and I can see that that lower third. And then if I'm still struggling, one of the things we can do is use an ophthalmoscope to look inside the vagina. So you wouldn't place it in the vagina, but the light can help you and can magnify as well. And then if there is a foul odor or you're worried because of this persistent discharge, or you've already treated them for an infection, it's coming back. So you're pretty convinced there's a foreign body there. You may want to reswab, or the other option potentially in the office, depending on the cooperation of the child, is vaginal flushing. So we use some warm saline or sterile water, and you there again you can get the child involved. So you can fill a large syringe of 60 C C D's, you know, connect it to any small tubing you have, could be a pediatric folio or NG tube, whatever is available to you. And again, you'll have an assistant do a labial retraction, and then you'll hold whatever catheter you have just inside the vagina, and then you can have the child push the plunger so they're in control of how much water is going in. And then sometimes that will be enough to flush out the foreign body, if it's especially if it's the most common one that we see, which is toilet paper.

SPEAKER_00 16:43

Yeah. And what if you can't accomplish these things in the office? What criteria do you use to decide to take somebody to the OR and sedate them and do an exam under anesthesia?

Foreign Body: Detection And Flushing

SPEAKER_01 16:55

And I think there's three criteria we should consider and meet. So, first of all, is this pediatric gynecological exam necessary? Are the findings of this exam actually going to change my management plan? And then three, can the patient not tolerate this in clinic with alternatives? One of the other things that we are now using in our center is actually office vaginoscopy. And the patients think it's kind of cool to see their vagina on a screen. And sometimes that really helps. So it gives us good visualization, it reassures them, they can see what's going on. And we'll use the same trait that you just mentioned for the Q-tip. We'll use some local anesthetic jelly or nitrix oxide as well, which can be really helpful. So sometimes the patients are candidates for that, and that's kind of the step before the operating room. But if for whatever reason, whether it's a history of trauma or anxiety or whatever it is, if if they're not open to that, then absolutely we will take them to the operating room if we think it'll change our management plan for sure.

SPEAKER_00 17:56

And particularly with abnormal bleeding, because we are looking for polyps and other growths inside the vagina or on the cervix. And it's difficult, even if we're able to do vaginoscopy in the office, it's difficult to biopsy those in the office. So if I have abnormal bleeding, I'm I lean more towards going to the OR to do an exam.

When To Use OR Or Vaginoscopy

SPEAKER_01 18:19

We use the office vaginoscopy sort of as a little bit of a triage method. It helps us decide who we need to bring to the main OR and put under general anesthetic, especially depending on how quickly we can get into the OR to help prioritize.

SPEAKER_00 18:33

When you have residents and medical students or fellows with you, how do you teach them to do the pediatric gynecologic exam?

SPEAKER_01 18:42

Yeah, so we actually first start off with simulation. So we are very lucky in Ottawa to have quite a well-established pediatric gynecology simulation program. And every time we have a new resident, we teach them on different models to do the labial separation, to do the labial retraction, the swabbing, the flushing, and the vaginoscopy as well, so that before they even put their hands on the patient for the first time, they've had a chance to try it out on the models. And that's something that we've worked really hard at at NASPAG is teaching others how to do this exam. And we mentioned some other different types of providers, nurse practitioners and pediatricians or pediatric endocrinologists and family doctors who need to learn. So being able to provide those simulation curriculums is really important. And there's a few of us in the field that have been working quite hard on developing these simulation programs. And some of the videos that we've put together describing how to do those are actually even accessible on the NASPAD website. There's different ways of doing them. There's what we call low fidelity or high fidelity models, depending on the resources you have. It just takes a little bit of creativity, but you can definitely put something together that's going to be useful and that you can keep in your clinic for your trainees to practice on before they go in and see the patient.

SPEAKER_00 19:58

So our case was a patient takes strawberry-scented bubble bath. She sleeps in her underwear and often spends hours in a wet bathing suit. The bubble bath and prolonged time in wet bathing suits can contribute to her symptoms. Just to kind of use that case to summarize what we've talked about so far, how would you approach that patient?

Simulation And Training Programs

SPEAKER_01 20:19

Yeah, so I think it's important to have a differential diagnosis of vaginal or vulvar pritis, itching, and discharge. And once you have that differential diagnosis, then that's going to help you walk through obviously your history, but then also your exam. And as we talked about, so, so important to have an approach to the exam, a systemic one where you don't forget any parts of the exam. So for this case, you know, initially I'm thinking maybe there's an infection like, you know, a staph or a stretch from an upper respiratory tract infection. And, you know, they're not quite good at washing their hands yet and they've cross-contaminated, or maybe it's from E. coli if they're wiping back to front instead of front to back. As we talked about, could be a foreign body as they're learning to potty train. Uh, sometimes they overwipe and the toilet paper disintegrates and accumulates inside the vagina and and becomes a foreign body. And then, of course, there's what we call non-specific vulva vaginitis that is due to all these non-specific irritants that children love, like bath bombs and uh bubble baths and scented soaps. But really, we know as pediatric gyneecologists that anything that's scented is actually really not good for the vulva and the vagina. The other thing it could be as well, those wet bathing suits that she's sitting in, or tight clothing if she's often in leotards or dance or gymnastics wear. And then, of course, it could also be, you know, a vulvar dystrophy like lichen sclerosis. So really important to have all those in mind when you're examining the patients and looking for all those things.

Case: Irritants, Itch, And Discharge

SPEAKER_00 21:51

And that's why a pediatric genital exam is so important and knowing how to do it correctly, because we may be the first person that this child sees for this problem, or we might be the second or third, because they might have been to the emergency room, they might have been to their pediatrician or family physician, and now they're coming to us. And so they're may they may have been traumatized a little bit by all these visits and all this attention to their genitals. And so it's so important that we approach the patient and the parents correctly. Also, because if the parents have anxiety about what's going on, that's going to be communicated to their child. That's why knowing how to do these exams correctly, how to approach the patient, how to talk to them, how to explain things is so important so that we can give them a positive experience.

SPEAKER_01 22:46

I would just like to say what an opportunity, and thank you so much for inviting me to share my knowledge. I think you touched on all the important points: consent, having someone else in the room there, reassurance, normalizing all the feelings.

SPEAKER_00 23:01

We have to remember that what we do in the office today is going to impact them for their whole reproductive life going forward. All right. So thank you everyone for listening to Pag Over Pastries. You can find the podcast on the NASBAG website with an outline of the information that we covered today. You can also find the podcast on any place you enjoy listening to podcasts like Spotify and Apple. If you have any questions or feedback for us, please contact us at Pagital P A G overpastries at gmail.com. Thank you for listening.