Gynecologic Problems of

Childhood
Presentation by:
Anne Margrette C. Velasquez
FEMALE REPRODUCTIVE SYSTEM
HISTORY AND PHYSICAL EXAMINATION
• HISTORY
– Mostly from a parent or a caregiver
• Recent growth and
– Problem-focused history development
• Signs of puberty
• Vaginal discharge or bleeding • Trauma
• Vaginal discharge
• External genital lesions • Perineal
• •hygiene
AnatomicMedication
findings exposure
• Onset and duration of symptoms
• History of foreign objects in
• Pruritus • Developmental
• Presence and
thequality
vaginaof discharge
changes
• Exposure to skin irritants
• Congenital
• Recent antibioticsanomalies
• Travel
• Presence of infections or medical
conditions in the patient or family
members
• Other systemic illness or skin
conditions
 VULVOVAGINITIS
• Most common gynecologic-based problem
for prepubertal children
• Most commonly caused by
– Poor or excessive hygiene
– Chemical irritants
• Improved by
– Hygiene measures
– Education of both caregivers and child
 V U LV I T I S VA G I N I T I S
• External genital pruritus, • Inflammation of the
burning, redness, or rash vagina
• Manifests as a discharge
with or without an odor or
bleeding
• Can cause vulvitis
 VULVOVAGINITIS
• HISTORY
– Hygiene
– Possible chemical irritants
– Diarrhea
– Perianal itching
– Nightime itching
– Possibility of foreign objects being placed into the
vagina
Labial adhesions. (Photo courtesy of Diane F. Merritt, MD.)
 EPIDEMIOLOGY
• Escherichia coli
• Streptococcus pyogenes
• Staphylococcus aureus
• Haemophilus influenzae
• Candida spp.
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Shigella
• Yersinia enterolittica
 CLINICAL
MANIFESTATIONS
• PHYSIOLOGIC LEUKORRHEA
– Neonates and prepubertal girls can present with a
white discharge
– physiologic effect of estrogen
• DIAPER DERMATITIS
– Most common dermatologic problem in infancy
– occurs in half of all diaper-wearing infants and
children
– Most common cause – Candida spp.
– First line Tx: hygiene
 CLINICAL
MANIFESTATIONS
• APTHOUS ULCERATION
– Epstein-Barr Virus
– Vestibule if the most frequent location
– Painful red-rimmed ulcer with a necrotic or
eschar-like base
– 7-14 days before remission occurs
– Very painful so urinary diversion with a
Foley catheter is necessary
Apthous ulcers
(Photo courtesy of Diane F. Merritt, MD.)
 SPECIFIC VULVAR
DISORDERS IN CHILDREN
• Molluscum contagiosum
• Condyloma accuminata
• Herpes simplex
• Labial Agglutination
• Lichen sclerosus
• Psoriasis
• Atopic dermatitis
• Contact dermatitis
• Seborrheic dermatitis
 Molluscum contagiosum
• Presentation • Treatment
– 1- to 5-mm discrete, – self-limited
skin-colored – lesions can resolve
– dome-shaped spontaneously
umbilicated – cryosurgery, application
– central cheesy plug of topical anesthetic
• Diagnosis – Curettage
– Visual Inspection – topical silver nitrate
– Use of topical 5%
imiquimod cream
Molluscum contagiosum
(Photo courtesy of Diane F. Merritt, MD.)
 Condyloma accuminata
• Presentation • Treatment
– Skin-colored papules – Destructive and excisional
options
– shaggy cauliflower-like – general or local anesthesia
appearance • topical trichloroacetic acid
• local cryotherapy,
•
• Diagnosis •
electrocautery,
excision by scalpel or scissors,
– Visual inspection • aser ablation
– Biopsy • Products not approved for
children include
– provider application of
podophyllin resin
– home application of
imiquimod, podophylox, and
sinectechins
Condyloma
Accuminata
 Herpes simplex
• Presentation Treatment
– Blisters that break, leaving • Infants:
tender ulcers – Acyclovir 20 mg/kg body
weight IV q8 hr
• Diagnosis • 21 days for disseminated
and CNS Disease
– Visual inspection
• 14 days for disease limited
confirmed by culture to the skin and mucous
membranes
• Children > 2 yr may be
treated
– Oral acyclovir 30-60
mg/kg/day x 10 days
Herpes Simplex
 Labial Agglutination
• Presentation • Treatment
– cause urinary dribbling – Not required if
– associated with vulvitis, asymptomatic
urinary tract infection, or – Symptomatic
urethritis • Topical estrogen cream or
betamethasone application
daily for 6 weeks on the
• Diagnosis line of adhesions
– Visual inspection of the • Use a cotton swab while
adherent labia applying gentle labial
traction
– Often with a central semi- • Adhesions usually resolve
translucent line in 6-12 weeks
– Petroleum jelly and A&D
ointment for > 1 month
Labial adhesions
(Photo courtesy of Diane F. Merritt, MD.)
 Lichen sclerosus
• Presentation • Diagnosis
– sclerotic, atrophic, – Visual inspection
parchment-like plaque – Biopsy
with an hourglass or
keyhole appearance of • Treatment
vulvar, perianal, or perineal – Ultrapotent topical
skin, corticosteroids is the first-
– subepithelial hemorrhages line therapy (clobetasol
may be misinterpreted as propionate ointment
sexual abuse or trauma 0.05%) once or twice a day
for 4-8 wk
– Perineal itching, soreness,
or dysuria – Once symptoms are under
control, the patient should
be tapered off the drug
unless therapy is required
for a flare-up
Lichen sclerosus
(Photo courtesy of Diane F. Merritt, MD.)
 Psoriasis
• Presentation • Diagnosis
– Red plaques with well- – Confirmed by locating
demarcated silvery other affected areas on
scales that are intensely the scalp or in nasolabial
pruritic folds or behind the ears
• Treatment
– Topical Corticosteroids
Genital Psoriasis
 Atopic dermatitis
• Presentation • Diagnosis
– Chronic cases can result – May be seen in the
in crusty, weepy lesions vulvar area but
that are accompanied by characteristically affects
intense pruritus and the face, neck, chest and
erythema extremities
– Scratching often results • Treatment
in excoriation of the – Avoid common irritants
lesions and secondary
bacterial or candidal – Topical corticosteroids
infection for flare-ups
– Lotion or bath oil to seal
in moisture after bathing
 Contact dermatitis
• Presentation • Diagnosis
– Erythematous, edematous, exposure to an irritant
or weepy vulvar vesicles or – perfumed soaps
pustules can result – Bubble bath,
– more often the skin – talcum powder
appears infl amed
– Lotions
– elastic bands of
undergarments or
disposable diaper
components
• Treatment
– Tropical Corticosteroids for
flare-ups
Diaper Dermatitis
 Seborrheic Dermatitis
• Presentation • Diagnosis
– Erythematous and – Visual inspection
greasy, yellowish scaling
on vulva and labial crural
folds • Treatment
– associated with greasy – Gentle cleaning, topical
dandruff-type rash of clotrimazole with 1%
scalp, behind ears and hydrocortisone added
face
 ANTIBIOTIC RECOMMENDATIONS FOR
SPECIFIC VULVOVAGINAL INFECTIONS
• Penicillin V, 250 mg PO bid-tid X 10
days
• Amoxicillin 40 mg/kg/day (max 500
Streptococcus mg/dose) divided into 3 doses daily
X 7 days
pyogenes • Erythromycin ethyl succinate, 30-50
mg/kg/day (max 400 mg/dose)
Streptococcus divided into 4 doses daily
pneumoniae • TMP-SMX 6-10 mg/kg/day
(trimethoprim component) divided
into 2 doses daily X 10 days
• Clarithromycin 7.5 mg/kg bid (max
1 g/day) X 5-10 days
 ANTIBIOTIC RECOMMENDATIONS FOR
SPECIFIC VULVOVAGINAL INFECTIONS
• Cephalexin
– 25-50 mg/kg/day PO X 7-10 days
divided every 6-12 hr
• Dicloxacillin
Staphylococcus – 25 mg/kg/day PO x 7-10 days divided
q6 hr
aureus • Amoxicillin-clavulanate
– 20-40 mg/kg/day PO divided BID or
TID x 7-10 days
• Cefuroxime
– 30 mg/kg/day BID (max 1g) x 10 day
– tabs: 250 mg bid
 ANTIBIOTIC RECOMMENDATIONS FOR
SPECIFIC VULVOVAGINAL INFECTIONS

• TMP-SMX double
Methicillin – Resistant strength 8-10
Staphylococcus mg/kg/day;
• culture abscesses,
aureus incision and drainage

• Amoxicillin, 40
Haemophilus influenzae mg/kg/day TID x7 days
ANTIBIOTIC RECOMMENDATIONS FOR
SPECIFIC VULVOVAGINAL INFECTIONS
• TMP-SMX 8-10 mg/kg/day
(trimethoprim component)
• Shigella BID X 5 days
• Ampicillin 50-100
mg/kg/day divided into
q6h (adult max 4 g/d) X 5
• Chlamydia days
trachomatis • For resistant organisms:
Ceftriaxone 50-75
mg/kg/day IV or IM divided
ANTIBIOTIC RECOMMENDATIONS FOR
SPECIFIC VULVOVAGINAL INFECTIONS
• Children < 45 kg: Ceftriaxone, 125
mg IM in a single dose
– (alternate: spectinomycin 40
Neisseria mg/kg (maximum 2 g IM) once plus
if chlamydial infection is not ruled
gonorrhoeae out, prescribe for chlamydia as
above
• Children ≥ 45 kg: adult regimen of
Cefixime, 400 mg PO 1 dose, or
Ceftriaxone, 125 mg IM 1 dose
– If chlamydial infection is not ruled
out, add Azithromycin, 1 g PO 1
Dose or Doxycycline, 100 mg PO
bid x 7 days
• Children with bacteremia or
arthritis: Ceftriaxone, 50 mg/kg
(max dose for children < 45 kg: 1
g) IM or IV OD x 7 days
ANTIBIOTIC RECOMMENDATIONS FOR
SPECIFIC VULVOVAGINAL INFECTIONS
• Metronidazole, 15
• Trichomonas mg/kg/day tid (maximum
250 mg tid) x 7 days
• Tinidazole 50 mg/kg ( ≤ 2
g) as 1 dose for > 3 yr
• Mebendazole (Vermox), 1
• Pinworms chewable 100 mg tablet,
repeated in 2 wk or
• Albendazole, 100 mg for
–Enterobius < 2 yr or 400 mg for older
vermicularis child, repeated in 2 wks
 BLEEDING
• Should always be evaluated
• 1st week of life from maternal estrogen
withdrawal until puberty when menstruation
occurs
• Spotting (light serosanguineous spotting) to
heavy bleeding with clots
 BLEEDING
• Common causes : vulvovaginitis, foreign
bodies, dermatologic conditions, urethral
prolapse
• Less common: endogenous or exogenous
estrogenic effects
• Most worrisome: Neoplasms and Trauma
 NEOPLASMS
• Most common in the prepubertal girl
– Hemangiomas (cavernous hemangiomas of the
vulva)
– Polyps (hymenal polyps)
– Sarcoma botyroides
– Rhabdomyosarcoma (RMS)
• Survival rate is >90% when an early diagnosis
is made
 PRECOCIOUS PUBERTY
• Pubertal development that is 2.5 – 3 SD earlier
than the average age
• Guidelines: evaluation of premature
development state that pubic hair or breast
development requires evaluation only when it
occurs before age 6-7 yrs old
• Gonadotropin-dependent or central
precocious puberty
• Serum estradiol levels >100pg/mL
 PRECOCIOUS PUBERTY
• Gold standard: measurement of
gonadotropins after GnRH or GnRH-agonist
stimulation
• IN ALL CASES: MRI imaging of the brain is
needed to determine if a tumor is present in
the hypothalamus
 POLYCYSTIC OVARY
SYNDROME
• Common disorder of reproductive hormone
dysfunction
• Associated with metabolic abnormalities
– Obesity, insulin resistance, metabolic syndrome
• 5-8% of women of reproductive age
• Triad of androgen excess (Rotterdam Criteria)
– Oligoovulation or anovulation
– Clinical or biochemical hyperandrogenism
– Ovarian cysts (>= 12 immature follicles)
Polycystic Ovarian
Syndrome
 GYNECOLOGIC MALIGNANCIES
• Second most common cause of death in
adolescents, after injuries
• Most common in children and adolescents is
of ovarian origin and manifests as an
abdominal mass
– 1% of all childhood malignancies
– Account for 60-70% of all gynecologic
malignancies in this age group
– About 10-30% of all ovarian neoplasms are
malignant
 GYNECOLOGIC MALIGNANCIES
• Chemotherapy and radiation therapy
– Acute ovarian failure
– Premature menopause

• Risk factors
– Older age
– Abdominal or spinal radiation
– Certain chemotherapeutic drugs
(Cyclophosphamide, busulfan)
 UTERINE IRRADIATION
• Infertility
• Spontaneous pregnancy loss
• Intrauterine growth restriction
• Decreased uterine volume
• Injury of the vagina, bladder, ureters, urethra
and rectum
• Vaginal shortening, vaginal stenosis, urinary
tract fistulas and diarrhea
-END-