Paediatric gynaecology Special patients: need special approach! Selected topics for this presentation: –Examination of the prepubertal child and adolescent –Paediatric vulvovaginal conditions –Lower abdominal mass –Contraception for adolescents

Examination of the prepubertal child2 Principles: Trust will lead to improved cooperation –Private, peaceful, unhurried: respect wishes of the child History: from parents/care providers and child herself –Key issues: --Growth and development –Childhood and other illnesses –Family structure –Friends, play patterns, “best friend” –Molestation

Examination 3 Do not press child down! Remember anatomical differences between child and adult Standard systemic examination Gynaecologic examination: frog-legged position (on bed or parent’s lap) better than knee-chest –Thin catheter: MCS specimens –Single finger PR when required –EUA if trauma or office examination does not work out

Examination of adolescent 4 Principles: teach patient concept of doctor-patient relationship and privacy –See patient on her own, let her speak History: standard systemic history –Key issues: pubertal development, menstruation, tampon use, sexual activity (voluntary or not) Examination: standard technique –Occasional use of “virgo” speculum –PR or 1 finger PV

Vulvovaginal conditions 5 Common; can usually sort out with simple tests 1 Bleeding –Vaginitis: Shigella, Strept, E coli, threadworm, candida may all cause blood stained discharge Usually preceding watery diarrhoea Rx; Antibiotics + topical oestrogens for 1 week

Bleeding (continued) 6 –Foreign body : chronic discharge with bleeding. Perform PR and MCS of discharge, and for vaginoscopy if in doubt. Remove objects, requently under GA. Assist healing with topical oestrogen –Trauma –Sarcoma botryoides : rare; mass with bleeding: refer –Urethral mucosal prolapse : common, looks like tumour. Oedema, necrosis, inflammation. Caused by hypo-oestrogenism. Rx: oestrogen cream 2 weeks, if necrotic excise dead tissue

Vulvovaginal conditions 7 2 Abnormal appearance –Labial adhesions: hipo-oestrogenism and mild vulvitis: 80% asymptomatic, noted by mother. May separate at examination, assist with oestrogen cream. –Imperforate hymen and hymen variants/cysts –Lichen sclerosus –Condylomata acuminata

Vulvovaginal conditions (continued)8 3 Discharge –Threadworm –Chemical irritants –Candidiasis –Pyogenic infection: gram + and – organisms, chlamydia and anaerobes: specimen for culture and then specific Rx.

Lower abdominal mass in a child 9 Clinical: asymptomatic swelling / bladder symptoms / pain / hormonal changes / complications Tests: ultrasound, beta-hCG Principles of treatment: most are benign: longitudinal incision, inspect, washing, USO. Preserve fertility if possible. If malignant: refer for chemotherapy

Contraception for adolescents 10 Problems: adolescent sexual behaviour irregular, unplanned, fears and anxieties, poor compliance Law: what can doctor do Principles: by the time help is required, patient is already sexually active –Information on sex, STD, HIV, pregnancy –Motivate for proper pill use and follow-up –Motivate for abstinence: do not moralise