1. Gynaecological disorder of childhood
Dr.Asmaa al sanjary 2016

2. Gynaecological problems in the prepubertal child and at adolescence create great levels of anxiety in parents particularly,but fortunately very few of these disorders could be considered common. Examination of the prepubertal child requires cooperation from both the patient and the mother and requires extreme sensitivity if a successful examination is to be carried out.

3. Positioning the child for examination may require considerable time to gain the confidence of the child to allow examination. External examination should be performed with minimal handling of the vulva and, in order to expose the vaginal orifice, gentle traction on the buttocks to expose the vaginal opening can be performed. Specimens can be obtained using syringes with Flexible catheters or occasionally a swab may be inserted if the hymenal orifice allows. In adolescents, vaginal examination should be avoided unless there is good evidence that it is necessary in order to make a diagnosis.

4. This is the only gynaecological disorder of Childhood which can be thought of as common. Its aetiology is based on opportunistic bacteria colonizing the lower vagina and inducing an inflammatory response.

5. Aetiology:factors
At birth … the vulva and vagina are well oestrogenized due to
the intrauterine exposure of the fetus to placental oestrogen.
This Oestrogenization causes thickening of the vaginal
epithelium, which is entirely protective against any
bacterial invasion.
However, within 2–3 weeks of delivery the resultant
hypo-oestrogenic state leads to changes in the vulval skin,
which becomes thinner, and the vaginal epithelium also
becomes much thinner. The vulval fat pad disappears and
the vaginal entrance becomes unprotected. The vulval
skin is thin, sensitive and easily traumatized by injury,
irritation, infection or any allergic reaction that may ensue.

6. The lack of labial protection and the close apposition
of the anus mean that the vulva and lower vagina are
constantly exposed to faecal bacterial contamination.
The hypo-oestrogenic state in the vagina means that
there are no lactobacilli and therefore the vagina has a
resulting pH of 7, making it an ideal culture medium for
low-virulence organisms.
The childhood problems of poor local hygiene
compound the risk of low-grade non-specific infection.
Children also have the habit of exploring their genitalia
and in some cases masturbating.
Vulvovaginitis may also occur in childhood in those who have
an impaired local host defence deficiency due to the lack of an
innate local protective response from neutrophils.

7. Aetiology
The vast majority of cases are due to Non specific bacterial contamination, although the Other causes should be remembered. Candidal infection in children is extremely rare, although because it is a common cause of vulvovaginitis in the adult, it is a common Misdiagnosis in children. Candida in children is usually associated with diabetes mellitus or immunodeficiency and almost entirely related to these two medical disorders.

8. The presence of viral infections, for example Herpes simplex or condyloma acuminata, should alert the clinician to the possibility of sexual abuse. Vulval skin disease is not uncommon in children, particularly atopic dermatitis in those children who also have eczema.

9. Lichen sclerosis is also seen in children and may cause persistent vulval itching. The skin undergoes atrophy and fissuring and is very susceptible to secondary infection. Sexual abuse in children may present with vaginal discharge. Any child who has recurrent attacks of vaginal discharge should alert the clinician to this possibility. However, as non-specific bacterial infection is a common problem in children,Only those bacterial infections related to venereal disease,for example gonorrhoea, may be cited as diagnostic of sexual abuse.

10. urinary incontinence, particularly at night, and this creates a moist vulva allowing secondary infection by bacteria leading to vulvovaginitis.

11. Diagnosis:
The first is inspection of the vulva and vagina with good illumination,particularly if there is a history of a vaginal foreign body. It is usually possible to examine the vagina through the hymen using an otoscope. This may well allow the Diagnosis of a foreign body to be made. The second aspect of diagnosis involves the taking of bacteriological specimens. This can be extremely difficult

12. If a diagnosis of pinworms is to be excluded, then a piece of sticky tape over the anus early in the morning before the child gets out of bed will reveal the presence of eggs on microscopy.

13. Causes of childhood vulvovagnitis
Bacterial
… Non-specific (common)
… Specific (rare)
Fungal (rare)… Candida of vulva only
Viral (rare)
Dermatitis
… Atopic
… Lichen sclerosis
… Contact
Sexual abuse
Enuresis
Foreign body

14. The vast majority of children do not have a
Pathological organism. The primary treatment
in this group is…1. advice about perineal hygiene.
parents should be reassured that this is a local problem
only.
The mother should clean the perinium after defecation, from front to back, as this avoids the transfer of enterobacteria to the vulval area.
After micturition the mother and child should be instructed to clean the vulva completely and not to leave the vulval skin wet, as this damp warm environment is an ideal culture surface for bacteria that cause vulvovaginitis.
vulval hygiene through daily washing gentle and not scented.
Excessive washing of the vulva must be avoided as this leads to recurrent exfoliation and vulval dermatitis.

15. …2.During acute attacks of non-specific recurrent vulvovaginitis, children often complain of burning duringmicturition due to the passage of urine across the inflamed vulva. The use of barrier creams in these circumstances may be very useful. …3.In the case of specific organisms being Identified antibiotics can be prescribed and Amoxicillin is probably the most effective.

16. :Foreign body Foreign bodies are occasionally found in the vagina and may lead to vaginal discharge. In patients who have Persistent vaginal discharge despite treatment, an Ultrasound scan may detect a foreign body or, if a history of a foreign body is forthcoming, it is probably best to carry out an examination under anaesthetic and remove any foreign body at that time.

17. Vaginal bleeding Vaginal bleeding in childhood is extremely rare
And should always be treated with extreme caution.
The causes of vaginal bleeding in childhood include:
foreign body,
trauma,
a neoplasm,
premature menarche
urethral prolapse .
the diagnosis can almost always be made on clinical inspection.
Treatment should be appropriate but if trauma is suspected, sexual
Abuse must always be considered and referral to the appropriate
team made.

18. Labial adhesions
Labial adhesions are usually an innocent finding and a trivial
Problem, but its importance is that it is frequently
misdiagnosed as congenital absence of the vagina. The
physical signs of labial adhesions are easily recognized.
In the post-delivery hypo-oestrogenic state the labia minora
Stick together in the midline, usually from posterior to
anterior until only a small opening is left through which
urine is passed. Similar adhesions sometimes bind down the
clitoris. It may be difficult to distinguish the opening at all.

19. The vulva has the appearance of being flat , and there are no normal tissues beyond the clitoris evident. However, a translucent, dark, vertical line in the midline where the adhesions are thinnest can usually be seen, and these appearances are quite different from Congenital absence of the vagina. There are usually no symptoms associated with this condition, although older, that the manifestation Of children may complain that there is some spraying When they pass urine.

20. The aetiology of the hypo-oestrogenic state means
That they are never seen at birth, and instead occur
during early childhood. As late childhood ensues
and ovarian activity begins, there is spontaneous
resolution of the problem.
In the majority of cases no treatment is required
and the parents should be reassured that their
daughters are entirely normal.
treatment
In those children in whom there are some clinical
problems, local oestrogen cream can be applied for
about 2 weeks. There is usually complete resolution
of the labial adhesions.

21. In some rare circumstances this will not resolve the problem, but at the end of the oestrogen therapy the midline is so thin that gentle separation of the labia may be undertaken using a probe, and this procedure causes no discomfort to the child. Application of a bland barrier cream at this stage will prevent further adhesion formation. Finally, in taking a history it is important to establish that there has not been any trauma to the vulva, as very rarely labial adhesions may be the result of sexual abuse. /////////////////////////////////////////////