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Let symptoms be your guide in vulvovaginitis. (Never Use Speculum).

HOUSTON - Familiarity with prepubertal anatomy and an appropriate examination are your best tools for diagnosing pediatric vulvovaginopathies, according to Dr. Susan Pokorny.

Signs and symptoms are less useful diagnostic aids but can help determine the pace and extent of the exam, she said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Focus on the external genitalia first because in most cases that alone will allow you to identify and treat the problem, said Dr. Pokorny, a pediatric gynecologist in Houston.

Redness or irritation is a clue that the child may be using a soap that's too strong or contains irritants such as perfume. Substituting a milder soap, plus thorough rinsing and drying, using a hairdryer if necessary, can improve symptoms dramatically.

Good hygiene may also treat condylomata, which may appear and bleed in children as young as 18 months.

Condylomata often resolve on their own by the time the child is from 2 to 2 1/2 years old.

Bleeding or discharge from the vagina or other symptoms in the presence of an unremarkable examination of the external genitalia are signals for a more extensive evaluation.

Sometimes looking at the child's soiled panties can help identify the nature of the discharge. Vaginal hyperkeratosis and polyposis could indicate the presence of a foreign body, although by the time you see the child it may be gone.

It is always inappropriate to use a pediatric speculum on a child, despite its name, as it may cause traumatic stretching of the hymen, Dr. Pokorny said.

For peering into the vagina, she recommended an endoscope with irrigating properties.

Tissue that has been exposed to estrogen is thicker than non-estrogenized tissue and is better able to tolerate the insertion of instruments, Dr. Pokorny said.

Newborns, who are exposed to high estrogen stimulation in utero, will have thick external genitalia. The vulvar epithelium may take on a textured or "cobblestone" appearance. The hymen and labia minora are also thick and pink-white. Mucosal tissues will not be vascular.

This estrogen effect may persist into the first year of life but wanes by the age of 2-3 years.

In these patients, mucosal redness may be the result of irritation from poor hygiene.

By age 6 years the estrogen effect should have abated completely. In general, the vulva, labia minora, hymen, and mucosal tissues all will have much thinner epithelium.

Often the capillary network will be visible through the skin, especially on the mucosa of the vestibular sulcus, which may appear erythematous.

As the girl approaches puberty, she will start showing signs of estrogen exposure once again, with thickening of the vulva, labia, and hymen.

In an adolescent, a thick, pale pink hymen generally correlates with breast development at Tanner stages 3-4.

The normal hymen can take one of several configurations, Dr. Pokorny said.

A membranous, annular, or circumferential hymen is most common in prepubertal children after the estrogen effect has subsided, but as puberty approaches it usually develops a fimbriated or dentate appearance.

Occasionally a patient will have an annular hymen with a cleft between the 10 o'clock and 2 o'clock positions; this is an embryologic remnant and shouldn't be taken as evidence of abuse.

A posterior or crescent-shaped hymen that doesn't go all the way around the mouth of the vagina is also normal, but it offers less support to the urethra.

Dr. Pokorny said she suspects this configuration raises the risk of urethral prolapse later in life. It can be treated in children by applying estrogen cream.

An imperforate, microperforate, or septate hymen also is normal. In most cases these resolve spontaneously with time and can be left alone, unless they cause discomfort. Sometimes the septum of a septate hymen will break loose, bleed, and cause pain or discomfort.

In those cases you can tie it off with a ligature; it will fall off painlessly within a few. days.

Microperforated hymens often resemble imperforate hymens but will open with time and estrogen secretion.

If it bothers an adolescent patient, you can administer local anesthesia and incise it in your office.

A complete lack of hymenal tissue at the posterior rim and the presence of caruncles similar to those seen in adult women suggest significant stretch trauma and may signal possible chronic abuse, Dr. Pokorny warned. She has seen similar types of trauma in patients inappropriately examined with a speculum.
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Author:MacReady, Norra
Publication:Pediatric News
Geographic Code:1USA
Date:May 1, 2003
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