Pediatric gynecology

Psychology and history taking

Examination of children differs significantly from adult appointments due to psychological factors: anxiety, fear, and embarrassment. The physician must reassure the patient and gain her trust.

• Order of conversation: First, the physician conducts a detailed interview with the mother (optimally without the child present), asks clarifying questions, and only then talks to the girl herself.
• Life and medical history (Anamnesis vitae et morbi): It is important to find out the health of the parents, the course of pregnancy with this girl, and the diseases she has suffered. Particular attention is paid to infections (measles, rubella, tonsillitis), which can stunt sexual development, and rickets, which can cause pelvic deformation.
• Pubertal period: The establishment of menstrual function and the presence of vaginal discharge unrelated to the cycle are carefully recorded.

Physical examination and development assessment

Before the procedure, the girl must empty her bladder and bowels (cleansing enema). Children under three years of age are examined on a changing table, older ones on an adjustable pediatric gynecological chair. During an inpatient examination, the presence of the mother or a close relative is mandatory.

The physician evaluates height, body weight, development of subcutaneous adipose tissue, and mammary glands (Status praesens). Based on the condition of the external genitalia, a number of clinical syndromes can be suspected:

• Hyperestrogenism: vulva and labia minora are edematous, pink, and the hymen (hymen) looks "juicy".
• Hypoestrogenism: mucous membrane is pale, dry, and thin, organs are underdeveloped.
• Hyperandrogenism (in puberty): male-pattern hair growth, hyperpigmentation of the labia, slight enlargement of the clitoris.
• Congenital adrenal hyperplasia: phallus-like clitoris and male-pattern hair growth in childhood.

Special gynecological examination

Local examination (Status localis) includes a strict sequence of actions: inspection of secondary sexual characteristics, abdominal examination, inspection of external genitalia and anus (anus), vaginoscopy, and bimanual examination.

1. Vaginoscopy: Performed at any age to assess the mucosa, cervix, "pupil" sign, and search for anomalies. In infants, a urethroscope with an obturator is used; in puberty, pediatric speculums with illuminators are used.
2. Bimanual recto-abdominal examination: Mandatory for all patients. In younger children, it is performed with the fifth (little) finger; in older children, with the index or middle finger. It allows assessing the position, mobility, and tenderness of the uterus, as well as the condition of the appendages.

Important clinical rule: If unilateral ovarian enlargement is detected (especially before menstruation), the patient must be re-examined after it ends.

Laboratory and instrumental diagnostics

• Smears: Vaginal discharge is collected from everyone. The urethra and rectum are examined only when indicated. The instrument (grooved probe or catheter) is inserted into the vagina up to the posterior fornix, having previously treated the introitus with warm isotonic sodium chloride solution.
• Diagnostic imaging: Hysterosalpingography is rarely used and only in girls over 14–15 years of age (a special pediatric tip is used). CT and MRI in young children are performed under parenteral drug-induced sleep.
• Cytogenetics: Determination of sex chromatin and karyotype is indicated for delayed or impaired sexual differentiation.

Assessment of menstrual and reproductive function

When taking a gynecological history in older patients, the following must be recorded:

• Menstruation: Age of menarche, cycle length, amount of blood loss, and pain. The first day of the last menstrual period is always noted.
• Sexual life: Age of onset, presence of pain or spotting during intercourse. Absence of pregnancy for 1 year of regular intercourse without contraceptives indicates infertility.
• Surgical history: Particular attention is paid to uterine surgeries (e.g., myomectomy), after which a scar forms. To assess risks, a discharge summary with a detailed surgical protocol is required.

Class and exam questions

What else to study on this topic

• Differential diagnosis of congenital adrenal hyperplasia and testicular feminization.
• Technique for performing aspiration biopsy with a Pipelle instrument.
• The impact of past childhood infections (poliomyelitis, diphtheria) on pelvic and vaginal anatomy.
• Assessment of extragenital pathology and its impact on the course of pregnancy and childbirth.

Other topics in the "Gynecology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.