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Physical examination
Abstract The physical examination should look for evidence of chronic
The evaluation of vulvovaginitis, which is common in pediatric practice, illness or dermatological disease and include determination of
depends on the pubertal development of the patient, keeping the possi- the pubertal stage. The genitalia should be inspected in the frog-
bility of sexual abuse in mind. Prepubescent girls are especially suscep- leg supine position, with attention to the vulva, introitus, hymen
tible to vulvovaginitis because of anatomic and hormonal factors and and anterior vagina, including gentle lateral retraction of the
because of their tendency to have poor local hygiene. If symptoms persist labia as well as gripping of the labia and pulling anteriorly and
despite hygienic measures vaginal secretions should be investigated laterally. Signs of inflammation or injury should be sought as
microbiologically and specific antimicrobial treatment prescribed accord- well as the presence of a foreign body. For further assessment of
ingly. When the major complaint is of perineal pruritus, especially at the vagina and the hymen the girl can also be examined in the
night, empirical treatment with Mebendazole can be considered. In knee chest position. In a rectal examination a foreign body or
adolescents, who usually present with vaginal discharge, pruritus or mass may be palpated. If sexual abuse is suspected careful
dysuria, the pH of vaginal secretions should be tested and the secretions documentation of the appearance of the hymen and introitus are
should be examined under the light microscope and sent for microbiolog- necessary. In a sexually active adolescent, a complete pelvic
ical investigations. Physiologic leukorrhea is a common cause of vaginal examination with speculum should be performed.
discharge in adolescents. In the sexually active adolescent a complete
pelvic examination with speculum should be performed including evalua- Investigations
tion of endocervical specimen for sexually transmitted pathogens. Treat-
ment is then directed at the specific cause. The diagnosis of one sexually Vaginal secretions should be obtained for examination under the
transmitted disease necessitates investigation for others and treatment of light microscope and for microbiological investigation in both the
the partner. prepubertal and adolescent patient. The specimen can be
collected with a saline-moistened swab or using a sterile
Keywords acute vaginitis; adolescent; cervicitis; pediatrics; prepubertal; newborn suction catheter carefully inserted 2e3 cm into the
sexual abuse; review; sexually transmitted diseases; vaginal foreign vagina. Vaginal fluid should be evaluated microscopically for
body; vulvovaginitis epithelial cells, white cells, motile trichomonads, clue cells, and
for hyphae or spores on a potassium hydroxide wet mount. A
‘‘whiff’’ test is performed by adding 10% potassium hydroxide to
wet mount and smelling for the distinctive amine odor. If sexual
abuse is a consideration, appropriate cultures should be
Definitions collected. In the adolescent, vagina pH should be measured by
Vulvar inflammation, vulvitis, may precede or accompany vagi- touching a swab to the sidewall of the vagina and then to a pH
nitis, which is inflammation of the squamous epithelial tissues paper and in the sexually active adolescent endocervical spec-
lining the vagina. The hallmarks of the former are irritation and imen should be tested for Chlamydia trachomatis and Neisseria
redness of the vulva causing itching, pain and dysuria, whereas gonorrhoeae.
the major symptom of vaginitis is vaginal discharge. Usually
patients suffer from concurrent inflammation of both the vulva Vulvovaginitis in the prepubescent girl
and the vaginal tissues, namely, from vulvovaginitis. Vulvovag- Vulvovaginitis is the most common gynecological problem in
initis is common in the pediatric practice. The differences in prepubertal girls. Factors that explain the increased susceptibility
cause and presentation between prepubescent and adolescent of children to vulvovaginitis include: The close anatomic prox-
girls should guide the evaluation. imity of the rectum; lack of labial fat pads and pubic hair; small
labia minora; thin and delicate vulvar skin; thin, atrophic,
History anestrogenic vaginal mucosa; and children’s tendency to have
History should include questions about itching, discharge poor local hygiene and to explore their bodies. Most cases of
(colour, quantity, odour, consistency and duration), dysuria and vulvovaginitis are of nonspecific etiology. However in some
redness. Other issues which should be discussed are: Perineal patients the symptoms are caused by infections with specific
hygiene, exposure to irritants such as bubble baths and soaps, respiratory, enteral or skin pathogens. Candida albicans vulvo-
the possibility of a vaginal foreign body, the use of medications, vaginits is uncommon in prepubescent girls and occurs mostly in
underlying diseases, anal pruritus, recent infections in the child association with diapers, treatment with antibiotics, diabetes
or family, and obviously sexual activity and use of contraception mellitus and immunosuppression.
PAEDIATRICS AND CHILD HEALTH 20:3 143 Ó 2009 Elsevier Ltd. All rights reserved.
Downloaded for FK UMI Makassar (mahasiswafkumi05@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on March 30, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
PERSONAL PRACTICE
PAEDIATRICS AND CHILD HEALTH 20:3 144 Ó 2009 Elsevier Ltd. All rights reserved.
Downloaded for FK UMI Makassar (mahasiswafkumi05@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on March 30, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
PERSONAL PRACTICE
PAEDIATRICS AND CHILD HEALTH 20:3 145 Ó 2009 Elsevier Ltd. All rights reserved.
Downloaded for FK UMI Makassar (mahasiswafkumi05@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on March 30, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.