Examination of children with gynecological diseases

Examination of children with gynecological diseases differs in many respects from the examination of adults.
Children, especially when they first go to the gynecologist, are anxious, afraid, embarrassed and uncomfortable with the upcoming examination. First of all, you need to establish contact with the child, calm down, achieve the disposition and trust of the girl and her relatives. Preliminary conversation with the mother is best done in the absence of the child. It is necessary to give the mother the opportunity to talk about the development of the disease in her daughter, then ask additional questions. After that, you can ask the girl.

A general survey of girls begins with a clarification of complaints, anamnesis of life and illness. It is necessary to pay attention to the age, the health of the parents, the course of the mother’s pregnancy and childbirth, related to the girl being examined, to carefully find out the diseases that the child had during the neonatal TM period, at an early and later age. The general reaction of the body of the girl to previously transferred diseases (temperature, sleep, appetite, behavior, etc.) is noted. Also find out the conditions of life, nutrition, mode of the day, behavior in a team, relationships with peers. Particular attention should be paid to the period of puberty: the formation of menstrual function, discharge from the vagina, not associated with menstruation.

Before the examination it is necessary to empty the intestines (cleansing enema) and the bladder. Younger girls (up to 3 years) are examined on a changing table, older girls are examined at a children’s gynecological chair, the depth of which can be changed. When examining girls in polyclinic conditions, as well as during the initial examination in a hospital, the presence of the mother or one of the closest relatives is necessary.

On examination of the external genital organs, the character of body hair is evaluated (by the female type – horizontal hairline; by the male type – in the form of a triangle with a transition to the white line of the abdomen and the inner surfaces of the thighs), the structure of the clitoris, large and small labia, virginal membrane, color, color of the mucous membrane of the vaginal opening, discharge from the genital tract. Penis-like clitoris in combination with male type hair growth in childhood indicates congenital androgenital syndrome (AGS); clitoral growth during puberty is about an incomplete form of testicular feminization or virilizing gonad tumors. “Juicy” hymen, swelling of the vulva, small labia and their pink color at any age indicate hyperestrogenism. During hypoestrogenism, the external genitals are underdeveloped, the mucous membrane of the vulva is thin, pale and dryish. With hyperandrogenism during puberty, hyperpigmentation of the large and small labia, male hair growth, a slight increase in the clitoris are noted.

Vaginoscopy is the examination of the vagina and cervix with an optical device, a combined urethroscope, and children’s vaginal mirrors with illuminators. Vaginoscopy is performed on girls of any age; it allows you to find out the state of the mucous membrane of the vagina, the size, shape of the cervix and external os, the presence and severity of the symptom of “pupil”, pathological processes in the cervix and vagina, the presence of a foreign body, developmental defects.

Vaginoscopy for girls in the “neutral” period is performed by a combined urethroscope using cylindrical tubes of different diameters with an obturator. In the pubertal period, the vagina and cervix are examined with children’s vaginal mirrors with illuminators. The choice of urethroscope tube and children’s vaginal mirrors depends on the age of the child and the structure of the hymen.

A two-handed rectal-abdominal examination is performed for all girls with gynecological diseases. When examining young children, a bimanual study should be carried out with the little finger, and when examining older girls, with the index or middle finger, which is protected by a fingertip smeared with petroleum jelly. The finger is injected when straining the patient.

A rectal examination ascertains the state of the vagina: the presence of a foreign body, a tumor, a collection of blood; during a bimanual examination, they determine the condition of the uterus, appendages, fiber and adjacent organs. On palpation of the uterus examine its position, mobility, pain, the ratio of the size of the cervix and the body of the uterus and the severity of the angle between them.

Detection of unilateral enlargement of the ovary, especially on the eve of menstruation, is an indication for a mandatory re-examination after the end of menstruation.

In younger children (up to 3-4 years) with injuries of the genitals and in girls of older age, if a pelvic tumor is suspected, rectal-abdominal examination is performed under general anesthesia.

When inspecting girls, you must carefully follow the rules of asepsis and antisepsis due to the high susceptibility of children’s genitalia to infection. After the end of the external and internal studies of the external genitalia and vagina are treated with furatsilina solution (1: 5000). When irritated on the skin of the vulva, it is smeared with streptocidal ointment or sterile petroleum jelly.

In addition, depending on the nature of the disease, the following additional research methods are used.

Methods of functional diagnostics and hormonal studies (described above) are used in patients with juvenile hemorrhage, in case of pathology of puberty and when hormonally active ovarian tumors are suspected.

Probing of the vagina and uterine cavity is indicated for the diagnosis of malformations of a foreign body, in case of suspected hematome or pyometra.

Separate diagnostic curettage of the mucous membrane of the uterus with hysteroscopy is indicated both for stopping uterine bleeding and for diagnostic purposes in patients with scanty long-term bleeding in patients with a disease duration of more than 2 years and with ineffective symptomatic and hormonal therapy. Diagnostic curettage do under short-term mask or intravenous anesthesia. The cervix is ​​exposed in children’s mirrors with a lighting system. Gegar’s dilators to No 8-9 are introduced into the cervical canal, endometrial scraping is made into a small curette (No 2, 4). With proper performance of diagnostic curettage, the integrity of the hymen is not broken.

Endoscopic methods (hysteroscopy, laparoscopy) do not differ from those in adults.

Ultrasound examination of the internal genital organs. Pelvic ultrasound is widely used in connection with safety, painlessness and the possibility of dynamic observation. Ultrasound can diagnose genital malformations, ovarian tumors and other gynecological diseases.

In girls, normally, the uterus with ultrasound is visualized as a dense formation with multiple linear and point echo structures, having the form of an elongated ovoid and located in the center of the pelvis behind the bladder. The average length of the uterus in children aged 2 to 9 years old is 31 mm, from 9 to 11 years old – 40 mm, from 11 to 14 years old – 51 mm. In girls over 14, the length of the uterus is on average 52 mm.

In healthy girls up to the age of 8 years, the ovaries are located at the entrance to the pelvis and only towards the end of the 1st phase of puberty descend deeper into the pelvis, adjacent to its walls, visualized as an ellipsoidal formation with a more delicate structure than the uterus. The volume of ovaries in children aged 2 to 9 years on average is 1.69 cm3, from 9 to 13 years old – 3.87 cm3, in girls older than 13 years old – 6.46 cm3.

In pediatric gynecology, as in adults, X-ray examination of the skull and extremely rarely (according to strict indications) – hysteroshingingography are used. It is carried out with the help of a special small baby tip in case of suspected tuberculosis of the genitalia or in case of abnormal development of the genital organs in girls older than 14-15 years.

Of great importance is the X-ray examination of the hands, which is carried out to determine the bone age with its comparison with passport data. There are specially designed tables in which the dates and sequence of the appearance of ossification nuclei and the closure of growth zones depending on age are indicated.

In children, as in adults, CT and MRI are used for differential diagnosis. In young children, studies are conducted using parenteral drug sleep.

To conduct hysterosalpingography, hysteroscopy, diagnostic curettage and laparoscopy, CT and MRI, you must obtain the consent of the girl’s parents, about which you should make an appropriate entry in the history of the disease.

In addition to these methods of examination, for the diagnosis of a number of gynecological diseases, cytogenetic research is used (determination of sex chromatin, according to indications – karyotype). It is indicated for violations of somatic and sexual development (violation of sexual differentiation, delayed sexual development, etc.).

local_offerevent_note January 29, 2019

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