Common Gynecologic Problems in Prepubertal Girls

Abstract

1. Naomi F. Sugar, MD* 2. Elinor A. Graham, MD, MPH† 1. *Clinical Associate Professor, Department of Pediatrics, Division of General Pediatrics, University of Washington, Seattle, Wash 2. †Associate Professor, Department of Pediatrics, Division of General Pediatrics, University of Washington, Seattle, Wash After completing this article, readers should be able to: 1. Describe techniques to perform an adequate and gentle genital examination in a school-age girl. 2. Discuss the differential diagnosis for vaginal bleeding in the prepubertal girl. 3. Identify a strategy to diagnose and treat vaginitis in the prepubertal child. Assessing gynecologic symptoms and signs in prepubertal children can be a challenge for pediatricians. Adult pelvic examinations are a standard part of medical school education, and learning objectives for the American Board of Pediatrics emphasize knowledge of adolescent gynecology. Pediatric practice standards recommend routine external examinations for girls of all ages at health supervision examinations. Unfortunately, pediatricians often lack training in examination techniques, determination of normal findings, and gynecologic pathology of infants and prepubertal children. In the past decade, a high level of concern for child sexual abuse and emphasis on the sentinel role of pediatricians in recognizing abnormalities due to child abuse paradoxically has left pediatricians and other child health clinicians more anxious and uncomfortable in performing these examinations. However, although child sexual abuse is common, it rarely is diagnosed primarily by physical complaints. It is much more likely that a girl who is brought to the physician because of genital symptoms has either normal variant findings or a nontraumatic disorder. (1) The aim of this article is to review normal anatomy and physiology in infants and prepubertal children, emphasizing developmental changes, normal variants, and the differential diagnosis for common signs and symptoms. ### Infant and Toddler The newborn girl is affected by maternal estrogens that cross the placenta. Breast buds are usual, and a milky discharge from the nipples is not uncommon. Like her mother, the neonate may develop mastitis. Vaginal discharge is common in newborns, as are long hymenal tags that frequently are visible, extending outside the vestibule. The vaginal epithelium also demonstrates the estrogen …