Genital Examination of the Prepubertal Female: Essentials for Pediatric Nurse Practitioners.

Abstract

INSTRUCTIONSTo obtain continuing education credit:1.Read the article carefully.2.Read each question and determine the correct answer.3.Visit PedsCESM, ce.napnap.org , to complete the online Posttest and evaluation.4.You must receive 70% correct responses to receive the certificate.5.Tests will be accepted until October 31, 2023.OBJECTIVES1.Describe prepubertal genital examination preparation and techniques.2.Discuss normal prepubertal hymenal variants.3.Identify hymenal variants requiring referral to pediatric gynecology.4.Discuss common prepubertal gynecologic problems.5.Identify genital examination findings concerning for abuse/trauma.Posttest QuestionsContact hours: 1.0Passing score: 70%This continuing education activity is administered by the National Association of Pediatric Nurse Practitioners (NAPNAP) as an Agency providing continuing education credit. Individuals who complete this program and earn a 70% or higher score on the Posttest will be awarded 1.0 contact hours.Earn FREE CE Contact Hours OnlineContact Hours for this online activity are FREE for NAPNAP Members. Non-Members will be charged a fee of $10 to receive contact hours for this online activity through PedsCESM. Payment can be made by credit card through PedsCESM.1.To take the Posttest for this article and earn contact hours, please go to PedsCESM at ce.napnap.org .2.In the Course Catalog, search for the name of the CE article.3.If you already have an account with PedsCESM, log in using your username and password. If you are a NAPNAP member, log in with your username and password. If you are a first-time user and NAPNAP nonmember, click on “New Customer? Click Here.”4.Once you have successfully passed the Posttest and completed the evaluation form, you will be able to print out your certificate immediately. To obtain continuing education credit:1.Read the article carefully.2.Read each question and determine the correct answer.3.Visit PedsCESM, ce.napnap.org , to complete the online Posttest and evaluation.4.You must receive 70% correct responses to receive the certificate.5.Tests will be accepted until October 31, 2023. 1.Describe prepubertal genital examination preparation and techniques.2.Discuss normal prepubertal hymenal variants.3.Identify hymenal variants requiring referral to pediatric gynecology.4.Discuss common prepubertal gynecologic problems.5.Identify genital examination findings concerning for abuse/trauma. Posttest Questions Contact hours: 1.0 Passing score: 70% This continuing education activity is administered by the National Association of Pediatric Nurse Practitioners (NAPNAP) as an Agency providing continuing education credit. Individuals who complete this program and earn a 70% or higher score on the Posttest will be awarded 1.0 contact hours. Earn FREE CE Contact Hours Online Contact Hours for this online activity are FREE for NAPNAP Members. Non-Members will be charged a fee of $10 to receive contact hours for this online activity through PedsCESM. Payment can be made by credit card through PedsCESM.1.To take the Posttest for this article and earn contact hours, please go to PedsCESM at ce.napnap.org .2.In the Course Catalog, search for the name of the CE article.3.If you already have an account with PedsCESM, log in using your username and password. If you are a NAPNAP member, log in with your username and password. If you are a first-time user and NAPNAP nonmember, click on “New Customer? Click Here.”4.Once you have successfully passed the Posttest and completed the evaluation form, you will be able to print out your certificate immediately. The gynecologic assessment in prepubertal children is an essential element of a thorough physical examination. It is not unusual for pediatric health care providers, including pediatric nurse practitioners (PNPs), to feel challenged by assessing for gynecologic signs and symptoms and performing a physical examination of the external genitalia in prepubertal girls (Bhoopatkar et al., 2017Bhoopatkar H. Wearn A. Vnuk A. Medical students’ experience of performing female pelvic examinations: Opportunities and barriers.Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017; 57: 514-519Crossref PubMed Scopus (11) Google Scholar; Dabson et al., 2014Dabson A.M. Magin P.J. Heading G. Pond D. Medical students’ experiences learning intimate physical examination skills: A qualitative study.BMC Medical Education. 2014; 14: 39Crossref PubMed Scopus (24) Google Scholar; McBain et al., 2016McBain L. Pullon S. Garrett S. Hoare K. Genital examination training: Assessing the effectiveness of an integrated female and male teaching programme.BMC Medical Education. 2016; 16: 299Crossref PubMed Scopus (4) Google Scholar). The benefits of routine genital examinations have been discussed in the literature, including increasing patient and caregiver comfort with an examination, improved health care provider skill and confidence with examination and diagnostic assessment, providing a baseline for future examinations, and documentation of previously undiscovered anomalies (Johnson, 2002Johnson C.F. Child maltreatment 2002: Recognition, reporting and risk.Pediatrics International. 2002; 44: 554-560Crossref PubMed Scopus (52) Google Scholar). This continuing education article will discuss genital examination preparation and techniques, normal prepubertal hymenal variants, common prepubertal gynecologic problems, and genital examination findings concerning abuse. Gathering a focused gynecologic history from birth to present should include the standard health care queries, including a history of congenital abnormalities, subsequent genital complaints, infections, especially sexually transmitted infections, lesions, rashes, discharge, pain/discomfort, bleeding, or injuries (Hornor, 2007Hornor G. Genitourinary assessment: An integral part of a complete physical examination.Journal of Pediatric Health Care. 2007; 21: 162-170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). There is additional information that should be gathered. Explore genital care practices with caregivers. See Box 1 for questions to elicit information regarding genital care practices. The PNP must then determine if the practices are age-appropriate or indicate an inappropriate emphasis on genital care (Hornor, 2007Hornor G. Genitourinary assessment: An integral part of a complete physical examination.Journal of Pediatric Health Care. 2007; 21: 162-170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). Inappropriate genital care can result in negative psychological and even physical consequences for children; they can be a form of medical child abuse (Hornor and Ryan-Wenger, 1999Hornor G. Ryan-Wenger N.A. Aberrant genital practices: An unrecognized form of child sexual abuse.Journal of Pediatric Health Care. 1999; 13: 12-17Abstract Full Text PDF PubMed Scopus (1) Google Scholar; Hornor, 2021Hornor G. Medical child abuse: Essentials for pediatric health care providers.Journal of Pediatric Health Care. 2021; 35: 644-650Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Anticipatory guidance should also address any caregiver concerns regarding sexual behaviors. Sexual behaviors in prepubertal children that are considered normal/age-appropriate sexual behaviors versus problematic sexualized behaviors are discussed in Box 2. Finally, explore if the caregiver has any concerns about sexual abuse, including previous concerning statements made by the child, family history of sexual abuse, or exposure to a known sexual abuse perpetrator (Hornor, 2007Hornor G. Genitourinary assessment: An integral part of a complete physical examination.Journal of Pediatric Health Care. 2007; 21: 162-170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). BOX 1Questions to elicit information about genital care practices 1Is your child independent with toileting, or are you involved with some aspect of their toileting needs?2Is your child independent with bathing, or do you regularly perform some aspects of care during the bath or shower?3Describe how you bathe your child's genitals?4Do you ever need to inspect your child's genitals? Why?5Describe how you inspect your child's genitals.6Do you ever use medications or creams on your child's genital? If yes, why and how frequently? Do you consult with a health care provider before using the medications or creams?Note. Hornor and Ryan-Wenger, 1999Hornor G. Ryan-Wenger N.A. Aberrant genital practices: An unrecognized form of child sexual abuse.Journal of Pediatric Health Care. 1999; 13: 12-17Abstract Full Text PDF PubMed Scopus (1) Google Scholar.BOX 2Sexual behaviors in prepubertal childrenNormal/age-appropriate behaviorsMasturbationTouching own genitalsSex play involvingAge mates (4 years or < age difference)Touching and looking at genitalsProblem sexualized behaviorsObject insertion into another child's vagina or anusSex play involving one or more of the following•4 years age difference between children•Oral-genital contact•Oral-anal contact•Anal-genital contact•Genital-genital contact•Digital penetration of vagina/anus•Force/threat/bribes involvedNote. Hornor, 2007Hornor G. Genitourinary assessment: An integral part of a complete physical examination.Journal of Pediatric Health Care. 2007; 21: 162-170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar. 1Is your child independent with toileting, or are you involved with some aspect of their toileting needs?2Is your child independent with bathing, or do you regularly perform some aspects of care during the bath or shower?3Describe how you bathe your child's genitals?4Do you ever need to inspect your child's genitals? Why?5Describe how you inspect your child's genitals.6Do you ever use medications or creams on your child's genital? If yes, why and how frequently? Do you consult with a health care provider before using the medications or creams? Note. Hornor and Ryan-Wenger, 1999Hornor G. Ryan-Wenger N.A. Aberrant genital practices: An unrecognized form of child sexual abuse.Journal of Pediatric Health Care. 1999; 13: 12-17Abstract Full Text PDF PubMed Scopus (1) Google Scholar. Normal/age-appropriate behaviors Masturbation Touching own genitals Sex play involving Age mates (4 years or < age difference) Touching and looking at genitals Problem sexualized behaviors Object insertion into another child's vagina or anus Sex play involving one or more of the following•4 years age difference between children•Oral-genital contact•Oral-anal contact•Anal-genital contact•Genital-genital contact•Digital penetration of vagina/anus•Force/threat/bribes involved Note. Hornor, 2007Hornor G. Genitourinary assessment: An integral part of a complete physical examination.Journal of Pediatric Health Care. 2007; 21: 162-170Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar. Each PNP develops a method to progress efficiently and confidently through the genital examination. However, basic principles exist to guide the genital examination in prepubertal females. First, caregiver understanding and assent are vital as anxiety on their part is easily transferred to the child. It is important that the child be relaxed during the examination; distracting conversation, use of toys or books, or bubbles are often helpful. A genital examination requiring physical or psychological force should be avoided as such force can develop fear and anxiety in both child and caregiver (Sugar and Graham, 2006Sugar N.F. Graham E.A. Common gynecologic problems in prepubertal girls.Pediatrics in Review. 2006; 27: 213-223Crossref PubMed Scopus (39) Google Scholar). The genital examination begins with a simple matter-of-fact explanation of the examination to the caregiver and child. Explain that the child should be checked head to toe to ensure that they are healthy and growing as they should, so now their private parts will be examined. This provides an excellent opportunity to educate both child and caregiver regarding the concept of private parts and sexual abuse (Box 3). Discuss with caregivers the importance of teaching their children the correct anatomical names for their private parts. Inform the caregiver that this is to help ensure that children who experience sexual abuse can disclose victimization in words that can be understood by any adult (Hornor, 2021Hornor G. Medical child abuse: Essentials for pediatric health care providers.Journal of Pediatric Health Care. 2021; 35: 644-650Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Educate caregivers that children who experience sexual abuse rarely have any physical findings on examination (Adams et al., 2018Adams J.A. Farst K.J. Kellogg N.D. Interpretation of medical findings in suspected child sexual abuse: An update for 2018.Journal of Pediatric and Adolescent Gynecology. 2018; 31: 225-231Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). BOX 3Child and caregiver sexual abuse education 1Explain to the child that everyone has private parts—parts of their body that no one should touch, kiss, tickle, hurt, or put anything in2What are your private parts? Have the child verbally tell you or point to their private parts3What should you do if anyone bothers or tries to bother your private parts?4Do you tell or keep it a secret?5Who could you tell if anyone bothered your private parts? Ensure the child can name at least two adults6You could also tell your teacher, nurse practitioner (doctor, nurse, etc.), or a policeman7Has anyone ever touched, tickled, kissed, or hurt your private parts?8Who is allowed to help you with your private parts if you need help? 1Explain to the child that everyone has private parts—parts of their body that no one should touch, kiss, tickle, hurt, or put anything in2What are your private parts? Have the child verbally tell you or point to their private parts3What should you do if anyone bothers or tries to bother your private parts?4Do you tell or keep it a secret?5Who could you tell if anyone bothered your private parts? Ensure the child can name at least two adults6You could also tell your teacher, nurse practitioner (doctor, nurse, etc.), or a policeman7Has anyone ever touched, tickled, kissed, or hurt your private parts?8Who is allowed to help you with your private parts if you need help? An adequate light source and knowledge of normal prepubertal genital anatomy are necessary to perform an accurate genital examination (Figure 1). The child should be relaxed, lying supine in the frog-leg or butterfly position. Stirrups can also be used. If the young child is anxious or reluctant, the caregiver could sit on the examination table with the child supine on their lap. The child should always be offered the presence of a supportive caregiver for the anogenital examination. There may be instances when the accompanying caregiver, such as the father, is not comfortable being in the examination room for the genital examination. It is best practice to use a staff chaperone, such as a medical assistant or nurse, during the anogenital examination. Chaperones play an important role in assuring the safety of both patient and provider (Maghfour et al., 2021Maghfour J. Chen L. Olson J. Roach C. Murina A. 27624 U.S. academic dermatologists’ attitudes and perceptions toward chaperone use during genital examinations.Journal of the American Academy of Dermatology. 2021; 85: AB157Abstract Full Text Full Text PDF Google Scholar). The PNP must understand that the appearance of normal female genital anatomy is influenced by the presence of estrogen in both adolescents and infants. Note Figure 2 for changes to female genitalia occurring with puberty. As the female enters puberty, estrogen is released, resulting in increased elasticity of the hymen and other genital structures, hymenal thickening, and redundancy, increased moisture, and loss of sensitivity/pain to touch (Mishori et al., 2019Mishori R. Ferdowsian H. Naimer K. Volpellier M. McHale T. The little tissue that couldn't - Dispelling myths about the hymen's role in determining sexual history and assault.Reproductive Health. 2019; 16: 74Crossref PubMed Scopus (8) Google Scholar). These estrogen changes can occur before menarche. Newborn females are also affected by maternal estrogen. The hymen is thickened, redundant, and elastic. This estrogen effect typically wanes by 2-years-old, but girls aged 7–8 years may still have persistent estrogen effects (Sugar and Graham, 2006Sugar N.F. Graham E.A. Common gynecologic problems in prepubertal girls.Pediatrics in Review. 2006; 27: 213-223Crossref PubMed Scopus (39) Google Scholar).Figure 2Adolescent estrogenized hymen.(This figure appears in color online at www.jpedhc.org.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Visualization of the hymenal opening is an important element of the examination. Achieving the opening of the hymen can be challenging, especially if the child is tense. Separation of the labia majora will allow visualization of the clitoris, labia minora, urethra, and posterior fourchette. Occasionally, the mere separation of the labia majora will allow visualization of the hymenal opening. However, a combination of separation and labial traction is often required. Labial traction refers to the examiner grasping the labia majora bilaterally with the thumb and forefinger and pulling the labia toward the examiner while simultaneously separating the labia. There are times when it is necessary to release traction and reapply to achieve the opening of the hymen. The hymen can also be floated with a few drops of normal saline or water to achieve floating the hymen to allow for visualization of the opening. The prepubertal hymen should never be touched with a cotton swab or any object to achieve opening as the prepubertal hymen is very sensitive/painful to touch. The vulvar vestibule is between the labia minora and the hymenal/vaginal opening (Nguyen and Duong, 2021Nguyen J. Duong H. Anatomy, abdomen and pelvis, female external genitalia. Stat Pearls Publishing, Treasure Island, FL2021Google Scholar). The face of a clock should be used when describing examination findings related to all structures within the vulvar vestibule, including the hymen (Mishori et al., 2019Mishori R. Ferdowsian H. Naimer K. Volpellier M. McHale T. The little tissue that couldn't - Dispelling myths about the hymen's role in determining sexual history and assault.Reproductive Health. 2019; 16: 74Crossref PubMed Scopus (8) Google Scholar). Variations in normal hymen morphology exist. These variations have been present since birth and do not indicate trauma or sexual abuse. The hymen may be described as annular with hymenal tissue present 360° around the opening from 12 o'clock to 12 o'clock (Figure 3) or crescentic with areas of missing hymen above 3 o'clock and 9 o'clock (Figure 4). Another less common variation in normal hymenal morphology is the redundant or sleeve-like hymenal opening (Figure 5).Figure 4Crescentic hymen.(This figure appears in color online at www.jpedhc.org.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Redundant hymen.(This figure appears in color online at www.jpedhc.org.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) There are also hymenal morphologies since birth, again not concerning for trauma or sexual abuse, requiring further examination to determine if medical intervention is indicated. One such morphology is the septate hymen (Figure 6). Most commonly, hymenal septa are vertical (longitudinal); however, a horizontal septum can be noted on examination. Patients with a horizontal hymenal septum require referral to pediatric gynecology (American College of Obstetricians and Gynecologists 2019American College of Obstetricians and GynecologistsDiagnosis and management of hymenal variants: ACOG Committee Opinion, number 780.Obstetrics and Gynecology. 2019; 133: e372-e376Crossref PubMed Scopus (14) Google Scholar). When a vertical septate hymenal is noted, it is crucial that the PNP determine that a cotton swab can be passed behind the septum. This ensures that the septum does not extend into the vagina, running the length of the vaginal canal, thus creating duplicate vaginas (North American Society for Pediatric and Adolescent Gynecology 2020North American Society for Pediatric and Adolescent GynecologyHymen variations.2020https://www.naspag.org/assets/docs/hymen_variations_2020.pdfGoogle Scholar). If cotton swab passage is not possible, referral to pediatric gynecology is indicated. Other normal hymenal morphologies requiring referral to pediatric gynecology are microperforated, with a very small hymenal opening (Figure 7); imperforate, with no hymenal opening (Figure 8); and cribriform, with multiple small hymenal openings. These children may require a hymenectomy to remove the extra hymenal tissue to ensure that the vaginal opening is adequate for menstruation, tampon use, and vaginal intercourse (North American Society for Pediatric and Adolescent Gynecology 2020North American Society for Pediatric and Adolescent GynecologyHymen variations.2020https://www.naspag.org/assets/docs/hymen_variations_2020.pdfGoogle Scholar). When a girl reaches menarche, an imperforate hymen prevents the exit of menstrual blood and normal vaginal secretions from the vagina, known as hematocolpos, often resulting in cyclic pelvic/abdominal pain or difficulty urinating (American College of Obstetricians and Gynecologists 2019American College of Obstetricians and GynecologistsDiagnosis and management of hymenal variants: ACOG Committee Opinion, number 780.Obstetrics and Gynecology. 2019; 133: e372-e376Crossref PubMed Scopus (14) Google Scholar; North American Society for Pediatric and Adolescent Gynecology 2020North American Society for Pediatric and Adolescent GynecologyHymen variations.2020https://www.naspag.org/assets/docs/hymen_variations_2020.pdfGoogle Scholar). In addition, girls with microperforated and imperforated hymenal morphology are prone to recurrent urinary tract infections, vulvovaginitis, and ascending pelvic infections (Tardieu and Appelbaum, 2018Tardieu S.C. Appelbaum H. Microperforate hymen and pyocolpos: A case report and review of the literature.Journal of Pediatric and Adolescent Gynecology. 2018; 31: 140-142Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar). There are also instances when a hymenectomy is indicated for children with septate hymens that are not associated with vaginal septa if the extra hymenal tissue is yielding difficulties with tampon use or sexual intercourse once they have entered puberty (North American Society for Pediatric and Adolescent Gynecology 2020North American Society for Pediatric and Adolescent GynecologyHymen variations.2020https://www.naspag.org/assets/docs/hymen_variations_2020.pdfGoogle Scholar). Although an imperforated, microperforated, or septated hymen can be diagnosed at birth, and the American Academy of Pediatrics recommends that a genital examination be completed at every well-child visit (Hagan et al., 2017Hagan J. Shaw J. Duncan P. Bright futures: Guidelines for health supervision of infants, children, & adolescents.4th ed. American Academy of Pediatrics, Elk Grove Village, IL2017Crossref Google Scholar), diagnosis commonly occurs in puberty following symptom development (North American Society for Pediatric and Adolescent Gynecology 2020North American Society for Pediatric and Adolescent GynecologyHymen variations.2020https://www.naspag.org/assets/docs/hymen_variations_2020.pdfGoogle Scholar). Genital examinations should be performed at every well-child check, including visualization of the hymenal opening to determine morphology.Figure 7Microperforate hymen.(This figure appears in color online at www.jpedhc.org.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Imperforate hymen.(This figure appears in color online at www.jpedhc.org.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) The size of the hymenal opening varies widely and is of no significance in distinguishing sexually abused from nonabused girls (Adams et al., 2018Adams J.A. Farst K.J. Kellogg N.D. Interpretation of medical findings in suspected child sexual abuse: An update for 2018.Journal of Pediatric and Adolescent Gynecology. 2018; 31: 225-231Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). Mounds or bumps can be present anywhere along the hymenal rim (Adams et al., 2018Adams J.A. Farst K.J. Kellogg N.D. Interpretation of medical findings in suspected child sexual abuse: An update for 2018.Journal of Pediatric and Adolescent Gynecology. 2018; 31: 225-231Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). Also, hymenal notches or clefts of any depth may be noted above 3 o'clock or 9 o'clock (anterior hymenal rim) and shallow notches or clefts not extending to the base of the hymen at or below 3 o'clock and 9 o'clock (posterior hymenal rim) may be present. Tags of tissue may also extend from anywhere on the hymenal rim. These findings are all normal variants with no clinical significance (Adams et al., 2018Adams J.A. Farst K.J. Kellogg N.D. Interpretation of medical findings in suspected child sexual abuse: An update for 2018.Journal of Pediatric and Adolescent Gynecology. 2018; 31: 225-231Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). Incomplete fusion of the perineum can occur during embryonic development resulting in a defect known as a failure of midline fusion or perineal groove (Sugar and Graham, 2006Sugar N.F. Graham E.A. Common gynecologic problems in prepubertal girls.Pediatrics in Review. 2006; 27: 213-223Crossref PubMed Scopus (39) Google Scholar). This defect has no clinical significance or known complications. Failure of midline fusion (Figure 9) appears as a wedge of visible submucosa in the perineum near the anus or the posterior fourchette. The defect can be mistaken for an acute wound; however, the finding is symmetrical with no signs of healing and no pain on palpation. Reexamination in 1-week can confirm that an acute wound is indeed not present, and thus, the lesion is a failure of midline fusion. One of the most common gynecologic conditions noted in prepubertal females is labial adhesions, occurring in approximately 22% of girls aged 3 months to 6 years (Muram, 1999Muram D. Treatment of prepubertal girls with labial adhesions.Journal of Pediatric and Adolescent Gynecology. 1999; 12: 67-70Abstract Full Text PDF PubMed Scopus (67) Google Scholar). Labial adhesions typically develop as the result of genital irritation, such as occurring in chronic diaper dermatitis (Sugar and Graham, 2006Sugar N.F. Graham E.A. Common gynecologic problems in prepubertal girls.Pediatrics in Review. 2006; 27: 213-223Crossref PubMed Scopus (39) Google Scholar). The labia fuse starts at the posterior introitus and can be minimal with no clinical significance or extensive blocking of the entire introitus (Figure 10). Most labial adhesions are asymptomatic. However, symptoms can develop as the result of the accumulation of urine behind the partially fused labia and include urinary tract infections, vulvovaginitis, pain, and postvoid dripping of urine (Dowlut-McElroy et al., 2019Dowlut-McElroy T. Higgins J. Williams K.B. Strickland J.L. Treatment of prepubertal labial adhesions: A randomized controlled trial.Journal of Pediatric and Adolescent Gynecology. 2019; 32: 259-263Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar). Treatment is only recommended for symptomatic individuals. Treatment involves lightly applying topical estrogen cream to the adhesions twice daily for 2 weeks and then once daily for 2 weeks (Seattle Children's Hospital 2020Seattle Children's Hospital. (2020). Labial adhesions. Retrieved from https://www.seattlechildrens.org/pdf/pe1149.pdfGoogle Scholar). Caregivers should be advised that side effects such as breast bud development or vaginal bleeding can develop, which resolve on cessation of treatment. Vulvovaginitis is a common gynecologic complaint in prepubertal girls. Symptoms include vaginal discharge, pruritus, discomfort, and dysuria (Brander and McQuillan, 2018Brander E.P.A. McQuillan S.K. Prepubertal vulvovaginitis.CMAJ: Canadian Medical Association Journal. 2018; 190: E800Crossref PubMed Scopus (3) Google Scholar). Vulvovaginitis can be caused by physical, chemical, or infectious irritants (Sugar and Graham, 2006Sugar N.F. Graham E.A. Common gynecologic problems in prepubertal girls.Pediatrics in Review. 2006; 27: 213-223Crossref PubMed Scopus (39) Google Scholar). Most children with vulvovaginitis, 70% to 80%, have nonspecific physical or chemical irritant vulvovaginitis requiring only reassurance and anticipatory guidance (Box 4) (Brander and McQuillan, 2018Brander E.P.A. McQuillan S.K. Prepubertal vulvovaginitis.CMAJ: Canadian Medical Association Journal. 2018; 190: E800Crossref PubMed Scopus (3) Google Scholar). Bacterial infections can also