Gynecological Examination of a Prepubertal Child
A full gynecological examination of the child mainly includes inspection of external genitalia and in some cases rectal examination. Vaginoscopic examination and samples are limited to certain cases.
The child must be comfortable. The best position is the frog-leg position: the child should be in a supine position, her legs flexed, with her knees apart and feet touching (
fig. 1). The physician should be sitting in front of her, with a lamp providing ample light from behind. A child under 2 years of age may sometimes be afraid of the table and can instead be examined in the same position on her mother’s lap. The abdomen, inguinal areas and labia majora are first inspected.
The physician should note the presence of pubic hair. The labia are then gently separated either by pulling the inferior part downward and laterally (fig. 2) or by pulling them anteriorly (fig. 3). The clinician should avoid a solely lateral maneuver, which puts a painful strain on the posterior fourchette and may split it, thus provoking a defensive reaction from the child and hindering further examination. The physician will note the size of the clitoris by pulling up the clitoral hood and inspecting it. This will enable the clinician to differentiate a clitoromegaly from a hood thicker than usual. A normal clitoral glans in a prepubertal child is on average 5mm in length and 3mm in transverse diameter and shows little variation after puberty (
A prepubertal child shows thin and sometimes short labia minora. They edge the vulva vestibulum, at the bottom of which the urethra and vagina open.
On each side of the urethra, Skene’s duct can be seen. Without estrogenization, the vulval mucosa appears thin and red and the perihymeneal tissue may look erythematous. The thick white substance noted in the anterior labia folds is called smegma, not to be mistaken for leukorrhea. The vaginal orifice is edged by the hymen, which varies in size and shape. The hymen will often gape open if the child is asked to take a deep breath or cough. If not, the best maneuver consists of gently pulling the labia anteriorly and laterally. The most often observed types of hymen are as follows
(fig. 5a–c): (a) the annular hymen with a hymeneal edge varying in size and an annular and regular orifice; (b) the crescentic hymen, the posterior rim of which looks like a crescent and whose ends are attached on the lateral vagina wall; there is no hymeneal suburethral tissue, and (c) the redundant hymen is the most common in girls under 3 years.
The hymeneal edge is large and fimbriated.
The first two types of hymen are most common from the age of 3 to the beginning of puberty. On average, the vaginal orifice measures 4–5 mm in girls until the age of 5 and remains under 10mm until the beginning of puberty.
These figures are given as an indication, the diameter of the vaginal orifice varying much with the position of the child, the degree of perineal relaxation, the hymen shape and the level of estrogenization.
A narrow and thin hymen does not completely cover the vaginal orifice, enabling examination of the anterior half or two thirds of it without resorting to endoscopy. The most appropriate maneuver is the one described above, which consists in gently pulling the labia majora anteriorly and laterally. The hymen opens and the vaginal axis is corrected. This maneuver is painless and easily accepted by the child. It may sometimes be difficult to visualize the free edge of the hymen and the vagina with certain types of hymens. Such is the case with redundant hymens, microperforate hymens with a suburethral orifice, and septate hymens. The physician will then use a small urethral catheter to unfold the hymeneal edge and look for hymeneal integrity and an opening
(fig. 6a, b).
Rectal examination is the following and last step, using the little finger until the age of 6. It is used to determine the existence and volume of the cervix.
The clinician will be able to palpate it on a small midline structure. It should measure about 5mm in transverse diameter. Ovaries are too small to be felt.
Any pelvic mass must evoke a cyst or tumor. The physician can then palpate the vagina and note any foreign body (tumor) or vaginal discharge.
Vaginoscopic examination must be limited to the identification of a tumor or foreign body when the clinical examination and ultrasound do not provide the origin of vaginal bleeding. A child’s vagina measures 5 cm in length. The vaginal mucosa appears red, thin and folded. It is very sensitive and petechial lesions may be caused by the vaginoscope. The cervix is small with a centered opening and flush with the vaginal vault, making it difficult to visualize.
Samples for culture purposes are sometimes necessary for bacteriological examination. These samples are required in case of vaginal leukorrhea when not caused by a foreign body. They are rarely necessary in the case of vulvitis unless specific and rare causes such as yeast infections, streptococcus, and so on, are suspected. Results must be interpreted according to the clinical context since the vaginal mucosa and vulva are the home of normal flora.
Once the perineum and rectum are inspected, the clinical examination is complete.
Child’s position for gynecological examination.
Vulval examination: separation of labia majora by pulling the inferior part downward and laterally.
Vulva examination: separation of labia majora by pulling them anteriorly.
Configuration of hymen in prepubertal girls: (a) annular hymen, (b) crescentic hymen, and (c) redundant hymen [according to 5].
Fig. 6. a Microperforate hymen. b Opening unfolded with small catheter.
Revision date: July 3, 2011
Last revised: by Jorge P. Ribeiro, MD