Gynecologic Clinical Examination of the Child and Adolescent

Elisabeth Thibaud Unité d'Endocrinologie et de Gynécologie Pédiatriques, Hôpital Necker-Enfants Malades, Paris, France

Clinical examination is always necessary and most of the time is sufficient to diagnose and treat the child's gynecological problems. A pelvic ultrasound can often be useful.

Evidence Leading to Gynecological Examination

Reasons for undertaking a gynecological examination include:

(1) Gynecological complaints: vaginal discharge, pruritus, vulval or abdominal pains, and bleeding indicating there may be an infection, tumor or malformation.

(2) Endocrine reasons: signs of estrogen exposure or androgenization; ambiguous genitalia observed during examination.

(3) Suspected or confirmed sexual abuse. The physician is increasingly asked to look for and describe objective evidence of abuse.

Preparation for the Examination

Gynecological examination of the child is very simple and painless. The gynecologist must be very familiar with the anatomy and physiology of the genitalia before and during puberty. The child must be calm and cooperative, which is possible with careful preparation of the examination and attention focused on the child and her mother. The child should therefore be asked to explain in her own words the reason for the visit. If, as in most cases, the mother or accompanying adult begins to speak in the child's place, the physician must make sure the child listens, understands and nods to what is being said regarding her problem. The prerequisite for a well-accepted, non-traumatic and even therapeutic gynecological examination is the respect shown to the child by choosing her as the privileged and active interlocutor. During the examination, the mother must stay if the child is very young. Between the ages of 10 and 13, the child's wish must be respected. Beyond 13 years of age, the teenager must be seen alone.

The Examination

Complete pediatric assessment as well as palpation of the breasts must precede the gynecological examination itself.

Figures Fig. 1. Child's position for gynecological examination. Fig. 2. Vulval examination: separation of labia majora by pulling the inferior part downward and laterally. Fig. 3. Vulva examination: separation of labia majora by pulling them anteriorly. Fig. 4. Prepubertal vulva. Fig. 5. Configuration of hymen in prepubertal girls: (a) annular hymen, (b) crescentic hymen, and (c) redundant hymen [according to 5].