Gynecological Examination of a Prepubertal Child

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 (fig. 4).

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.