Genital Tract Obstruction • Labial adhesions • Result of inflammation and erosion of superficial layers of mucosa (infection, dermatitis, mechanical trauma) agglutination • Usually < 1cm, may cover vaginal vestibule and rarely urethra • Usually asymptomatic; urine may be trapped further irritation extension of adhesion • Treatment, if desired • Estrogen cream BID x 2 wks, then QHS x 1 wk • Zinc oxide-based cream QHS x several months • NO Manual separation (OUCH!!) • Prevent recurrence (remove irritants, tx infections, hygiene) • True adhesions (first few months of life, no response to tx) need further evaluation
Genital Tract Obstruction • Imperforate Hymen • Thick membrane just inside the hymenal ring • Hydrocolpos - secondary to vaginal secretions • Midline swelling of lower abdomen that feels cystic • Whitish, bulging membrane at introitus • Hematocolpos • Infancy if neonatal withdrawal bleed/trauma • Late puberty • DDx of amenorrhea • Intermittent lower abdominal/back pain, progresses in severity • Difficulty in urination/defecation • Cystic swelling palpable on rectal exam • Treatment – excision of membrane • Not associated with other GU abnormalities
Genital Tract Obstruction • Vaginal atresia or agenesis • Transverse vaginal septum • Androgen insensitivity • Absence of cervix/uterus • Tumors • Obstructing mullerian malformations, with elements of duplication, agenesis, and/or incomplete fusion • Initial imaging with ultrasound, may need MRI
Genital Trauma • Prepubescent vs. adolescent/adult • Genital structures and pelvic supporting tissues more rigid and smaller • Increased risk of tearing with blunt or penetrating trauma, and of internal extension of injury
Genital Trauma • Superficial Perineal Injuries • Straddle injury – abrasion, contusion, or tear in and around clitorus and anterior labia majora or minora • Minor falls – simple perineal and vulval lacerations • Mild blunt trauma – usually at junction of labia minora and majora; also tears of labia majora or perineal body • Sexual abuse • Tears of posterior portion of hymen, porterior fourchette, or perineal body • Usually scant bleeding, mild discomfort or pain on urination • Management – supportive • Analgesia, topical bacteriostatic/anesthetic, sitz baths
Genital Trauma • Moderate blunt trauma • Perineal tears venous disruption hematomas (tense, round swellings) • Intense perineal pain; interfere with urination if periurethral • Also submucosal tears of vagina or mucosal separation with vaginal bleeding/hematoma (inspect vaginal orifice) • Moderate penetrating injuries • Result from falls onto sharp objects, rape, auto accidents • Perineal tears that extend into vagina, rectum, or bladder but do not breach peritoneum • May have deceptively minor external injuries
Genital Trauma • Indications for OR exploration/repair • Bleeding through vaginal orifice, vaginal hematoma, rectal bleeding/tenderness, abnormal sphincter tone, gross hematuria, inability to urinate • Obviates the need for extensive exam in ED/office
Genital Trauma • Severe trauma • Falls from heights on flat surfaces can simulate penetrating injury • Can disrupt pelvic vessels, mesentery, and intestine, w/ or w/out pelvic trauma • If peritoneal extension, patients complain of lower abdominal/perineal pain initially guarding/rebound hypovolemia • Prompt hemodynamic stabilization, imaging and surgical exploration and repair
Vulvovaginitis • Unestrogenized vaginal epithelium is thin, friable and more easily traumatized • Labia do not fully cover and protect the vaginal vestibule from friction and external irritants
Physiologic Leukorrhea Thin, white, nonodorous discharge without erythema Treatment - reassurance
PrepubertalVulvovaginitisNoninfectious etiologies • Poor hygeine • May see pieces of stool or toilet paper in perineum; soiled underwear • Sitz baths and careful cleansing after urination/defecation • Poor perineal aeration • Moisture from normal secretions, perspiration, swimming; incontinence • Obesity, tight clothing, nylon underwear • Secondary infection common after maceration; intertrigo • Contact dermatitis, allergic vulvitis • Itching is predominant sx; dysuria from excoriation • Acute - microvesicularpapular eruption, erythematous, edematous • Chronic – eczematoid with cracks, fissures, lichenification • Perfumed soaps or toilet paper, poison ivy, OTC/prescribed ointments/creams • Adolescents – feminine hygiene products, cosmetics, spermicides, douches
PrepubertalVulvovaginitisNoninfectious etiologies • Chemical irritants • Bubble bath, soaps, laundry detergents, fabric softeners, perfumed toilet paper • Infrequent diaper changing • Frictional trauma • Tight clothing, sporting activities (gymnastics, running), sand from sandboxes, excessive masturbation, shaving • If chronic, lichenification and atrophic changes
Prepubertal vulvovaginitisNoninfectious etiologies • Fistula • Vesicovaginal fistulas, ectopic ureters • Constantly wet perineum • Appendicitis • After rupture and abscess formation of a pelvic appendix, females may develop a purulent vaginal discharge caused by sympathetic inflammation of the vaginal wall.
Prepubertal VulvovaginitisNoninfectious etiologies • Vaginal foreign body • Profuse, foul-smelling, brownish/blood-streaked vaginal discharge • 3 to 8 year old, developmental delay, behavioral problems • Result of disturbed behavior or chronic sexual abuse • Toilet tissue, paper, cotton, crayons, small toys • Long latency period for inert materials • Direct vaginoscopy usually required • Under anesthesia or conscious sedation
DDx of Vulvovaginitis • Urethral prolapse • Dysuria, perineal pain, bleeding • AA, obese prepubertal girls • Constipation, coughing, crying may contribute • Red/purplish swollen, friable tissue overlying anterior introitus; doughnut shaped; tender • Estrogen cream, analgesics, tx underlying cause
DDx of Vulvovaginitis • Lichen sclerosus • Chronic dermatologic disorder involving perineum and perianal area • Etiology unknown • May be preceded by perineal itching or mild watery discharge • Small pink or white, flat-topped papular lesions on cutaneous and mucosal surfaces; coalesce to plaquelike, scaly lesions • May see vesiculation, superficial ulceration/excoriation with erythema, maceration, punctate bleeding (usu from scratching) • Progress to thin, atrophic, hypopigmented epithelium • Wax/wane for several years; resolves around puberty • Tx acute exacerbations with high-potency topical steroids
Prepubertal Vulvovaginitis Infectious etiologies • Respiratory/skin pathogens • Result of orodigital transmission • GAS • Abrupt onset of severe burning and dysuria • Sharply demarcated area of intense erythema • Seroanguineous or grayish-white d/c • S.pneumo and H. flu • Purulent d/c, vulvitis, vaginitis • Viral • Varicella, adeno, echovirus, measles, EBV • Folliculitis/impetigo • Poor hygiene, sweating, shaving, mechanical irritation
Prepubertal vulvovaginitisInfectious etiologies • GI pathogens • Shigella • No GI sx; 1/3 have diarrhea • Acute/chronic vaginal d/c, otherwise no sx • PE: purulent, blood-streaked d/c, vulvar and vaginal erythema • G-stain: PMN with GNR; pos cx diagnostic • High rate of coinfection with pinworms
Prepubertal vulvovaginitisInfectious etiologies • Pinworms • Enterobius vermicularis • May cause vaginal infection and discharge; usually a history of preceding perianal pruritus • Wet mount of vaginal secretions; if neg, do sticky tape test or empiric treatment
Prepubertal vulvovaginitisInfectious etiology • Candida • Rare in healthy prepubertal child • Risk factors: recent abx, poor perineal ventilation, DM, immunodeficiency, pregnancy, use of OCP • Pruritus, contact dysuria, dyspareunia • PE: diffuse erythema, thick white d/c; pink/white cobblestone plaques if chronic; satellite lesions • KOH prep-budding yeast; low vaginal pH • Topical azole antifungal cream or oral fluconazole (single dose) • Recurrent • Consider predisposing factor (HIV) • Other fungi (Torulopsis); do fungal culture
Prepubertal VulvovaginitisEvaluation • History • Dysuria, frequency, urgency, perianal pruritus • Duration • Recent respiratory, GI or urinary tract infections • Exposure to irritants • Bowel and bladder habits • Type of clothing worn • Recent activities (daily swimming) • Medications, topical agents • Caretakers (if abuse suspected) • Developmental, behavioral, environmental, medical hx
Prepubertal VulvovaginitisEvaluation • Physical exam • Degree ofpubertal development • Inguinal and abdominal exam • Rectal, perineal, vaginal inspection • Degree of inflammation/excoriation (may appear normal) • Examine underwear • No bathing 12 to 24 hours before exam • Send any vaginal d/c for testing; ua/culture
Prepubertal vulvovaginitisTreatment • Noninfectious • Removal of offending agent • Provide sufficient opportunities to urinate • Front-to-back wiping • Regular washing with mild soap; no scrubbing • Avoid skin/vaginal cosmetics, scented pads, bubble bath, fabric softeners, dryer sheets • Wear loose-fitting clothing; white cotton underwear
