1. Paediatric gynaecology • Special patients: need special approach! • Selected topics for this presentation: • Examination of the prepubertal child and adolescent • Paediatric vulvovaginal conditions • Lower abdominal mass • Contraception for adolescents

2. Examination of the prepubertal child 2 • Principles: Trust will lead to improved cooperation • Private, peaceful, unhurried: respect wishes of the child • History:from parents/care providers and child herself • Key issues: --Growth and development • Childhood and other illnesses • Family structure • Friends, play patterns, “best friend” • Molestation

3. Examination 3 • Do not press child down! • Remember anatomical differences between child and adult • Standard systemic examination • Gynaecologic examination: frog-legged position (on bed or parent’s lap) better than knee-chest • Thin catheter: MCS specimens • Single finger PR when required • EUA if trauma or office examination does not work out

4. Examination of adolescent 4 • Principles:teach patient concept of doctor-patient relationship and privacy • See patient on her own, let her speak • History:standard systemic history • Key issues: pubertal development, menstruation, tampon use, sexual activity (voluntary or not) • Examination: standard technique • Occasional use of “virgo” speculum • PR or 1 finger PV

5. Vulvovaginal conditions 5 • Common; can usually sort out with simple tests • 1 Bleeding • Vaginitis: Shigella, Strept, E coli, threadworm, candida may all cause blood stained discharge • Usually preceding watery diarrhoea • Rx; Antibiotics + topical oestrogens for 1 week

6. Bleeding (continued) 6 • Foreign body: chronic discharge with bleeding. Perform PR and MCS of discharge, and for vaginoscopy if in doubt. Remove objects, requently under GA. Assist healing with topical oestrogen • Trauma • Sarcoma botryoides: rare; mass with bleeding: refer • Urethral mucosal prolapse: common, looks like tumour. Oedema, necrosis, inflammation. Caused by hypo-oestrogenism. Rx: oestrogen cream 2 weeks, if necrotic excise dead tissue

7. Vulvovaginal conditions 7 • 2 Abnormal appearance • Labial adhesions: hipo-oestrogenism and mild vulvitis: 80% asymptomatic, noted by mother. May separate at examination, assist with oestrogen cream. • Imperforate hymen and hymen variants/cysts • Lichen sclerosus • Condylomata acuminata

8. Vulvovaginal conditions (continued) 8 • 3 Discharge • Threadworm • Chemical irritants • Candidiasis • Pyogenic infection: gram + and – organisms, chlamydia and anaerobes: specimen for culture and then specific Rx.

9. Lower abdominal mass in a child 9 • Clinical: asymptomatic swelling / bladder symptoms / pain / hormonal changes / complications • Tests: ultrasound, beta-hCG • Principles of treatment: most are benign: longitudinal incision, inspect, washing, USO. Preserve fertility if possible. If malignant: refer for chemotherapy

10. Contraception for adolescents 10 • Problems: adolescent sexual behaviour irregular, unplanned, fears and anxieties, poor compliance • Law: what can doctor do • Principles: by the time help is required, patient is already sexually active • Information on sex, STD, HIV, pregnancy • Motivate for proper pill use and follow-up • Motivate for abstinence: do not moralise