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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

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genital tract obstruction
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 obstruction2
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 obstruction3
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
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 trauma5
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 trauma6
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 trauma7
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 trauma8
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
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
Physiologic Leukorrhea

Thin, white, nonodorous discharge without erythema

Treatment - reassurance

prepubertal vulvovaginitis noninfectious etiologies
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
prepubertal vulvovaginitis noninfectious etiologies12
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 vulvovaginitis noninfectious etiologies13
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 vulvovaginitis noninfectious etiologies14
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
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 vulvovaginitis16
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
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 vulvovaginitis infectious etiologies18
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 vulvovaginitis infectious etiologies19
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 vulvovaginitis infectious etiology
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 vulvovaginitis evaluation
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 vulvovaginitis evaluation22
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 vulvovaginitis treatment
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