Office Gynecology for the PCP
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1 Office Gynecology for the PCP Hatim Omar, MD Professor, Pediatrics, Obstetrics/Gynecology Chief, Division of Adolescent Medicine KY CLINIC, Rm. L412, University of Kentucky Lexington, KY Tel , Fax
2 Disclosure No conflict of interest to report
3 Objectives Common gynecologic concerns in the pediatric & adolescent population Incorporating gynecologic health in primary care
4 Key Points The prepubertal exam Postmenarcheal Girls (time permitting) Incorporating gynecologic health in everyday practice SOME SLIDES BELONG TO OTHER AUTHORS AND CREDIT IS GIVEN WHERE APPROPRIATE
5 General Considerations Various gynecologic conditions in prepubertal girls may present to any pediatric office They are worrisome to parents, child and medical providers They need appropriate history taking skills and expert examination
6 General Considerations History taking issues Preparation for examining a prepubertal girl Anatomic variations Knowledge of state & federal laws Why is the patient being seen Focus of presentation: Is there additional concern?
7 ABUSE
8 ABUSE
9 ABUSE
10 Abuse
11 TERMINOLOGY
12 Supine frog-leg diagram
13 Labial separation-diagram
14 Labial traction-diagram
15 Prone knee-chest position
16 The Exam: NORMAL HYMEN
17 Hymen: Frog leg Vs. Knee chest
18 Hymen: Frog leg Vs. Knee chest
19 Hymeneal tags & Vaginal Ridges
20 Hymeneal tags & Vaginal Ridges
21 CLASSIFICATION Erythema Itching and burning Vulvar rash Vaginal bleeding Vaginal discharge Something does not look right!
22 ERYTHEMA Nonspecific vulvovaginitis (poor hygiene) Diaper dermatitis Bacterial vulvovaginitis Early stages of STD s Estrogenization UTI
23 Nonspecific Vulvovaginitis
24 Bacterial VV
25 ESTROGENIZATION
26 ITCHING & BURNING UTI Nonspecific vulvovaginitis Bacterial vulvovaginitis Pinworm infestation Lichen Sclerosus Foreign body
27 Bacterial VV: E. Coli
28 Parasitic VV
29 Parasitic VV
30 Lichen Sclerosus & Sleeve-like hymen
31 Foreign Body
32 VULVAR RASH Diaper dermatitis Lichen Sclerosus Vulvovaginitis Contact dermatitis Drug-induced eruption Psoriasis Molluscum Contagiosum
33 Contact Dermatitis
34 Drug-induced eruption
35 Psoriasis
36 Molluscum Contagiosum
37 VAGINAL BLEEDING Urethral prolapse Genital prolapse Foreign body Vulvovaginitis (bacterial, pinworm etc.) Tumors/endocrine causes Accidental Trauma
38 Urethral Prolapse
39 Genital Prolapse
40 Prolapse
41 Foreign Body
42 Sarcoma Butroyides
43 Accidental Trauma (labial Lacer.)
44 Accidental Trauma (Straddle Injury)
45 Accidental Trauma (Straddle Injury)
46 VAGINAL DISCHARGE Foreign Body Vulvovaginitis Estrogenization STD s Anatomic abnormalities (Fistula)
47 Foreign Body
48 Physiologic Leucorrhea
49 Nonspecific VV
50 MISCELLANEOUS CONDITIONS Hemangioma Impetigo Abscess/hematoma Hernia (inguinal) Labial agglutination Congenital anomalies
51 Labial Hematoma
52 Hemangioma (Cavernous; Capillary)
53 Impetigo
54 Inguinal Hernia
55 Abscess following Trauma
56 Labial Agglutination
57 Labial Agglutination
58 Labial Agglutination
59 Labial Agglutination
60 Imperforate Hymen
61 Unilateral Labial Hypertrophy
62 Longitudinal Vaginal Septum
63 Hymenal Septum
64 Hymenal Septum- After Resection
65 Benign Hypertrophy
66 CLITOROMEGALY
67 Behcet Syndrome
68 Failure of Midline Fusion
69 WARTS
70 WARTS
71 Micro-perforate Hymen
72 Sleeve-like Hymen
73 Sleeve-like Hymen
74 Paraurethral Cyst
75 Vaginal Septum
76 Conclusion Thorough history is crucial Good exam without hurting patient Do not make conclusions you are not sure about and avoid using the term: GU exam WNL Ask for help as needed Consider sexual abuse in cases of physical abuse
77 Keys to exam Make genital inspection part of every routine exam. That will decrease anxiety when a symptom is present Routinely inspecting the genitalia will help the PCP learn the vast number of normal anatomic variations and avoid misdiagnosing a normal finding as pathology
78 Postmenarcheal Girls Increased estrogenization changes the appearance of the external genitalia, especially the hymen & labia Sexual activity also may contribute to changes in anatomical appearance
79 Normal adolescent hymen
80 Estrogenized hymen, physiologic leucorrhea
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101 Urethral prolapse and hymenal defect
102 An imperforate hymen combined with a hematocolpos in a pubertal girl (pubic hair shaved).
103 An 11 year old girl with an imperforate hymen and mucocolpos.
104 Imperforate hymen
105 Sexual Abuse/Rape
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