Office Gynecology for the PCP

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Transcription:

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 40536-0284 Tel. 859-323-5643, Fax. 859-323-3795 Email: haomar2@uky.edu

Disclosure No conflict of interest to report

Objectives Common gynecologic concerns in the pediatric & adolescent population Incorporating gynecologic health in primary care

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

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

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?

ABUSE

ABUSE

ABUSE

Abuse

TERMINOLOGY

Supine frog-leg diagram

Labial separation-diagram

Labial traction-diagram

Prone knee-chest position

The Exam: NORMAL HYMEN

Hymen: Frog leg Vs. Knee chest

Hymen: Frog leg Vs. Knee chest

Hymeneal tags & Vaginal Ridges

Hymeneal tags & Vaginal Ridges

CLASSIFICATION Erythema Itching and burning Vulvar rash Vaginal bleeding Vaginal discharge Something does not look right!

ERYTHEMA Nonspecific vulvovaginitis (poor hygiene) Diaper dermatitis Bacterial vulvovaginitis Early stages of STD s Estrogenization UTI

Nonspecific Vulvovaginitis

Bacterial VV

ESTROGENIZATION

ITCHING & BURNING UTI Nonspecific vulvovaginitis Bacterial vulvovaginitis Pinworm infestation Lichen Sclerosus Foreign body

Bacterial VV: E. Coli

Parasitic VV

Parasitic VV

Lichen Sclerosus & Sleeve-like hymen

Foreign Body

VULVAR RASH Diaper dermatitis Lichen Sclerosus Vulvovaginitis Contact dermatitis Drug-induced eruption Psoriasis Molluscum Contagiosum

Contact Dermatitis

Drug-induced eruption

Psoriasis

Molluscum Contagiosum

VAGINAL BLEEDING Urethral prolapse Genital prolapse Foreign body Vulvovaginitis (bacterial, pinworm etc.) Tumors/endocrine causes Accidental Trauma

Urethral Prolapse

Genital Prolapse

Prolapse

Foreign Body

Sarcoma Butroyides

Accidental Trauma (labial Lacer.)

Accidental Trauma (Straddle Injury)

Accidental Trauma (Straddle Injury)

VAGINAL DISCHARGE Foreign Body Vulvovaginitis Estrogenization STD s Anatomic abnormalities (Fistula)

Foreign Body

Physiologic Leucorrhea

Nonspecific VV

MISCELLANEOUS CONDITIONS Hemangioma Impetigo Abscess/hematoma Hernia (inguinal) Labial agglutination Congenital anomalies

Labial Hematoma

Hemangioma (Cavernous; Capillary)

Impetigo

Inguinal Hernia

Abscess following Trauma

Labial Agglutination

Labial Agglutination

Labial Agglutination

Labial Agglutination

Imperforate Hymen

Unilateral Labial Hypertrophy

Longitudinal Vaginal Septum

Hymenal Septum

Hymenal Septum- After Resection

Benign Hypertrophy

CLITOROMEGALY

Behcet Syndrome

Failure of Midline Fusion

WARTS

WARTS

Micro-perforate Hymen

Sleeve-like Hymen

Sleeve-like Hymen

Paraurethral Cyst

Vaginal Septum

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

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

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

Normal adolescent hymen

Estrogenized hymen, physiologic leucorrhea

Urethral prolapse and hymenal defect

An imperforate hymen combined with a hematocolpos in a pubertal girl (pubic hair shaved).

An 11 year old girl with an imperforate hymen and mucocolpos.

Imperforate hymen

Sexual Abuse/Rape

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