gyne - pedia adol

7/23/2019 Gyne - Pedia Adol

http://slidepdf.com/reader/full/gyne-pedia-adol 1/35

Janice Bernal-Lacuna,MD, FPOGS, FPSREI



Objectives



Infancy to Puberty

Vulvovaginitis

A!esive vulvitis

Acciental genital trau"a Ovarian tu"ors

Precocious #u$ert%



Gynecologic examination

of a child Slo& #ace, gentleness an #atience

A"$iance

Ra##ort Reassurance

Parental #resence



Components

'istor% A$o"inal e(a"

Ins#ection &it! visuali)ation o* t!e

vagina an cervi( A##ro#riate cultures o* t!e vagina

Rectal e(a" i* &it! $leeing ora$o"inal or #elvic #ain



PE

'%"en + crescentic, reunant,i"#er*orate

Vaginal e#it!eliu" + re, t!in Vaginal canal -c" long

Secretions + neutral #'



Inspection and

visualization .ounger c!il can $e e(a"ine on

!er "ot!er/s la#

For oler c!il, 0nee c!est #osition orsu#ine &it! 0nees a#art

1ultures + using saline saturatecotton ti# a##licator, #lastic"eicine ro##er

2arro& enosco#es



Rectal exam

Ma% $e o"itte

2on #al#a$le uterus

345 ratio, cervi(4uterus Inications

Bleeing

Pelvic #ain Foreign $o%

Pelvic "ass



ulvovaginitis

Most co""on g%ne #ro$le" in#re"enarc!eal

678 to 978 o* o# visits Introital irritation

Disc!arge :;8 non-s#eci<c etiolog% =GI >ora?

2@ gonorr!ea, @ vaginalis, 1!la"%ia,'SV, S!igella

M%cotic or $acterial vaginosis



ulvovaginitis ! vulvar

irritation o#ical allerg%

S0in or res#irator% in*ection

Foreign $o% I

Vulvar s0in isease

Ecto#ic ureter Pin&or" in*ection

Se(ual a$use



"usceptibility to

vulvovaginitis Lac0 o* la$ial *at #as an #u$ic !air

E#it!eliu" lac0s estrogen

#' is neutral Vagina lac0s gl%cogen, lacto$acilli

an anit$oies

Poor #erineal !%giene



#reatment

'%giene + clean, r% an cool Cee#ing lesions + !ot sit) $at!

containing 3 t$s# o* $a0ing soa

Ci#e *ront to $ac0 Loose cotton gar"ents Avoi $u$$le $at!s !ars! soa#s i* allergic

1ala"ine lotion or cornstarc! #o&er ont!e vulva o#ical crea"s an anti$iotics *or 3

&ee0s



$oreign body

Bet&een to 9 %o

oilet #a#er, to%s, cra%ons, san

Vaginal isc!arge Re"ove $% *orce#s, irrigation



aginal bleeding

Foreign $o% 2eo#lasia Precocious #u$ert%

ret!ral #rola#se rau"a Se(ual assault Vulvovaginitis

Lic!en sclerosis 1on%lo"a accu"inata Bloo %scrasia E(#osure to estrogen



aginal bleeding

S!igella

Grou# A $eta-!e"ol%tic

stre#tococcus :-57 a%s a*ter a sore t!roat



%dhesive vulvitis

Sel*-li"iting conseuence o* c!ronicvulvitis

La$ia "inora agglutinates an *uses

Mista0en *or congenital a$sence o* vagina

1o""on $et&een to %o

2o s%"#to"s e(ce#t *or icult% in

voiing i* *usion involves t!e uret!ra 2o treat"ent necessar%

Estrogen crea" 3( ail%



%ccidental genital

trauma Fall, strale inur% Se(ual a$use 'e"ato"a or laceration General anest!esia "a% $e neee to

investigate t!e e(tent o* t!e inur% I* non-e(#aning4 o$servation, serial

e(a"ination, ice #ac0 t!en !ot sit)

I* retro#eritoneal !e"ato"a or internalorgan inur% is sus#ecte, la#arosco#%or la#aroto"% "a% $e inicate

etanus to(oi inection



Ovarian #umors

A$o"inal #ain

A$o"inal enlarge"ent + increasing

a$o"inal girt! ltrasoun, a$o"inal 1, MRI

1A 53;, AFP, !1G, in!i$in, 1EA, LD',

estraiol an testosterone



Ovarian tumors

nilateral

Benign or "alignant

Ger" cell tu"or + "ost co""on in#reaolescents I""ature terato"as + surger% alone is

curative regarless o* grae

D%sger"ino"a + "ost co""on "alignant Benign terato"a + "ost co""on $enign

Functional luteal c%sts



Ovarian tumors

Goal o* surger%4 re"oval o*neo#lasia an #reservation o* *uture*ertilit%



Precocious puberty

A##earance o* signs o* seconar% se(ual"aturation at an age "ore t!an 3@;stanar eviations $elo& t!e "ean *or

t!e #o#ulation to &!ic! t!e c!il $elongs Breast evelo#"ent an #u$ic !air

a##earance $e*ore age : *or 1aucasianan age *or A*rican A"erican girls

suall% &it! s!ort stature + li"itegro&t! s#urt $ecause o* accelerate$one "aturation an #re"ature closureo* t!e istal e#i#!%seal gro&t! centers



Premature #helarche

Breast evelo#"ent

2eonatal + "a% $e nor"al u# to

"ont!s 5 + %o

3 + c" $reast $u

nilateral or $ilateral

Benign sel*-li"iting

2o treat"ent



Premature Pubarche

Isolate evelo#"ent o* #u$ic !air

Pre"ature arenarc!e + a(illar% !air

2o clitoro"egal%, $one age is notavance

Increase D'EA an D'EA-S $% t!earenals

2ot #rogressive

2o treat"ent, o$servation



GnR&'(ependent Precocious

Puberty Iio#at!ic evelo#"ent + :78 o*

cases

A$nor"al EEGs + 12S Pre"ature "aturation o* t!e 'PO a(is

Ma% evelo# ovarian *ollicular c%sts

As earl% as - %ears ol E"otional #ro$le"s + s!% an

&it!ra&n




Puberty 'eaac!es

Visual istur$ance

Sei)ures &it! ina##ro#riate laug!ter=gelastic sei)ures?




Puberty 12S lesions near !%#ot!ala"us near r ventricle

u$erculosis, ence#!alitis, trau"a,

!a"arto"as, terato"as, seconar%!%roce#!alus, neuro<$ro"atosis,granulo"as, cranio#!ar%ngio"as, cranialirraiation,

S#ace occu#%ing "asses are "ost icultto treat

Poorl% unerstoo &!% it #rouces#recocious #u$ert%



GnR&'independent precocious

puberty Most co""on + estrogen-secreting

ovarian tu"or Granulosa cell tu"ors - H 6c"

!eco"as, luteo"as, terato"as,Sertoli-Le%ig cells,c!oriocarcino"as, an $enign

*ollicular c%sts + rare cause Prouce !1G or estrogen



)cCune'%lbright syndrome

Pol%ostotic <$rous %s#lasia

ria4 ca*-au-lait s#ots, <$rous

%s#lasia, c%sts o* s0ull an long$ones

Facial as%""etr%

78 !as isose(ual #recocious#u$ert%



%drenocortical neoplasms

Isose(ual or !eterose(ual

1ongenital arenal !%#er#lasia

I* treate uring neonatal #erio, nor"al#u$ert%

I* untreate, girl &ill evelo#!eterose(ual #u$ert% $ecause o*

anrogens I* treate late in c!il!oo, isose(ual

evelo#"ent "a% *ollo& initial treat"ento* arenal isease



&ypothyroidism

suall% associate &it! ela%e#u$ertal evelo#"ent

Rare4 "a% cause #recocious #u$ert% Bone age is retare =s#eci<c?

'as!i"oto/s t!%roiitis

Lo& t!%roi !or"ones

negative*ee$ac0 increase S'

increase gonaotro#!ins



Iatrogenic

Estrogen crea", #ills

Regresses a*ter iscontinuation



(iagnosis

'istor% an PE

Rule-out li*e t!reatening neo#las"s

o* t!e ovar%, arenals or 12S Delineate s#ee o* "aturation

anner stage



*aboratory exams

Brain 1 or MRI EEGs ltrasoun

Bone aging $% !an-&rist (-ra%s ever% "ont!s =i* 9;8 avance4 ovarianestrogen?

'or"onal assa%s incluing t!%roi *unction

GnR' sti"ulation test + L' increases i* true#recocious #u$ert%, L' oes not increase i*inco"#lete =#eri#!eral sources?



)anagement of Precocious

Puberty E(tir#ation o* tu"ors =ovarian,!a"arto"as?

1ontinuous c!ronic GnR' analogue

a"inistration =agonists? + "osteective $et&een -%o Do&n regulation o* GnR' rece#tors

Mini"al $ene<t &it! gro&t! !or"ones estolactone =aro"atase in!i$itor? +

Mc1une Al$rig!t 1ounseling

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