Obtaining a History

When evaluating a child in a routine office setting or in a specialized gynecologist’s practice, the clinician can ask the child directly if she has any worries or concerns about her body or health. If the child defers to the parent, the clinician can then direct questions to the parent or care provider while the child plays in the office or examining room. Having child-friendly toys and books available, with safety precautions such as electric socket covers for outlets, can help allow the child to relax in a safe way. Periodically, questions can be directed to the child to put the child at ease, focusing on toys, school, and other nonthreatening topics at first. The parent should be asked about their current specific concerns, along with background history of growth, development, and past problems. If the parent raises a specific gynecologic concern, the child can then be asked if she has pain or itching in her bottom or vagina. If sexual abuse is a concern, she should be asked if anyone has ever touched her “girl parts” or private parts, and asked, “Tell me about it.” Open-ended questions are most useful to prevent having answers influenced by the questioner. In trying to glean specific details, it may be necessary to ask whether she or anyone else has ever placed something in her vagina. All questions should be asked without stern or judgmental looks, with good eye contact maintained with the child; this approach helps to make the child feel that she is an important member of the team and gives her a chance to ask questions. In cases of abuse, it can also help prevent or minimize shame, guilt, and negative feelings that the child may be directing at herself.

Establishing Confidentiality

With an older child (over age 10) with concerns of sexual abuse and with all adolescents, all questions regarding sexual history, vaginal discharge, and vulvar itching should be asked without a parent in the room. Adolescents are often loathe to answer questions honestly with a parent listening, especially if they are engaging in a risk behavior about which they don’t want the parents to know. Older children with suspected sexual abuse may not wish to disclose with the perpetrating parent or the spouse of the perpetrator present for fear of punishment at disclosure or for fear of not being believed, with consequences for “lying.” Establishing confidentiality provides an opportunity to ask questions directly of the child without the influence of the parents, with an expectation of honesty. The child or adolescent may still withhold the truth, often delaying to determine whether the clinician is “trustworthy” or if he/she can really help.

Before establishing confidentiality, the clinician should obtain information on current concerns, past medical history, family illnesses, and other less personal questions, with the parent and the child together. The parent can then be asked if there are any private concerns he or she wishes to discuss without the child present. At this time, the clinician should clearly and concretely define confidentiality with both parent(s) and child present. One way to do so would be to state, “Everything I talk about alone with your parent is confidential, meaning I will not share with you any of your parents’ private concerns. In the same way, everything I talk about with you without your parent is confidential, meaning I will not share with them your private concerns. The only exception is if you or your parent tell me something life-threatening or dangerous; then, I would say, ‘we need to talk to your parent about this.’”

When possible, getting parent confidential history before patient confidential history works better, because it guides you toward the parent’s immediate concerns sooner and also helps the child not feel “reported on.” The child also recognizes that you didn’t “spill the beans” or disclose the parent’s confidential concerns, building trust so that they do not feel the clinician will disclose the child’s private concerns.

After confidentiality has been outlined/established, the child can be asked if she prefers the parent in the room or out of the room for the examination. If she prefers the parent in the room, the clinician can state, “I will take a few minutes with your daughter alone to address any of her private concerns. Then, we will bring you back in the room for the exam.” If the child prefers the parent to leave the room for the examination, confidential questions can be asked during the performance of the examination.

The HEADS Questions

The major adolescent morbidities and mortalities stem from risk-taking behaviors rather than disease processes. Therefore, questions designed to elucidate those risk-taking behaviors in an expedient way can be used to avoid the “Oh By the Way” experience, or the major problem casually mentioned in the last few minutes allotted for a visit. A useful acronym for obtaining the psychosocial history from an older child or adolescent is HEADS.^1,2 Table 13-1 outlines these questions, which are geared more toward the adolescent but can be modified into simpler terms for the child. With risk behaviors such as cigarettes or drugs, asking about peers’ or friends’ use can be particularly helpful with the older child or younger adolescent, because they may easily talk about others’ risk behaviors, which can then make it easier to talk about themselves.

Table 13-1 The HEADS Examination

If a teen perceives that all of her friends smoke, but she states that she does not smoke, the clinician can then ask what she says to her friends when they ask her to smoke with them. If the teen has no answer, the clinician has the chance to suggest an appropriate response (e.g., “I like my lungs the way they are” or “I choose not to smoke.”). Thus, the clinician can role-model responses without artificially setting up a role-play. This strategy represents a form of motivational interviewing or helping the teen build skills while obtaining the history. Similarly, with a younger child, the clinician can ask, while examining private parts, “What would you do if another adult or child wanted to look at or touch your private parts?” If the child has no response, the clinician can help guide her towards ways to keep herself safe, often providing the parent with strategies to initiate/continue these educational moments.

Asking questions in a nonjudgmental manner inspires confidence in the child and adolescent, increasing the likelihood that they will disclose sensitive information that may have an impact on their health. With adolescents, prior sexually transmitted diseases, vaginal discharge or odor, methods of contraception used, menstrual history, and other related questions should also be asked confidentially.

The Gynecologic Examination Itself: The Rules

The genital examination of the child should be approached with special verbal acknowledgement to the child and parent before requesting the child to disrobe. With the younger child at preventive healthcare visits, the clinician can state that he/she will look at her bottom every year to make sure that everything is okay, reminding the child and parent that this part of the examination is an expected and routine part of every well-child visit. With younger children, it is useful to state, “It is okay if a doctor looks at your private parts with your mommy here, but it’s not okay if anyone else looks at your private parts without your mommy’s permission. If anyone ever did that, what would you do?” If the child does not respond, often the parent will chime in, “Oh, she knows about strangers, tell the doctor what you know.” Give positive feedback for whatever response the child gives, especially if the child states that she would tell mommy (and the doctor and the police).

If the child does not respond or does not say that she would tell mom, the clinician needs to state that it is very important for her to tell her mommy and/or the doctor so that we can keep her safe and healthy. The clinician can further elaborate on stranger danger, stating that sometimes strangers or even people the child might know can try to scare her into silence, telling her that she must not tell when something bad has happened. The clinician can then state that telling is the best way to have us protect the child, and that the bad person keeps power only through the child’s silence, or not telling. In cases of abuse, this can be a sophisticated concept that can be put into understandable terms for the child.

The examination can also be used to educate the child on the rules of hygiene. For instance, the clinician can state, “I want to talk to you about the rules. One rule is that you don’t let poop get near your girl parts. That is why we wipe from front to back (demonstrating), so that the poop stays away from where you tinkle.” (Other phrases can be substituted, but here layman’s terms tend to be more useful than elimination, voiding, and other more medically accurate terms; the point is to have the child understand the concept). A mirror can be used to teach a child how to wipe correctly after elimination and to show her which parts are where. Education on avoidance of bubble bath can also be reiterated, teaching parents to use baby shampoo rather than bubble baths that may cause a chemical irritation (bubble bath vaginitis).

As the clinician performs the examination, he or she should state clearly what he or she is doing, describing findings and using words like “normal,” “perfect,” and “everything is in the right place.” The patient’s comfort remains the priority, with the child feeling in total control over the examination. The clinician must promise not to hurt the child or to cause any pain, and should keep that promise!

Parents often have misconceptions about the hymen. Before and during the examination, the clinician can teach the parents that hymens come in varying shapes and sizes, and that the examination will not harm or “break” the hymen in any way. Use of a diagram can help educate the parent or child about normal female anatomy and can help clear up any misconceptions (Figs. 13-1 and 13-2). Because not all clinicians routinely inspect genitalia despite national recommendations that it should be part of the annual examination, parental anxiety may set a tone for the child. The clinician can educate both parent and child while allaying anxiety and teaching parents to send calming cues to their child, helping reassure the child rather than raise anxiety. Occasionally, this may require more than one visit to complete a gynecologic examination.

Figure 13-1 Normal female anatomy in the prepubertal child.

Figure 13-2 Various hymenal configurations. A, Normal posterior crescentic appearance. B, Normal annular hymen. C, Hymen with redundant or fimbriated appearance. D, An imperforate hymen. E, A microperforate hymen. F, A cribriform hymen. G, A septate hymen.

Use of “tricks” such as hiding behind drapes, use of headphones, or murals on the ceiling should be avoided, because they may not allow a child to feel in control of the examination and be an active participant, thus destroying a child or parent’s confidence in the clinician. Rather, a straightforward approach with both parent and child can allow for proper examination while maximizing educational moments for both the parent and child.

Helping the Child Feel in Control

Attention to the little things can help a child feel in control. Rather than asking if the child wants to be in a gown, asking, “Do you prefer the green gown or the yellow one?” allows the child some autonomy in the process. The otoscope or hand lens can be used for magnification; allowing the child to look through the lens to see how it works can help put her at ease. If a colposcope will be used, letting the child view jewelry or fingers through the instrument and showing her how the light turns on and off can demystify the examination. Asking the older child if she prefers the parent in or out of the room can also help the child feel in control.

Most children are comfortable lying on the examination table with a parent close by. If a child appears anxious, the clinician can ask if the child prefers to be a big girl on the table herself or to lie in the parent’s lap for the examination to help the child maintain control. The parent can then be placed in a semireclining position on the examination table with the parent’s feet in the stirrups and the child’s legs straddling the parent’s thighs. Even a father can be taught to assume this position, with the child on his lap—often as more of a challenge for him than for his child! If necessary, this position can be tried with the patient in clothes before performing the actual examination. A handheld mirror can be used to educate the patient (and parent) on normal anatomy while providing a means of recruiting the child as an active participant.

The child can also maintain control by being asked to assist in holding her labia apart. If the clinician acts relaxed and confident, the patient (and parent) will usually cooperate.³ An abrupt or hurried approach may lead to a child’s refusal to continue, so patience and a calm, confident tone are required. If a child needs more time, the examiner can leave the room until the patient feels ready. Several visits may be necessary to set the child at ease and build confidence that she will not be hurt. If an acute need for an examination exists, as in the case of vaginal bleeding, often an examination under anesthesia may be necessary.

The Actual Examination

Examination of the child with gynecologic complaints should include measuring height, weight (and body mass index if obese), performing a visual inspection from head to toe, including head, neck, heart, lungs, abdomen, Tanner staging (see Chapter 11), breasts (inspection and palpation for masses or discharge), and skin for rashes/lesions. A simple way to remember Tanner staging is as follows. For pubic hair, Tanner I means prepubertal, or no hair. Tanner II hair is fine and downy, and you can count them. Tanner III hair is coarse, in a triangular pattern, and you can count them if you are obsessive-compulsive! Tanner IV pubic hair means too many to count, and Tanner V means out to the thighs. For breast development, Tanner I means no bud yet, or prepubertal. Tanner II means just a breast bud under the nipple. Tanner III extends beyond the nipple, and Tanner IV is a mound of areola on top of a mound of breast. Tanner V refers to adult breasts, with the areola now flush with the breast but the nipple protruding.

Gynecologic assessment includes inspection of the external genitalia, palpation of the inguinal area for hernias or masses, and visualization of the vagina. Hymenal anatomy should be noted and documented in the medical record (see Figs. 13-1 and 13-2). Hymens come in different configurations, with many variants of “normal.” Hymens can be classified as crescentic or posterior rim, annular, or redundant.^3,4 Recognition of an imperforate hymen before puberty is generally greatly appreciated by parents, so that anticipatory guidance can be given and an easy procedure accomplished before menstrual flow accumulates behind a blocked passageway. Cribriform or microperforate hymens and septate hymens can also be confusing to the untrained eye; pictures of each are seen in Figure 13-2. Further subtleties of the hymenal examination are addressed in the section Approach to the Child who Has Been Sexually Abused.

For a complete gynecologic examination, rectoabdominal palpation should be performed and the cervix should also be visualized. For the younger child, the latter can usually be performed in frogleg position, either on or off the parent’s lap. If, however, the hymen cannot be fully assessed or concerns about the presence of a foreign body exist, the child can be placed in knee-chest position. The child can be told that she should lie on her tummy with her bottom in the air, “just as you may have done when you were a baby sleeping.” The parent or the child herself can be recruited to spread the buttocks gently, and an otoscope can be used on the outside to illuminate the area. Two thirds of the vagina and even the cervix may be visualized in this manner.

Often foreign bodies such as bits of toilet paper can be identified with the child in this position. A butterfly catheter of any size with the needle cut off can be attached to a tuberculin syringe with 1 μL of saline, and then placed inside a 12-inch red rubber bladder catheter to irrigate or wash off the genitalia.⁵ This catheter within a catheter can be squirted on the patient’s hand or thigh, so as not to surprise her, with explanation that it may feel cold and wet, allowing the area to be irrigated easily.

During the gynecologic examination, the clinician should note the presence of pubic hair, the size of the clitoris, hymenal configuration, signs of estrogenization of the vagina and hymen, and perineal hygiene.³ A clitoris larger than 10 mm in a pubertal girl is considered enlarged. The clitoris in the premenarchal child averages 3 mm in length and 3 mm in transverse diameter.⁶ If the hymen is viewed in lithotomy or frogleg position and likened to the face of a clock, irregular notching or transactions of the hymen between 5 and 7 o’clock are suggestive of sexual abuse, forced sexual intercourse, or trauma.

If the hymenal orifice and edges cannot be easily visualized in this position, the labia can be gently gripped and pulled forward with gentle traction. The child can be asked to cough or take a deep breath and hold it for a few seconds, allowing the hymen to gape open. In the prepubertal girl, the vaginal mucosa tends to be red, thin, with erythematous perihymenal tissue. In the pubertal girl, the mucosa becomes dull pink and moist under the influence of estrogen. Estrogenized tissues tolerate instrumentation better than do atrophic or prepubertal tissues.

With the development of secondary sexual characteristics, the teen girl needs to hear that she is normal, even if she has been subjected to past sexual abuse. Sexual activity can cause friction, trauma, or infection, along with exposure to irritant or contact dermatitis if the teen is allergic to latex or sensitive to a particular spermicide or lubricant. Issues of hygiene and grooming can cause problems, with irritation from shaving, waxing, or laser hair removal. Ornamentation or body piercing can also be a source of infection or scarring. Genital mutilation can still occur in various countries and be a source of shame plus physical discomfort. The rules for evaluating all girls still apply: if you don’t look, you won’t find.

In the adolescent, inspection of the genitalia allows for identification of normal versus abnormal medical findings, including folliculitis or “razor burn” in patients who shave or use other means of hair removal (usually noninfectious). Candidal vulvovaginitis can also be seen and may be the first presenting sign of diabetes. In patients who present repeatedly with yeast vaginitis, a urinalysis can rule out diabetes, and a culture on bismuth sulfate (BiGGY) agar can determine whether Candida is the offending organism. Visual inspection allows the opportunity to educate the adolescent in tampon use and in proper hygiene techniques; it may also elicit questions that the teen may have been too embarrassed to ask about (e.g., clitoral size, irregularities in size or shape of labia). A “lump” felt by a teenager may be a Bartholin’s cyst rather than perceived cancer.