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Prepubescent patients typically require an external examination of the genitalia and specimen collection as indicated. A speculum examination is indicated for sexually active patients, or those with bleeding or a suspected foreign body.
Congenital vaginal obstruction may present as an abdominal mass or bulge at the introitus.
Treatment of asymptomatic labial adhesions is not indicated. For symptomatic relief estrogen cream is the first line of therapy.
Urethral prolapse occurs most commonly in prepubertal African American females. Therapy with estrogen cream may reduce swelling of urethral tissue.
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Normal Variation in Premenarcheal and Menarcheal Patients
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The female infant is under the influence of maternal estrogens for the first 6 months of life. Breast buds may be present, the labia majora appears full and there is thickening and enlargement of the labia minora.1 Hymenal tissue stays thick, redundant, and elastic throughout infancy. The hymen surrounds the vaginal orifice and appears circumferential.2 Estrogen levels fall within with first 6 months of life and continue to fall steadily until about 1.5 to 2 years of age.1
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Toddlers and younger school-age children (ages 2–6): As the estrogen levels reach their lowest levels between 3 and 9 years of age, the appearance of the female genitalia changes.2 The clitoris is less prominent and the labia become flatter.1 The hymen generally becomes thinner and may appear translucent, while also leaving a “crescentic” appearance as the hymen tissue recedes from the anterior vaginal orifice. There is a high degree of variability in timing of these changes among children. The vaginal pH during this time is alkaline.2
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Older school-age children (ages 7–12): The labia continue to develop and the hymen thickens, while the vagina elongates to about 8 cm. The vaginal mucosa thickens and the vaginal pH becomes acidic. A thin white vaginal discharge (physiologic leucorrhea) may be noted.1,2
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Adolescents (ages 12–21): The labia are well developed and the hymen is thick with a pale pink coloration. The vagina is typically an adult length at 10 to 11 cm, typically with an acidic pH. Physiologic leucorrhea may be noted depending on the timing of the menstrual cycle.1,2
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Evaluation of the Premenarcheal Child
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A successful examination of the premenarchal child requires adequate lighting and an environment in which the child feels relaxed and as comfortable as possible. Address any concerns or fears the child may have, especially in cases of sexual assault. Assess the stage of sexual development by examining the breasts and looking for any indication of puberty3,4 (Table 99-1). Utilize a standard speculum examination for patients who are sexually active or bleeding from trauma. In prepubertal girls, only external visualization may be needed. The frog-leg position allows easy visualization of the genitalia and may be performed with the child in ...