FROM THE AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician in Rendering Pediatric Care Clinical Report—Gynecologic Examination for Adolescents in the Pediatric Office Setting

Paula K. Braverman, MD, Lesley Breech, MD, and THE COMMITTEE ON ADOLESCENCE abstract KEY WORDS The American Academy of Pediatrics promotes the inclusion of the pelvic examination, Pap smear, sexually transmitted infections, menstrual disorders, pubertal development gynecologic examination in the primary care setting within the medical home. Gynecologic issues are commonly seen by clinicians who pro- ABBREVIATIONS STI—sexually transmitted infection vide primary care to adolescents. Some of the most common concerns AAP—American Academy of Pediatrics include questions related to pubertal development; menstrual disor- NAAT—nucleic acid amplification test ders such as , amenorrhea, oligomenorrhea, and abnor- This document is copyrighted and is property of the American mal uterine bleeding; contraception; and sexually transmitted and Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American non–sexually transmitted infections. The gynecologic examination is a Academy of Pediatrics. Any conflicts have been resolved through key element in assessing pubertal status and documenting physical a process approved by the Board of Directors. The American findings. Most adolescents do not need an internal examination involv- Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of ing a speculum or bimanual examination. However, for cases in which this publication. more extensive examination is needed, the primary care office with the The guidance in this report does not indicate an exclusive primary care clinician who has established rapport and trust with the course of treatment or serve as a standard of medical care. patient is often the best setting for pelvic examination. This report Variations, taking into account individual circumstances, may be reviews the gynecologic examination, including indications for the pel- appropriate. vic examination in adolescents and the approach to this examination in the office setting. Indications for referral to a gynecologist are included. The pelvic examination may be successfully completed when conducted without pressure and approached as a normal part of routine young women’s health care. Pediatrics 2010;126: 583–590

INTRODUCTION Gynecologic issues are commonly seen by clinicians who provide pri- mary care to adolescents. Some of the most common problems include www.pediatrics.org/cgi/doi/doi:10.1542/peds.2010-1564 questions related to pubertal development; menstrual disorders such doi:doi:10.1542/peds.2010-1564 as dysmenorrhea, amenorrhea, oligomenorrhea, and abnormal uter- All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless ine bleeding; contraception; and sexually transmitted infections (STIs) reaffirmed,revised, or retired at or before that time and non–STIs. Approximately one-half of adolescents attending high PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). school have been sexually active, which places them at risk for STIs and 1 Copyright © 2010 by the American Academy of Pediatrics pregnancy. Younger adolescents often have questions about pubertal development, and the gynecologic examination is a key element in assessing pubertal status and documenting physical findings. The American Academy of Pediatrics (AAP) promotes the inclusion of the pelvic examination in the primary care setting within the medical home. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women’s health care. At a minimum, examination of the external geni- talia should be included as part of the annual comprehensive physical examination of children and adolescents of all ages. Routinely explain- ing and including this examination normalizes the experience rather

PEDIATRICS Volume 126, Number 3, September 2010 583 Downloaded from www.aappublications.org/news by guest on September 28, 2021 than setting it apart as something that formation relayed by peers or family development, and look for evidence of is only performed as an exception. members, the adolescent may be fear- abnormal lesions, infection, or Most adolescents do not need an inter- ful or anxious about the examination. It trauma. However, with the availability nal examination involving a speculum is important to proactively allay any of urine-based and vaginal-swab STI or bimanual examination. However, for fears before performing the examina- testing, examination with a speculum cases in which more extensive exami- tion. Issues that need to be addressed in an asymptomatic patient is not nec- nation is needed, the primary care of- up front with the patient include fear of essary for diagnosing asymptomatic fice is often the best setting for pelvic discovering a disease or abnormality, STIs.2,3 Other non–sexually transmitted examination. The primary care clini- possible pain or discomfort, embar- vaginal infections, such as bacterial cian, who has established rapport, rassment in undressing or exposing vaginosis and yeast infections, can trust, and a comfort level with the pa- the genital area, and uneasiness with also be diagnosed with a vaginal swab tient, is allowed to prepare the patient the examiner, particularly when the obtained by either the provider or the in advance and to more successfully clinician is male or a trainee. Clini- patient.4,5 address preconceived negative atti- cians should always be sensitive to the Previous recommendations to per- tudes and fears. possibility of past or current sexual form Pap tests at the onset of sexual Although pediatric residency training abuse, which can affect the patient’s activity have changed. Current guide- comfort with the examination and her includes instruction in performing the lines state that the first Pap test preference regarding the gender of pelvic examination, many pediatri- should be performed at 21 years of the examiner. When performed in a cians may not use these skills in their age, except if a patient has immune thoughtful and sensitive manner, the current practice setting. The purpose suppression or infection with HIV, in pelvic examination can be a positive ex- of this report is to provide pediatri- which case annual Pap tests are perience. In some cases, it may be cians with background information re- started with the onset of sexual activ- helpful to have the patient make an ap- garding indications for the pelvic ex- ity. Adolescents who had been pointment specifically for the pelvic ex- amination, along with information screened previously and had docu- amination to ensure that the provider about the equipment and supplies mented cervical intraepithelial neopla- does not feel rushed in the midst of a needed and techniques used in per- sia (CIN) 2 or 3 or carcinoma would busy day of clinical practice. forming the examination in the pri- require continued screening as out- mary care office setting. Indications for the pelvic examination lined in the new recommendations.6 are listed in Table 1. In the past, a his- Cervical cancer generally develops tory of sexual activity was an auto- INDICATIONS FOR THE PELVIC several decades after initial exposure matic indication for a full pelvic exam- EXAMINATION to human papillomavirus (HPV) and is ination to perform Pap tests and STI Fewer adolescents require a complete rare in women younger than 21 years. testing and to act as a prerequisite to screening pelvic examination because Although many sexually active adoles- prescribing hormonal contraception. of recent changes in recommenda- cents are exposed to HPV, and some Certainly, the external genitalia of all develop abnormal cervical cells, these tions for the initiation and follow-up of patients should be examined to con- changes resolve without intervention abnormal Papanicolaou (Pap) test re- firm normal anatomy, assess pubertal sults, as well as newer tests available in the vast majority of adolescents. to screen for STIs, which can be per- Furthermore, there are indications formed on urine specimens, vaginal that interventions for abnormal cervi- swabs, or cervical samples. However, TABLE 1 Indications for a Pelvic Examination cal cytology in this age group cause there are instances in which the pelvic Persistent unnecessary anxiety and have the po- Dysuria or urinary tract symptoms in a sexually examination is a crucial part of the active female tential to contribute to pregnancy com- medical evaluation. The goals of a Dysmenorrhea unresponsive to nonsteroidal anti- plications in the future. pelvic examination are primarily to inflammatory drugs A speculum or bimanual examination Amenorrhea screen for and diagnose diseases and Abnormal vaginal bleeding is now considered unnecessary before abnormalities but also to provide edu- Lower abdominal pain prescribing most forms of contracep- cation about gynecologic issues and Contraceptive counseling for an intrauterine tion. The package insert for oral con- device or diaphragm reassure the patient about normal, Perform Pap test traceptive pills specifically states that healthy anatomy. Because of previous Suspected/reported rape or sexual abuse a gynecologic examination is not nec- negative experiences or inaccurate in- Pregnancy essary. The rationale is that there is

584 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS nothing that would be found on the pel- speculum examination can be used reassuring. Use of anatomic models, vic examination that would be a con- to diagnose trichomoniasis, bacterial pictures in handouts, and pamphlets traindication to prescribing oral con- vaginosis, and yeast infection, a blind that describe the examination are traceptive pills. The same reasoning vaginal swab is sufficient for obtaining valuable adjuncts. The amount of de- can be applied to the contraceptive an adequate sample for diagnosing tail included depends on the age and patch, ring, progestin-releasing im- these infections. Visualizing the maturity level of the patient. Depend- plant, and medroxyprogesterone injec- also allows for assessment for the ing on the patient’s preference, hav- tions. A urine-based pregnancy test presence of mucopurulent discharge ing the patient’s mother or another and STI screen can be performed, if and friability, which have been associ- trusted female, such as a relative, indicated, before a clinician pre- ated with the diagnosis of chlamydia present for both the preexamination scribes hormonal contraception. The 2 and gonorrhea. The speculum exami- preparation and the examination it- exceptions would be an intrauterine nation is also important for ruling out self can sometimes be helpful and device (IUD) or diaphragm, for which other causes of discharge, such as a reassuring to the patient. anatomic variation could affect inser- foreign body or a cervical abnormality It is important to reassure the patient tion or appropriate sizing of the device. such as a large ectropion. that nothing will be done without tell- A complete pelvic examination is al- Another indication for a complete pel- ing her first and that, although the ex- ways indicated in cases of suspected vic examination is menstrual disor- amination may be uncomfortable, it or reported rape or sexual abuse ders, including dysmenorrhea that is should not be painful in the absence of and/or as part of the evaluation of unresponsive to first-line therapy with pelvic abnormality. Patients should be lower abdominal pain. In the case of nonsteroidal anti-inflammatory drugs encouraged to give feedback to the cli- lower abdominal pain, the examination (NSAIDs) and/or hormonal therapy, nician during the examination if they is performed to identify the source of amenorrhea, and abnormal vaginal are not comfortable, either physically pain, which may be caused by pelvic bleeding. In these instances, the pelvic or emotionally. The patient should be inflammatory disease, ovarian mass examination is important for confirm- reminded that she is in control of her or torsion, and/or normal or ectopic ing normal anatomy, isolating the body and that it is fine to say, “Wait a pregnancy. When rape or sexual abuse source of pain, ruling out lesions or minute,” “Stop,” or “That’s not comfort- has occurred in the previous 72 hours, masses, and identifying sources of able.” For a cooperative patient, the ex- a pelvic examination should be per- vaginal/uterine bleeding. A complete amination can be completed in 10 to 15 formed in a clinical setting along with pelvic examination with a speculum minutes. However, the examination the physical examination to identify may not be necessary for all adoles- should be performed only when there and document evidence of trauma and cents with abnormal vaginal bleeding is adequate time allotted, particularly to collect and safeguard forensic spec- if it is determined that the clinical sce- if it is the patient’s first examination or imens obtained in a standardized man- nario is that of an individual with heavy if the patient has had a previous nega- ner. The necessary supplies, equip- and/or prolonged menses within the tive experience. If the patient does not ment, and staff knowledge and skills first few years after menarche who appear to be tolerating the examina- may not be available in the primary promptly responds to medical man- tion, it should be stopped and tried care office setting; therefore, some pa- agement and does not have any indica- again at a later time to minimize nega- tients may need referral to a special- tion of trauma or history of sexual ac- tive experiences. In addition to explain- ized medical center. tivity or abuse. ing some relaxation techniques to the Persistent symptomatic vaginal dis- patient, pressing on the perineal mus- charge is another indication for a PREPARATION FOR THE PELVIC cle without inserting a finger in the va- speculum examination. Although nu- EXAMINATION gina and having the patient practice cleic acid amplification tests (NAATs) Before performing a pelvic examina- contracting and relaxing that area can can be used on non–clean-catch urine tion, it is important to explain the be helpful in later successfully insert- samples to detect Chlamydia tracho- components of the examination to ing the speculum or a finger during the matis and Neisseria gonorrhoeae in- the patient and to show the patient bimanual examination. fections, cervical or vaginal specimens the equipment that will be used. Al- Before performing the examination, may be more sensitive, depending on lowing the patient to touch the the patient should be asked to empty the test that is used.2 Although vaginal speculum to demonstrate that it is her bladder. This will minimize any swab specimens obtained during the smooth and will not injure her can be pain or discomfort, particularly dur-

PEDIATRICS Volume 126, Number 3, September 2010 585 Downloaded from www.aappublications.org/news by guest on September 28, 2021 ing the bimanual examination. The tests. The jelly lubricant is reserved for PERFORMING THE PELVIC pelvic examination should be per- the bimanual examination, which is al- EXAMINATION AND COMMON formed in the lithotomy position on ways performed after the speculum FINDINGS an examination table with stirrups. examination is completed. Nonlatex External Genitalia Although frog-leg or knee-chest posi- gloves are needed, particularly for tion is used to examine younger girls, those who have latex sensitivity or al- The first part of the pelvic examination the use of stirrups is preferred when lergy. A variety of specula of varying is inspection of the pubic hair, noting performing a speculum examination widths should be available. The pediat- Tanner stage (sexual maturity rating) to allow for proper insertion and po- ric/infant speculum should never be and the presence of any lesions, in- sitioning of the speculum. The room used on a pubertal female, because it cluding pubic lice, nits, folliculitis, and should be set up to ensure privacy does not have the required 4-in length other inflammatory lesions such as with a curtain or locked door, and to reach the cervix. The speculum com- hidradenitis suppurativa. Folliculitis gowns and draping should be pro- monly used in a sexually active female presents as papules and pustules pri- vided. Chaperones are strongly rec- is the Pederson speculum, which is 7/8 marily in the pubic hair region. They ommended, with the permission of in wide. In cases of virginal adoles- can be mildly tender and are usually the patient, even when the patient cents or those who cannot relax their smaller than hidradenitis suppurativa, and clinician are the same gender, to vaginal muscles, the Huffman specu- which causes larger, tender, draining help avoid any false accusations of lum can be useful, because it is nar- lesions that represent recurrent infec- impropriety. The chaperone can also rower, with a width of 0.5 in, but has tion of apocrine glands. Folliculitis is serve as the assistant to the clini- the required length. Use of the Graves particularly common with the in- cian, which improves efficiency in speculum should be avoided, because creased popularity of shaving pubic collecting specimens. its width can cause unnecessary dis- hair. Teenagers need to be counseled The equipment needed to perform a comfort. Plastic disposable specula that shaving should be performed pelvic examination is listed in Table 2 are available in the appropriate sizes. carefully with adequate lubrication to and includes materials used to per- Specula with self-contained lighting minimize trauma. In addition, although form Pap tests and STI/non-STI cervici- can be useful, because they make visu- not as common as in other body loca- tis/ evaluation. Warm running alization easier. tions, some teenagers will have genital water is helpful to provide lubrication In light of existing barriers to repro- piercings. Teenagers should be coun- for the speculum before insertion. ductive health services for adoles- seled on proper hygiene and potential Jelly lubricants should not be used on cents with disabilities, the need for ac- medical complications of piercing in the speculum, because they interfere cess to appropriate screening and the genital area, particularly those with the results of Pap tests and STI sexual education cannot be over- that involve the clitoris. stated. Young women with physical The external genitalia are examined disabilities may require modification next to assess for signs of inflamma- TABLE 2 Materials and Equipment Needed for the Pelvic Examination of the physical approach to the exami- tion, including redness or swelling, as Room with warm running water nation because of limb, pelvic, or spine well as any pigmentary changes, in- Room with a curtain or locked door deformity or immobility. The teenager cluding hypopigmentation, which can Examination table with stirrups with physical, behavioral, or develop- be seen in lichen sclerosis or vitiligo. Adequate adjustable light source Nonlatex gloves mental disability may require a refer- Clitoral size should be evaluated after Water-soluble lubricant ral to a gynecologist and possibly an retracting the clitoral hood, and the Gowns, drapes examination under anesthesia. The width should be Ͻ10 mm. An enlarged Speculum: Pederson, Huffman Pap test materials: liquid-based or slide, same may apply to patients who are clitoris can indicate elevated andro- cytobrush, paddle, fixative unable or unwilling to cooperate. All gens associated with a problem at the Culture/antigen tests for STIs: chlamydia, efforts should be made to perform level of the ovary or adrenal gland. The gonorrhea, trichomoniasis Urine pregnancy tests the examination in the office setting, hymen should be assessed for patency Swabs: cotton, calcium alginate, Dacron but forcing a patient to undergo pel- and configuration, including the pres- Microscopy materials: glass slides and cover vic examination is always contraindi- ence of an imperforate, microperfo- slips, saline solution, 10% potassium hydroxide pH paper cated (refer to the AAP clinical report rate, or cribriform hymen or hymenal Tampons/pads on sexuality of disabled children and band, which may impair uterine blood Tissues adolescents7). flow or preclude use of tampons. A

586 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS pubertal female with an imperforate infection.9 Genital warts (condylomata normal developmental finding of the hymen should be referred promptly to acuminata) can present as flat or exo- adolescent cervix in which the squa- a gynecologist to prevent accumula- phytic and are attributable to human mocolumnar junction is on the exocer- tion of blood in the vagina and upper papillomavirus. Condylomata lata are vix. This usually regresses into the cer- genital tract. Other abnormalities, flesh-colored papules on mucous vical canal with advancing gynecologic such as a vertical or transverse vagi- membranes, which can be confused age. When prominent, the ectropion nal septum, would be an indication for with warts but are filled with spiro- can cause significant vaginal dis- further evaluation to rule out other chetes and are a manifestation of sec- charge. Friability and hyperemia of the genital tract anomalies. If there are ondary syphilis.8 cervix can indicate infection with an any questions about patency of the va- The presence of any blood coming STI. White plaques on the cervix that gina, a saline-soaked cotton swab can from the vagina should be noted; vagi- cannot be removed with a swab could be gently inserted to demonstrate pa- nal discharge should be assessed, in- indicate condyloma acuminata, and tency. The Bartholin glands are located cluding amount, color, and odor. The red punctate lesions (strawberry cer- in the posterior vestibule at the 4 and 8 perianal area should be included in the vix) may be seen with trichomoniasis. o’clock positions. When infected, they external examination with specific ref- The cervix has a bluish hue, known as present with swelling, erythema, and erence to evidence of trauma, dis- cervical cyanosis or Chadwick sign, in tenderness that can extend into the en- charge, or warts. Inguinal nodes pregnancy. tire labia minora. Although any vaginal should be palpated for size, tender- During the speculum examination, organism can infect the glands, they ness, and consistency. Enlarged pain- samples are obtained for laboratory are commonly infected by STI patho- ful nodes could be an indication of an and office-based analysis. If the office gens, including gonorrhea and chla- STI, including syphilis or herpes sim- has a microscope, vaginal pool sam- mydia. The Skene glands are located plex virus. ples can be examined immediately to on each side of the urethra, and infec- diagnosis yeast infection, bacterial tion can present as erythematous ar- Speculum Examination vaginosis, or trichomoniasis. Samples eas lateral to the urethra. Insertion of The speculum examination is per- are obtained from the pooled vaginal a finger into the vagina and anterior formed after completion of the exter- secretions for wet prep, potassium hy- pressure may produce discharge from nal examination. Although not always droxide examination, and vaginal pH the ducts. necessary, a single finger can be in- testing. A cotton swab is used to collect Any lesions, including papules, vesi- serted along the posterior vaginal wall vaginal secretions, which can be cles, pustules, ulcers, fissures, and before insertion of the speculum to lo- placed in a tube with 1 mL of normal warts, should be noted. These could be cate the cervix. Lubricating the specu- saline solution and then used to pre- signs of an STI or other dermatologic lum with warm water can facilitate in- pare a glass slide for microscopic ex- conditions. In addition, any signs of sertion of the speculum, and anterior amination. Alternatively, the slide can trauma, including laceration, should pressure should be avoided during the be directly smeared with the swab, af- be noted. Ulcers found on the external insertion process to prevent pain ter which a drop of saline or potas- genitalia as well as in the vagina are along the urethra. If the speculum is sium hydroxide is added. With the wet commonly caused by herpes simplex completely inserted before opening saline solution preparation, the clini- virus (HSV), syphilis, or chancroid, the blades, the cervix frequently is eas- cian looks for an increased number of which are sexually transmitted. Al- ily viewed without much further ma- white blood cells as an indication of though lymphogranuloma venereum nipulation. Opening the speculum be- infection; clue cells (bacterial-covered can present with an ulcer, it is an un- fore inserting it the complete length of epithelial cells), which are a sign of common STI in the United States.8 the vagina can be painful. Once in- bacterial vaginosis; moving flagellated Because HSV and syphilis are the most serted, the vaginal walls should be in- trichomonads; and hyphae or budding common cause of genital ulcers in the spected for discharge and lesions. yeast. Potassium hydroxide prepara- United States, a viral culture for HSV The cervix should be completely visual- tion is helpful for identifying yeast not and serologic tests for syphilis should ized to note the presence of any lesions seen on the saline-solution prepara- be performed for suspicious lesions. as well as the presence or absence of tion. Ideally, the wet mount should be Some ulcers are not acquired sexually, an ectropion (transition between the read as soon as the pelvic examination including aphthous spectrum ulcers columnar and squamous epithelium) is completed to increase the likelihood and those caused by Epstein-Barr virus on the exocervix. The ectropion is a of detecting trichomonads. In the case

PEDIATRICS Volume 126, Number 3, September 2010 587 Downloaded from www.aappublications.org/news by guest on September 28, 2021 of bacterial vaginosis, when the vagi- cytology laboratory whether they use the vagina with a water-based lubri- nal secretions are mixed with potas- 1- or 2-slide Pap tests in which the en- cant on the gloved hand. The cervix is sium hydroxide, there is a characteris- docervical or ectocervical specimens assessed for consistency. The normal tic fishy odor, known as a positive whiff are either placed on 1 slide or sepa- nonpregnant cervix is firm, while the test, because of the amines that are rated. Any nonulcerative lesions of the cervix of a gravid uterus is softer. The present in the discharge. The normal cervix should be evaluated with a Pap cervix should be gently moved to as- vaginal pH should be Ͻ4.5; pH is ele- test, and any patient with unknown sess for cervical motion tenderness, vated with bacterial vaginosis and suspicious lesions should be referred which indicates pelvic infection or in- trichomoniasis. An easy method for to a gynecologist for further evaluation flammation. It is important to remem- measuring pH is to dip the pH paper in regardless of the Pap test result. The ber that adolescents, particularly the secretions left on the tip of the Pap test is performed before obtaining those not experienced with the exami- speculum after it is removed and then the endocervical swab for STI testing. nation, commonly mistake movement to read the color change within 10 sec- Cervical specimens should be ob- or pressure for pain. Distinguishing onds. Other tests that are commer- tained for gonorrhea and chlamydia between discomfort and true pain can cially available include cards that mea- testing by using an NAAT, culture, or be challenging. The uterus is then pal- sure pH and for the presence of DNA probe (nonamplified DNA test- pated for size and tenderness. The amines, which may be helpful in the ing). Some of the NAATs for gonor- nonpregnant uterus is small and firm, diagnosis of bacterial vaginosis. The rhea and chlamydia have also been whereas at 10 to 12 weeks’ gestation, it wet mount can miss trichomoniasis approved for vaginal swab speci- is the size of a grapefruit and is softer, 30% to 50% of the time; culture, nucleic mens. In cases of sexual abuse or globular, and starting to protrude acid probe, or antigen-based rapid rape, cultures may be legally re- from the pelvis. The uterus starts be- testing may be more sensitive in de- quired for gonorrhea and chlamydia coming larger and softer between 8 tecting this infection.3 Clinicians can instead of the NAAT. For non-NAATs and 10 weeks’ gestation. The adnexa consult with their referral laboratory including culture, an endocervical (ovaries) are then assessed for pain or about performing the wet-mount or specimen must be obtained for chla- masses. Normal ovaries are usually potassium-hydroxide examination if a mydia, because this organism, unlike barely palpable. microscope is not available in the of- gonorrhea, is an intracellular organ- When the examination is completed, fice or if Clinical Laboratory Improve- ism that infects columnar cells. The the patient should be given time to re- ment Act compliance is an issue. NAATs are the most sensitive tests for chlamydia, but depending on move any excess lubricant and offered When indicated, Papanicolaou tests tampons or pads for bleeding. The are obtained by using a Papanicolaou transport issues, culture for gonor- rhea may be equivalent to an NAAT. findings and recommendations are paddle, which is rotated 360° to sam- then discussed once the patient is ple the entire exocervix, and a cyto- Testing using NAATs should not be dressed. brush is used to collect an endocervi- performed sooner than 3 weeks af- cal specimen. The cytobrush can cause ter treatment for chlamydia or gon- The common gynecologic abnormali- bleeding, which may be more promi- orrhea because of the possibility of ties that are identified during pelvic ex- nent in patients with an STI. The patient false-positive results. Blind vaginal amination are listed in Table 3. should be warned about the possibility swab for Trichomonas testing is REASONS TO REFER TO A of some light bleeding or spotting after equivalent to a specimen obtained 2,3,5 GYNECOLOGIST the Pap test. Liquid-based Pap tests during speculum examination. are preferred, because they produce Once the speculum examination is com- The role of the pediatrician is to recog- fewer inadequate readings and false- pleted, the speculum is closed and then nize abnormalities that warrant refer- negative results. An additional benefit carefully removed with posterior pres- ral to a gynecologist and to identify of liquid-based Pap tests is that, in sure while avoiding pinching the sides of common infections that can be treated some cases, STI testing can be per- the vaginal wall. The speculum should without referral. The types of condi- formed on the same specimen. Alter- never be removed in the open position. tions that should be referred to a gyne- natively, direct smearing of a slide, cologist are listed in Table 4 and in- which is immediately fixed before air Bimanual Examination clude masses, chronic pelvic pain, drying, is still used in many laborato- The bimanual examination is per- pregnancy, menstrual disorders unre- ries. It is important to verify with the formed by inserting 1 or 2 fingers into sponsive to medical management,

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TABLE 3 Common Gynecologic Findings Seen Recently, changes were made in the LEAD AUTHORS on Gynecologic Examination recommendations for follow-up of ab- Paula K. Braverman, MD External genitalia normal Pap test results. As opposed to Lesley Breech, MD Bartholin gland abscess Skene gland infection high-grade lesions, low-grade lesions COMMITTEE ON ADOLESCENCE, Genital ulcers/fissures and atypical squamous cells of unde- Warts: condyloma acuminata 2009–2010 Papular lesions (condylomata lata from termined significance should now be Margaret J. Blythe, MD, Chairperson syphilis) followed up by repeat Pap tests at Paula K. Braverman, MD Molluscum contagiosum 1-year intervals. Colposcopy is recom- Cora C. Breuner, MD, MPH Urethral prolapse mended only if the abnormality per- David A. Levine, MD Folliculitis Pamela J. Murray, MD Hidradenitis suppurativa sists or becomes a high-grade lesion Rebecca F. O’Brien, MD Vulvitis over a 2-year period.6 Warren M. Seigel, MD Pigmentary changes Papillomatosis Cervix CONCLUSIONS LIAISONS Ectropion Many gynecologic issues can be man- Rachel J. Miller, MD – American College of Strawberry cervix Obstetricians and Gynecologists Human papillomavirus/condyloma aged by the primary care clinician Jorge L. Pinzon, MD – Canadian Paediatric Cervical polyp without performing a speculum or bi- Society Cervical ulcers Benjamin Shain, MD – American Academy of Vagina manual examination. For conditions Child and Adolescent Psychiatry Ulcers that require a complete pelvic exami- White adherent plaques: Candida species nation, the patient may prefer to have Condyloma acuminata STAFF it performed in a familiar setting Mark Del Monte, JD rather than being referred to another Karen Smith TABLE 4 Reasons to Refer to a Gynecologist provider. There are instances in which [email protected] the pelvic examination must be per- OTHER SUGGESTED READINGS Vulvar or cervical lesion of undetermined etiology formed during a problem visit and can- Possible genital tract anomaly (imperforate hymen, duplicated upper tracts, absence of not be deferred to a separate, dedi- Emans SJ, Laufer MR, Goldstein DP. Pe- vagina, uterus) cated appointment time slot. These diatric and Adolescent Gynecology. 5th Abnormal Pap test result requiring colposcopy ed. Philadelphia, PA: Lippincott, Wil- Acute pelvic pain with possible ovarian torsion, urgent situations may affect office ectopic pregnancy, tubo-ovarian abscess, costs in terms of physician and assis- liams & Wilkins; 2005 adnexal mass tant time. However, providing urgent Cavanaugh RM Jr. Screening adoles- Pelvic inflammatory disease (if the clinician is not comfortable with management) examinations will provide more com- cent gynecology in the pediatrician’s Chronic pelvic pain prehensive continuity of care for the office: have a listen, take a look. Pedi- Dysmenorrhea unresponsive to medical therapy patient. Specific details concerning Abnormal vaginal bleeding unresponsive to atr Rev. 2007;28(9):332–342 billing and coding, including billing for medical therapy or with severe anemia Braverman PK. Body art: piercing, tat- Intrauterine device insertion confidential services, can be found in Pregnancy other AAP publications and policy tooing, and scarification. Adolesc Med statements.10–13 With appropriate Clin. 2006;17(3):505–519, ix backup from a gynecologist, most Morse SA, Ballard RC, Holmes KK, Mo- unknown vulvar or cervical lesions, ab- medical gynecologic issues can be reland AA. Atlas of Sexually Transmit- normal Pap test results requiring managed by the clinician in the pri- ted Diseases and AIDS. 3rd ed. Phila- colposcopy, and genital anomalies. mary care office setting. delphia, PA: Mosby-Elsevier Ltd; 2004 REFERENCES

1. Eaton DK, Kann L, Kinchen S, et al; Centers 3. Huppert JS, Batteiger BE, Braslins P, et al. 5. Sobel JD. What’s new in bacterial vaginosis for Disease Control and Prevention. Youth Use of an immunochromatographic assay and trichomoniasis? Infect Dis Clin North risk behavior surveillance: United States, for rapid detection of Trichomonas vagina- Am. 2005;19(2):387–406 2007. MMWR Surveill Summ. 2008;57(4): lis in vaginal specimens. J Clin Microbiol. 6. American College of Obstetricians and Gy- 1–131 2005;43(2):684–687 necologists. Cervical cancer in adolescents: screening evaluation, and management. 2. Johnson RE, Newhall WJ, Papp JR, et al. 4. Blake DR, Duggan A, Quinn T, Zenilman J, Committee Opinion No. 463. Obstet Gynecol. Screening tests to detect Chlamydia tra- Joffe A. Evaluation of vaginal infections in 2010;116(2):469–472 chomatis and Neisseria gonorrhoeae adolescent women: can it be done without infections: 2002. MMWR Recomm Rep. 2002; a speculum? Pediatrics. 1998;102(4 pt 1): 7. Murphy NA, Elias ER; American Academy of 51(RR-15):1–38 939–944 Pediatrics, Council on Children With Disabil-

PEDIATRICS Volume 126, Number 3, September 2010 589 Downloaded from www.aappublications.org/news by guest on September 28, 2021 ities. Sexuality of children and adolescents tion of aphthosis. J Pediatr Adolesc Gynecol. Pediatrics 2010: A Manual for Pediatric Doc- with developmental disabilities. Pediatrics. 2006;19(3):195–204 umentation and Payment. 15th ed Elk Grove 2006;118(1):398–403 10. Blythe MJ, Diaz A; American Academy of Pe- Village, IL: American Academy of Pediatrics; 8. Centers for Disease Control and Prevention; diatrics, Committee on Adolescence. Con- 2010 Workowski KA, Berman SM. Sexually trans- traception and adolescents. Pediatrics. 13. American Academy of Pediatrics, Commit- mitted diseases treatment guidelines, 2006 2007;120(5):1135–1148 tee on Adolescence, Committee on Child [published correction appears in MMWR 11. American Academy of Pediatrics, Commit- Health Financing. Underinsurance of Recomm Rep. 2006;55(36):997]. MMWR tee on Adolescence. Emergency contra- adolescents: recommendations for im- Recomm Rep. 2006;55(11):1–94 ception. Pediatrics. 2005;116(4): proved coverage of preventive, reproduc- 9. Huppert JS, Gerber MA, Deitch HR, et al. Vul- 1026–1035 tive, and behavioral health care services. var ulcers in young females: a manifesta- 12. American Academy of Pediatrics. Coding for Pediatrics. 2009;123(1):191–196

590 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 Gynecologic Examination for Adolescents in the Pediatric Office Setting Paula K. Braverman, Lesley Breech and The Committee on Adolescence Pediatrics 2010;126;583 DOI: 10.1542/peds.2010-1564 originally published online August 30, 2010;

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Gynecologic Examination for Adolescents in the Pediatric Office Setting Paula K. Braverman, Lesley Breech and The Committee on Adolescence Pediatrics 2010;126;583 DOI: 10.1542/peds.2010-1564 originally published online August 30, 2010;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/126/3/583

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