Physical Examination

As is the case for most pediatric presentations in the ED, children should be completely undressed and thoroughly examined. This enables physicians to look for subtle signs of disease, injury, and abuse. A child's development of secondary sex characteristics should be assessed and compared with the Tanner stages of breast and pubic hair growth. Most premenarchal girls should not undergo a speculum examination or vaginoabdominal palpation except in the event of vaginal bleeding and trauma. The vast majority of examinations and procedures can be done with the parent holding the child.

Young children presenting with vaginal bleeding or trauma can be examined on the parent's lap. Children older than age 3 should be comfortable supine, lying "like a frog," for the examination of the external genitalia (Fig 98-24). Draping of the legs and perineum is unnecessary and usually cumbersome. Visualization of the vagina is best done by asking the child to "get up on your hands and knees like you are crawling" ( Fig, 98-2B). She can rest her head on her forearms and look at her parent.

The labia and buttocks are gently pressed upward and outward. If the child relaxes the abdominal and back muscles, the resulting lordosis should enable one to see the lower half of the vagina with an otoscope light. Children over age 3 may also be examined while they are supine in the knee-chest position, like a "cannonball."

Supine Position For Vaginal Examination

If cultures are indicated, they should be taken with the child in the supine position with a saline-soaked cotton-tipped swab or a soft medicine dropper. If the findings of the vaginal examination are suboptimal, or if a pelvic mass or foreign body is suspected, a rectoabdominal examination should be performed while the child is in the frog-leg position. The cervix is palpated as a midline button of tissue often described as similar in size and consistency to the eraser on a pencil. The ovaries and uterus should not be palpable. The vagina can be "milked" for blood or discharge.

The use of restraints for pelvic and vulvar examination has no role in modern practice. Conscious sedation or general anesthesia may be required to obtain an adequate examination. A speculum examination should not be performed without appropriate anesthesia.

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