Features of gynecological examination of children and adolescents

A survey of girls with various gynecological diseases is divided into general and special.

When conducting a general examination, it is necessary to take into account that a number of somatic diseases can be a direct cause of lesions of the reproductive system. It is expedient to conduct it according to the method adopted by pediatricians and including the following.

1. Anamnesis:
   • family: the age and profession of parents at the time of the birth of the child, the diseases they have suffered, the presence of their bad habits and occupational hazards at the time of the birth of the girl, menstrual function in the mother, the features of the course of pregnancy and childbirth;
   • personal: height and weight at birth, general condition, living conditions in childhood and in puberty, acute infectious diseases, chronic extragenital diseases, surgical interventions, contact with patients with tuberculosis, hereditary diseases;
   • special gynecological history: the age of appearance of secondary sexual characteristics, the age of onset of menarche, the characteristic of the menstrual cycle, the causes and characteristics of menstrual irregularities, the methods of treatment and their effect.
2. Complaints of the patient: the onset of the disease, the sequence of the appearance of symptoms, the nature and localization of pain, the presence of secretions from the genital tract and their nature.

Depending on the nature of the disease, the pattern of anamnesis can vary.

3. At the general inspection pay attention to the general view, body weight, growth, the nature of the skin and the degree of their hair, the development of subcutaneous fat and mammary glands, the degree of sexual development.

The degree of sexual development is expressed by the formula

Ma * P * Ax * Me, where Ma is the mammary gland; Ax - axillary hair; P - pubic hair; Me - the age of menarche.

For evaluation, a four-point system is used:

• Ма0Р0Ах0 - up to 10 years;
• Ma1P1Ax1 - 10-12 years - the mammary gland is represented by the "thorax point", single straight hair in the armpit and pubic region, swelling of the caudal mug, which has a conical shape with the nipple;
• Ма2Р2Ах2Мв2 - 12-13 years - moderate axillary and pubic hair, mammary glands cone-shaped with a flat nipple;
• Ma3P3Ax3Me3 - pronounced axillary and pubic hair (curly hair), mammary glands of a rounded shape, areola pigmented, the nipple rises above the teat cup (14 years and more).

Evaluate the sexual development of the girl helps the morphogram, which is drawn by the indicators of growth, the circumference of the chest, the amount of external dimensions of the pelvis, age. The data obtained during the measurement is applied to the grid of the morphogram. In healthy girls, the morphogram is represented by a straight line.

4. General examination of the systems ends with palpation of the abdomen.

The purpose of a special gynecological examination of girls is to determine both the physiological and pathological state of the genitals in different age periods using special techniques and methods.

1. Examination of external genitalia : the nature of hairiness (according to the male or female type), the structure of the external genitalia, the hymen are evaluated.

For hyperestrogenia characterized by "juicy" hymen, "puffiness" of the vulva, labia minora, their pink color.

When gipoestrogenii marked underdevelopment of the external genitalia, thin, pale, dryish vulvar mucosa.

2. Bacterioscopic and bacteriological examination : the material is taken by conventional methods from the vestibule of the vagina, urethra, paraurethral passages, excretory ducts of the Bartholin glands, rectum with the help of children's catheters, gaunt probes, Folkman spoons, special sticks.
3. Rectoabdominal examination, which replaces vaginal-abdominal in girls, is supplemented by examination of the vagina and vaginal part of the cervix with the help of special children's mirrors.

When rectal examination draw attention to the location of the uterus, its magnitude, mobility, consistency, the presence of an angle between the body and neck. With sexual infantilism, the angle between the body and the neck is not expressed, the uterus is high, the ratio of neck and body is 1: 1. When palpation of appendages pay attention to the size and shape of the ovaries, their consistency, the presence of adhesive process, tumor-like formations of inflammatory genesis.

To avoid diagnostic errors, rectal examination is performed after a cleansing enema in the presence of a mother or a nurse. In children under 4 years it is better to produce it under inhalation anesthesia in the knee-elbow position, the older - on the gynecological chair.

Additional survey methods include:

Endoscopic methods:

1. Vaginoscopy - examination of the vagina and cervix using lighting systems. For this use a vaginoscope, a lookout urethroscope of the "Valentina" type, children's mirrors with illuminators;
2. hysteroscopy - examination of the uterine cavity and cervical canal (cervicoscopy) with the help of optical instruments (hysteroscopes). It allows to identify the pathology of the endometrium, malformations, malignancies, monitor the effectiveness of the treatment;
3. laparoscopy - examination of the pelvic organs and abdominal cavity with an optical device inserted into the abdominal cavity through an opening in the anterior abdominal wall. The method helps to clarify the location of the tumor, the nature of the inflammatory process, the initial forms of endometriosis.

Instrumental methods:

1. Probing - often in children, the vagina is probed to detect and remove foreign bodies from the vagina;
2. test puncture - is performed in girls in the area of gynathesis if there is a suspicion of hematocolpos;
3. diagnostic curettage of the mucous membrane of the uterine cavity is performed in girls according to strict indications ( juvenile bleeding, life threatening, suspicion of a malignant tumor).
4. taking aspirate - because of the easy patency of the cervical canal in girls, aspirate removal from the uterine cavity for a cytological examination is done by a Brown syringe without expanding it;
5. a biopsy - is made at suspicion on malignant tumors of a vagina and shejki uteruses konhotomom.

Methods of functional diagnostics are widely used in pediatric gynecology for judging the nature of the menstrual cycle.

1. Basal temperature - its measurement is performed in girls of pubertal age to determine the presence or absence of ovulation.
2. Colpocytological examination is used to obtain an idea of the hormonal function of the ovaries. The smear is taken from the upper-lateral vaginal vault with a spatula, cotton swab, baby probe, pipette, etc.

Age colpocytology: in the first week of life, surface cells make up 10%, intermediate ones prevail, from the 7th day of life to 7-8 years - basal and parabasal, which indicates a low proliferative activity of the vaginal epithelium due to low estrogen saturation. From 8-9 years, intermediate and surface cells appear. In the period of puberty, the specific gravity of highly differentiated surface cells, reflecting the change in the phases of the menstrual cycle, increases.

In order to clarify the hormonal status of the girl, the level of hormones in the blood and urine is also determined .

X-ray studies are used to identify or exclude a number of pathological conditions in the reproductive system.

1. Pneumopyelviography (X-ray and PG) - under conditions of pneumoperitoneum, the contours of the internal genitals are clearly visible: the size and shape of the uterus, ovaries, the presence of tumors, and their localization.
2. Hysterography - X-ray examination of the uterus and fallopian tubes with the introduction of a water-soluble contrast agent into the uterine cavity.
3. Cervicography - X-ray examination of the cervix with the introduction of contrast material in the cervical canal.
4. Hysterography (metrosalpingography) and cervicography make it possible to get a clear idea of the internal contours of the genital organs.
5. Vaginography - is made with suspicion of malformations of the vagina.
6. Radiography of the skull and Turkish saddle allows us to judge the structure of the bones of the cranial vault, the shape and magnitude of the Turkish saddle, i.e., indirectly about the size of the pituitary gland. The size of the Turkish saddle is compared with the size of the skull.

With endocrine diseases of central genesis, often accompanied by violations of menstrual function, there is a change in the bones of the skull ( osteoporosis or thickening, depression, etc.).

With the inferiority of the Turkish saddle, it is reduced in size. With tumors of the pituitary gland - increased or the entrance to it is enlarged. Finger impressions of the cranial vault indicate hydrocephalus or a transferred neuroinfection.

The use of X-ray methods in girls, despite their sufficient information content, must be strictly justified.

Ultrasound examination is one of the most modern and widespread methods of non-invasive diagnostics. It is distinguished by safety, painlessness, the possibility of dynamic observation and allows to diagnose malformations, tumors, to clarify the size of the uterus and ovaries. The method has no contraindications.

Genetic methods are becoming increasingly important in the survey of girls. At the heart of various forms of gonadal dysgenesis are structural numeric disorders in the system of sex chromosomes. For each form of dysgenesis, a certain change in the karyotype is characteristic, for example, in the Shereshevsky-Turner syndrome, the karyotype of 45X0 or 46XX / 45X0 patients; chromosome anomalies in the form of mosaicism - 46XX / 45X0 or structural anomalies of one X chromosome, etc., are observed with the erased form of gonadal dysgenesis.

In the genetic examination, clinical-cytogenetic ( definition of sexual chromatin, karyotype ), genealogical, biochemical methods of investigation are used.

When examining girls, study of hemostasiograms, tuberculin samples, consultations with related specialists (ENT doctor, oculist, neurologist, psychiatrist, etc.) is shown .

The scope of the survey should be determined by the nature of the girl's illness:

1. Inflammatory diseases: a detailed account of the history, especially infectious, extragenital diseases; clarification of living conditions, parents' diseases, hygienic skills, nutrition conditions, allergic anamnesis, metabolic disorders, helminthic infestations; bacteriological and bacterioscopic examination of vaginal discharge, urethra, rectum; identification of the pathogen and its sensitivity to antibiotics; Vaginoscopy.
2. Juvenile bleeding: a comprehensive examination involving a pediatrician, hematologist, endocrinologist, otolaryngologist, neuropathologist. In the interpretation of anamnestic data, attention should be paid to the antenatal development period, the peculiarities of the delivery process, the development of the girl during all periods of life, the transferred diseases, the nature of menstrual function and possible adverse effects during this period. In addition to general and special gynecological examination in patients with juvenile bleeding, it is necessary to study the parameters of the blood coagulation system; to investigate the composition of the vaginal smears. According to the indications, fluoroscopy of the chest, x-ray of the skull, EEG, ECG, the functional state of the liver, kidneys, endocrine glands is determined.

To determine the nature of menstrual cycles, the usual methods of functional diagnosis are used, the level of hormones in the blood and urine is determined. The amount of hormone excretion depends on the duration of menstrual function and to a lesser extent on the age of the girl. The ratio of the main fractions of estrogens is such that more than 50% is estriol; in the first phase of the menstrual cycle, the ratio of estrone / estradiol is 3.5, in the 2 nd phase - 2.8. The level of pregnanodil in the urine in most cases is low (up to 1 mg in the daily urine), which indicates anovulatory cycles. Their frequency in girls 12-14 years - 60%, 15 years - 47%, 16-17 years - 43%. Consequently, in the period of puberty this phenomenon is physiological. In cases of menstrual irregularities and suspected anatomical changes in the ovaries, it is advisable to use ultrasound.

3. Anomalies of development. When collecting an anamnesis, attention should be paid to the possible effects of adverse factors in the antenatal period (gynathesis), transferred to infectious diseases, which may cause the emergence of acquired gynatrace. To clarify the diagnosis, examination with children's mirrors, probing of the vagina and uterus, ultrasound, radiography of pelvic organs, pyelography, hysterography, computed tomography can be used.
4. Tumors. With vaginal and cervical tumors, vaginoscopy, cytological examination of the contents of the vagina, biopsy with the help of a snubber is of great diagnostic importance.

When suspected of swelling of the uterus, sounding is used , sometimes hysterography and diagnostic curettage of the mucous membrane of the uterine cavity.

Patients with suspected ovarian tumors use ultrasound, an overview fluoroscopy of the abdominal cavity organs, and a radiograph of the stomach and intestines.

5. Injuries to the genital organs. In addition to conventional research methods, if necessary, vaginoscopy, cystoscopy, urethroscopy, digital rectal examination or rectoscopy are performed. According to indications, radiography of pelvic bones.

Therefore, in each specific case, an individual set of research methods should be chosen, while the main thing is to obtain maximum information by the most simple and sparing survey methods.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],