Peculiarities of gynecologic examination of children and adolescents

Examination 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 damage to the reproductive system. It is advisable to conduct it according to the methodology adopted by pediatricians and including the following.

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

Depending on the nature of the disease, the anamnesis collection scheme may vary.

3. During a general examination, attention is paid to the general appearance, body weight, height, nature of the skin and the degree of hairiness, development of subcutaneous fat and mammary glands, and the degree of sexual development.

The degree of sexual development is expressed by the formula

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

A four-point system is used for evaluation:

• Ма0Р0Ах0 - up to 10 years;
• Ma1P1Ax1 - 10-12 years - the mammary gland is represented by a "chest point", single straight hairs in the armpit and on the pubis, swelling of the areola, which has a conical shape with the nipple;
• Ma2P2Ax2Mv2 - 12-13 years - moderate axillary and pubic hair, cone-shaped mammary glands with a flat nipple;
• Ma3P3Ax3Me3 - pronounced axillary and pubic hair (curly hair), rounded mammary glands, pigmented areola, nipple rises above the nipple circle (14 years and older).

A morphogram helps to assess the sexual development of a girl, which is drawn according to the indicators of height, chest circumference, the sum of the external dimensions of the pelvis, age. The data obtained during the measurement are applied to the morphogram grid. In healthy girls, the morphogram is represented by a straight line.

4. A 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 at different age periods using special techniques and methods.

1. Examination of the external genitalia: the nature of hair growth (male or female type), structure of the external genitalia, and hymen are assessed.

Hyperestrogenism is characterized by a "juicy" hymen, "swelling" of the vulva, labia minora, and their pink color.

With hypoestrogenism, underdevelopment of the external genitalia and thin, pale, dry mucous membrane of the vulva are observed.

2. Bacterioscopic and bacteriological examination: material is collected using generally accepted methods from the vestibule of the vagina, urethra, paraurethral ducts, excretory ducts of the Bartholin glands, rectum using pediatric catheters, grooved probes, Volkmann spoons, and special sticks.
3. Rectoabdominal examination, which replaces vaginal-abdominal examination in girls, is supplemented by examination of the vagina and vaginal part of the cervix using special children's mirrors.

During a rectal examination, attention is paid to the location of the uterus, its size, mobility, consistency, and the presence of an angle between the body and the cervix. In sexual infantilism, the angle between the body and the cervix is not expressed, the uterus is located high, the ratio of the cervix to the body is 1:1. During palpation of the appendages, attention is paid to the size and shape of the ovaries, their consistency, the presence of adhesions, and tumor-like formations of inflammatory genesis.

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

Additional examination methods include:

Endoscopic methods:

1. vaginoscopy - examination of the vagina and cervix using lighting systems. For this purpose, a vaginoscope, a viewing urethroscope of the "Valentina" type, and children's mirrors with lighting are used;
2. hysteroscopy - examination of the uterine cavity and cervical canal (cervicoscopy) using optical instruments (hysteroscopes). Allows to identify endometrial pathology, malformations, malignant tumors, and 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 localization of the tumor, the nature of the inflammatory process, and the initial forms of endometriosis.

Instrumental methods:

1. probing - vaginal probing is often used in children to detect and remove foreign bodies from the vagina;
2. test puncture - performed on girls in the area of gynatresia 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 that threatens life, suspicion of a malignant tumor).
4. taking an aspirate - due to the easy patency of the cervical canal in girls, taking an aspirate from the uterine cavity for cytological examination is done with a Braun syringe without dilating it;
5. biopsy - performed when there is a suspicion of malignant tumors of the vagina and cervix using a conchotome.

Functional diagnostic methods are widely used in pediatric gynecology to assess the nature of the menstrual cycle.

1. Basal temperature - its measurement is carried out 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. A smear is taken from the upper-lateral vaginal vault with a spatula, cotton swab, children's probe, pipette, etc.

Age-related colpocytology: in the first week of life, superficial cells make up 10%, intermediate cells predominate, from the 7th day of life to 7-8 years - basal and parabasal cells, which indicates low proliferative activity of the vaginal epithelium, due to low estrogen saturation. From 8-9 years, intermediate and superficial cells appear. During puberty, the proportion of highly differentiated superficial cells increases, reflecting the change in phases of the menstrual cycle.

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

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

1. Pneumopelviography (X-ray pelviography, pneumogynecography) - under conditions of pneumoperitoneum, the contours of the internal genitalia are clearly visible: the size and shape of the uterus, ovaries, the presence of tumors, their localization.
2. Hysterography is an X-ray examination of the uterus and fallopian tubes with the introduction of a water-soluble contrast agent into the uterine cavity.
3. Cervicography is an X-ray examination of the cervix with the introduction of a contrast agent into the cervical canal.
4. Hysterography (metrosalpingography) and cervicography provide a clear picture of the internal contours of the genitals.
5. Vaginography - performed if there is a suspicion of vaginal malformations.
6. X-ray of the skull and sella turcica allows us to judge the structure of the bones of the cranial vault, the shape and size of the sella turcica, i.e. indirectly the size of the pituitary gland. The size of the sella turcica is compared with the size of the skull.

In endocrine diseases of central genesis, often accompanied by menstrual dysfunction, changes in the bones of the skull are observed ( osteoporosis or thickening, depressions, etc.).

In case of congenital inferiority of the sella turcica, it is reduced in size. In case of pituitary tumors, it is enlarged or the entrance to it is widened. Finger impressions of the cranial vault indicate hydrocephalus or previous neuroinfection.

The use of X-ray examination 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 safe, painless, allows dynamic observation and allows diagnosing malformations, tumors, and specifying the size of the uterus and ovaries. The method has no contraindications.

Genetic methods are becoming increasingly important in examining girls. The various forms of gonadal dysgenesis are based on structural numerical abnormalities in the sex chromosome system. Each form of dysgenesis is characterized by a specific change in the karyotype, for example, in Shereshevsky-Turner syndrome, the karyotype of patients is 45X0 or 46XX/45X0; in the erased form of gonadal dysgenesis, chromosomal abnormalities are observed in the form of mosaicism - 46XX/45X0 or structural abnormalities of one X chromosome, etc.

During genetic examination, clinical-cytogenetic ( determination of sex chromatin, karyotype ), genealogical, and biochemical research methods are used.

When examining girls, it is recommended to study hemostasiograms, conduct tuberculin tests, and consult with related specialists (ENT doctor, ophthalmologist, neurologist, psychiatrist, etc.).

The scope of the examination should be determined by the nature of the girl’s illness:

1. Inflammatory diseases: detailed recording of anamnesis data, especially infectious, extragenital diseases; clarification of living conditions, parental illnesses, hygiene skills, nutritional conditions, allergy history, metabolic disorders, helminthic invasions; bacteriological and bacterioscopic examination of discharge from the vagina, urethra, rectum; identification of the pathogen and determination of its sensitivity to antibiotics; vaginoscopy.
2. Juvenile bleeding: a comprehensive examination involving a pediatrician, hematologist, endocrinologist, otolaryngologist, and neurologist. When interpreting anamnestic data, attention should be paid to the antenatal period of development, the characteristics of the course of labor, the girl's development in all periods of life, past illnesses, the nature of the menstrual function, and possible adverse effects during this period. In addition to a general and special gynecological examination, patients with juvenile bleeding should study the parameters of the blood coagulation system; examine the composition of vaginal smears. According to indications, chest X-ray, skull X-ray, EEG, ECG are recorded, the functional state of the liver, kidneys, and endocrine glands is determined.

To determine the nature of menstrual cycles, conventional methods of functional diagnostics 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 girl's age. The ratio of the main estrogen fractions is such that more than 50% is estriol; in the 1st phase of the menstrual cycle, the estrone/estradiol ratio is 3.5, in the 2nd phase - 2.8. The level of pregnanediol in urine is low in most cases (up to 1 mg in daily urine), which indicates anovulatory cycles. Their frequency in girls aged 12-14 is 60%, 15 years - 47%, 16-17 years - 43%. Consequently, this is a physiological phenomenon during puberty. In case of menstrual cycle disorders and suspected anatomical changes in the ovaries, it is advisable to use ultrasound examination.

3. Developmental anomalies. When collecting anamnesis, attention should be paid to the possible impact of unfavorable factors in the antenatal period (gynatresia), previous infectious diseases that can cause the occurrence of acquired gynatresia. To clarify the diagnosis, examination with a child's mirror, probing of the vagina and uterus, ultrasound, radiography of the pelvic organs, pyelography, hysterography, computed tomography can be used.
4. Tumors. In case of tumors of the vagina and cervix, vaginoscopy, cytological examination of the vaginal contents, and biopsy using a conchotome are of great diagnostic importance.

If a uterine tumor is suspected, probing, sometimes hysterography and diagnostic curettage of the mucous membrane of the uterine cavity are used.

For patients with suspected ovarian tumors, ultrasound examination, plain fluoroscopy of the abdominal organs, and radiography of the stomach and intestines are used.

5. Traumas of the genitals. In addition to generally accepted methods of examination, if necessary, vaginoscopy, cystoscopy, urethroscopy, digital rectal examination or rectoscopy are performed. X-ray of the pelvic bones is performed if indicated.

Therefore, in each specific case an individual set of research methods must be selected, while it is necessary to proceed from the main thing - obtaining maximum information using the simplest and most gentle examination methods.

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