Gynecologic Evaluation in Children and Adolescents

Gynecologic evaluation of prepubertal children is done only if there is a medical indication and involves a focused examination based on the specific symptoms or concerns. The knowledge of prepubertal anatomy and different stages of puberty is important for accurate documentation of the findings.

The medical history is obtained from the parent (or caregiver) and the child, if age-appropriate. The parent and child should be educated regarding the examination so they know what to expect and to build trust between the patient and clinician. The goal of the examination should be to obtain necessary information without causing fear or unnecessary discomfort to the child.

For most vulvar or vaginal conditions in children, external examination is sufficient. Young children can be examined on their parent’s lap. Older children can be examined in the knee-chest or frog leg position or on their side with one knee drawn up to their chest.

If there is a vaginal discharge and infection is suspected, cultures can be obtained using one of the following techniques:

• Gently insert along the hymenal ring a sterile cotton swab moistened with sterile saline

• Squirt sterile saline into the vagina; use 3 swabs held near the introitus to collect saline expelled while the child coughs

• Attach a syringe filled with sterile saline to a catheter; insert catheter into the vagina and instill a small amount of saline; remove sample by pulling back on the syringe's plunger

Without confirmation of fungal culture, prepubertal girls should not be treated for Candida infection. If sexual trauma is suspected, testing for sexually transmitted infections can be done.

Internal pelvic examination is warranted in some cases, if there are persistent genitourinary symptoms or a vaginal or upper genital tract abnormality is suspected. Examples of issues that require an internal pelvic examination include physical trauma, sexual assault, unexplained vaginal bleeding, suspected foreign body, or genital tract or pelvic mass. Normal anatomical variants or common vulvar conditions (eg, failure of midline fusion, urethral prolapse, labial adhesions, pemphigoid, or hymenal abnormalities) should not be confused with physical injury.

In children, internal pelvic examination is typically performed as an examination under anesthesia. The vagina and cervix may be examined using Killian nasal speculum, a fiberoptic vaginoscope, cystoscope, or flexible hysteroscope with saline lavage.

In children, pelvic masses may be palpable in the abdomen.

An adolescent's medical history may be obtained with or without the patient's parent (or caregiver) present. Obtaining the medical history without the parent or caregiver present may make an adolescent feel more comfortable while speaking with the clinician, especially regarding sexual history, sexually transmitted infections (STI) testing and test results, contraceptive counseling, or sexual abuse. However, sometimes patients are more comfortable discussing menstrual history in the presence of a caregiver, and sometimes the caregiver can give more precise information about menstrual patterns than the adolescent, who may ignore certain details. In the United States, state laws vary regarding the definition of a minor and which medical decisions, if any, a minor can make without consent from a parent or legal guardian.

Pelvic examinations are done in patients < 21 years only when medically indicated (eg, gynecologic symptoms, risk factors for STIs). A pelvic examination is not required before initiating most types of contraception, except for an intrauterine device (2).

For adolescents who are not sexually active, the examination is similar to that of children (ie, internal examination, if required, may need to be performed under anesthesia).

Adolescents who are sexually active may be offered a pelvic examination at the time of routine preventive care visits. However, if the patient declines a pelvic examination and has no current symptoms, clinicians can test for some STIs using a first-void urine sample or a self-collected vaginal swab and thus avoid doing an internal pelvic examination. For all sexually active females < 25 years, the Centers for Disease Control and Prevention (CDC) recommends annual screening for gonorrhea and chlamydia infection (see CDC: Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources).

General physical examination should include measurement of height and weight. Other measurement may be done in cases of short stature or genetic or chromosomal disorders. Pubertal status should be assessed. Signs of endocrine disorders, such as enlargement of the thyroid, hirsutism, acne, male-pattern baldness, or clitoromegaly, should be noted.

During the visit, information about contraception, safer sex, and STI testing should be offered as appropriate, and the human papillomavirus (HPV) vaccine should be discussed and offered.

1. 1. French A, Emans SJ. Office Evaluation of the Child or Adolescent. In: Emans SJ, Laufer MR, DiVasta A, eds. Emans, Laufer, Goldstein's Pediatric and Adolescent Gynecology. 7th ed. Wolters Kluwer; 2019; 3-22

2. 2. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice: Opinion No. 754: The utility of and indications for routine pelvic examination. Obstet Gynecol 132 (4):e174–e180, 2018 (reaffirmed 2020). doi: 10.1097/AOG.0000000000002895