THE PEDIATRIC DIAGNOSTIC EXAMINATION - PART 10 pps

The Pelvic Examination 729 and theca lutein cysts. Other benign ovarian tumors include dermoids (mature cystic teratomas) and sex cord tumors (thecomas, fibromas, and gonadoblastomas). Fibromas are associated with the Meig s syndrome (ascites, pleural effusion, and fibrous ovarian tumor), usually seen in adult females. Gonadoblastomas occur in those with gonadal dysgenesis and a Y chromosome. They are at increased risk fo r a malignant germ cell tumor, and the gonadoblastomas may be associated with primary amen- orrhea, virilization, and developmental abnormalities. The most com- mon malignant ovarian neoplasm in adolescent females is the ge rm cell carcinoma [dysgerminoma (most common), embryonal carcinoma, endoder- mal sinus tumor, polyembryoma, choriocarcinoma, and immature teratoma]. Other malignant ovarian neoplasms include the Sertoli-Leydig cell tumor associated with virilization and the granulosa cell tumor associated with iso- sexual precocity. (See Essential Adolescent Medicine, Greydanus DE, Patel DR, Pratt HD, eds. New York: McGraw-Hill, 2006, p. 608–612.) Vaginal Discharge TABLE 21–5 re views various causes of vaginal discharge in adolescent females. Vaginal discharge in an ado- lescent may be an indication of normal estrogen stimulation or geni- tal infection owing to sexual activity. Physiologicle ukorrhea develops in young adolescents be cause of estrogen stimulation, typically appear- ing some months before menarche and continuing for a number of years after menarche. The discharge can be cle ar to white, watery to mucoid, an d scant to copious in nature; there is no odor or irritation. Non- sexually active adolescents also may develop a vaginal discharge owing to vaginal foreign-body retention, group A streptococcal infectio n, genital contact dermatitis, candidiasis (Candida albicans, C. glabrata), or bacterial vaginosis. Sexual behavior also can be involved with the development of candidiasis, group A streptococcal infect ion, and bacterial vaginosis. Sexually active adolescent females may develop a vaginal discharge because of acquisition of an STD or infection (STI). STD agents include C. trachomatis, N. gonorrh oeae, herpes simplex virus, and T. vaginalis. Ado- lescents are at increased risk for STDs because of high sexual activity rates, multiple sex partners, use of sex and drugs concomitantly, imma- ture cervix, magical thinking of adolescence (i.e., no harm will come to them despite high-risk behavior), and difficulty dealing with the med- ical system for treatment. TABLE 21–6 considers STDs not reviewed in TABLE 21–5. The Pelvic Examination Most adolescents have unspoken fears and anxiety regarding the pelvic examination. Clinicians also vary in their degree of comfort, skill, and knowledge of performing this examination. Many clinicians use an adult model to per form the pelvic examination. While the technique may not be significantly different, the levels of sensitivity, communication, and patience required for an adolescent are significantly diff erent. The pelvic KEY PROBLEM 730 TABLE 21–5 Vaginal Discharge in Adolescent Females Cause of Condition Laboratory or Disorder Special Comment Differential Diagnosis Testing Physiologic leukorrhea (due to estrogen stimulation) Foreign body (tampons, toilet paper, others) Group A Streptococcus Contact dermatitis Physiologic process that starts weeks to months before menarche and cont inues for some years thereafter; can be increased by oral contraception; adolescent may complain of yellow staining of underpants. Retained foreign bodies in the vagina can lead to a brown or bloody foul-smelling vaginal discharge. Vagin al discharge that is sometimes bloody; it may or may not be associated with a streptococcal pharyngitis and sexually activity Chemical irritation of the genitalia can lead to a sensitization reaction; can see vaginitis, ureth ritis, proctitis, or dermatitis of the external genitalia; precipitants can include bubble baths or soaps, vaginal deodorant sprays, douches, perfumes, latex condoms or diaphragms, vaginal spermicides, sexual lubricants, and other s. STDs if sexually active; bacterial vaginosis if there are symptoms (as vaginal odor) Group A streptococcal vaginitis Foreign body vaginitis Scabies, pediculosis, eczema, tinea cruris, psoriasis, eczema, other types of dermatitis (see Chapt er 16) Saline preparation of vaginal fluid (normal results Foreign-body visualization Vaginal culture Examine for fungi, scabies, (Sarcoptes scabiei) and pediculosis (Phthirus pubis). Candida albicans (other Candida spp. such as C. glabrata) Bacterial vaginosis Vulvitis with pruritic, red, excoriations; vaginitis with white, thick, curdlike patches on the vaginal wall and cervi x; can be precipitated by diabetes mellitus, use of oral corticosteroids, antibiotics, and pregnancy. Clinical syndrome owing to the normal flora of Lactobacillus spp. being replaced by anaerobic bact eria such as Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus spp., Prevotella; sexually associated disorder; also seen in non-sexually active female adolescent; thin, white, malodorous, nonirritating, an d nonpruritic vaginal discharge that clings to vaginal walls. Tinea cruris, chemical vaginitis, other STDs if sexually active Chemical vaginitis, candidiasis; if sexually active: trichomoniasis Wet mount (saline or 10% KOH to d emonstrate yeast or pseudohyphae); Gram stain; fungal culture (Nickerson medium) Wet mount with clue cells [epithelial cells covered (“studded”) with many gram- negative bacilli]; “whiff test”: fishy odor be fore and after 10% KOH is added; gram stain; vaginal fluid pH <4.5. (Continued) 731 TABLE 21–5 Vaginal Discharge in Adolescent Females (Continued) Cause of Condition Laboratory or Disorder Special Comment Differential Diagnosis Testing Trichomonas vaginalis (unicellular, flagellated protozoan) Chlamydia trachomatis STD that can be asymptomatic; dysuria; vaginitis, cervicitis, secondary vulvitis; copious, intensely p ruritic greenish (or gray or yellow-green), frothy (“bubbly”) discharge; may be malodorous; pH of 5.0 to 5.5 or higher; vaginocervical ecchymosis (“strawberry marks”); swollen vaginal papillae. STD that can be asymptomatic; cervicit is with vaginal red mucosa, hypertrophic cervical erosion, and purulent (mucopurulent) cervical discharge), PID, perihepatitis (Fitz-Hugh-Curtis syndrome), proctitis, pharyngitis, and others; infections in male s also include urethritis, nongonococcal urethritis (NGU), prostatitis, and epididymitis. Bacterial vaginitis, chemical vaginitis, candidiasis, urethritis, cystitis. Gonorrhea, trichomoniasis, bacterial vaginosis Mycoplasma genitalium, U. urealyticum Saline prep. (moving trichomonads), Pap smear, rare:culture Cell culture, nucleic acid amplification tests or NAATs (i.e., polymerase chain reaction, l igase chain reaction, others), enzyme-linked immunoassay (EIA, ELISA), direct fluorescent antibody (DFA), and DNA probe (Gen-Probe PACE 2 assay) 732 Neisseria gonorrhoeae Mucopurulent cervicitis (MPC) Cervicitis [PMNs (polymorphonuclear leukocytes)/1000× magnification); purulent or mucopurulent cervicitis (MPC); bartholinitis, pharyngit is, PID, perihepatitis (Fitz-Hugh- Curtis syndrome), disseminated gonococcal infection (including dermatitis, arthritis), and others; menorrhagia can be seen; infections in males also include ure thritis, nongonococcal urethritis (NGU), prostatitis, orchitis, and epididymitis. Cervicitis with a purulent or mucopurulent (yellowish) discharge in the cervix and vagina sometimes caused b y N. gonorrhoeae or C. trachomatis; sometimes no microbe identified. Chlamydia, trichomoniasis, bacterial vaginosis, Mycoplasma genitalium, U. urealyticum Gram stain of the discharge (pairs of gram-negative, kidney-bean-shaped diplococci); culture with Thayer-Martin medium in a 10% carbon dioxide environment; DNA hybridization techniques (Gen- Probe), and NAAT s. Gram stain of the cervical discharge; laboratory testing for N. gonorrhoeae or C. trachomatis. (Continued) 733 TABLE 21–5 Vaginal Discharge in Adolescent Females (Continued) Cause of Condition Laboratory or Disorder Special Comment Differential Diagnosis Testing Herpes simplex virus Herpes genital infection is due to HSV type 2 and type 1; cervicitis (often with a mucopurulent discharge) along with vulvar ulcerations (see Chapter 16); an area of pruritus or hyperesth esia may first develop, followed by small-group vesicles on erythematous bases; these lesions become small, shallow, painful ulcers on the genitals along with inguinal lymphadenopathy. Primary syphilis (Treponema pallidum); chanc roid (Haemophilus ducreyi); contact dermatitis; molluscum contagiosum Viral serology, immunofluorescent techniques, and culture with typing are available as diagnostic tests; glycoprotein G- based HSV-2 enzyme- linke d immunoassay also available; Gie msa stain or Wright stain (Tzanck test) of material collected from a vesicle or ulcer will reveal balloon cells with intranuclear bodies or multinuclear giant cells; Pap smear also may show the multinucl ear giant cells; electron microscopy reveals viral herpetic particles. Abbreviations: KOH = potassium hydroxide; NAAT = nucleic acid amplification test; U = Ureaplasma; Pap = Papanicolaou. 734 TABLE 21–6 Sexually Transmitted Diseases Cause of Condition or Disorder Special Comments Differential Diagnosis Laboratory Chancroid Syphilis Granuloma inguinale Due to H. ducreyi and characterized by genital ulcers, especially in males (penile ulcers); starts as small erosion that is red and becomes a painful ulcer(s); unilateral, suppur ative inguinal lymphadenopathy. Due to T. pallidum; red ulcer called a chancre develops that is not painful unless complicated by secondary infection (see Chapter 16); inguinal lymphadenopathy develops that is non tender and unilateral or bilateral; chancre is the primary stage; untreated, other stages develop: secondary, asymptomatic, early latent, late latent, late (tertiary), neurosyphilis, and relapsing ( owing to HIV/AIDS). Due due to Calymmatobacterium granulomatis; starts as an erythematous papule (nodule) that becomes a painless ulcer with granulation tissue; inguinal granulomas may look like inguinal lymphadenopathy and are called pseudobubos; rare in the United States. Syphilis, granuloma inguinale, lymphogranuloma venereum, genital herpes Chancroid, granuloma inguinale, lymphogranuloma venereum, genital herpes Chancroid, lymphogranuloma venereum, sy philis, genital herpes Rule out other STD genital ulcers; PCR test for chancroid available; chancroid culture if available. Nontreponemal tests (RPR,VDRL), treponemal tests (FTA- ABS, MHA-TP); dark- field examination for T. palli dum. Rule out other STD ulcers; Donovan bodies on tissue smear; biopsy. 735 (Continued) TABLE 21–6 Sexually Transmitted Diseases (Continued) Cause of Condition or Disorder Special Comments Differential Diagnosis Laboratory Lympho- granuloma venereum Genital warts C. trachomatis (serovars L 1 , L 2 , or L 3 ; erythematous papule that may be missed and is sometimes painful; inguinal lymphadenopathy with the groove sign (nodes above/below the inguinal ligament); may see fever, malaise, myalgias, arthralgias; rectal sex l eads to protocolitis with fistulas and strictures; rare in the United States. Human papillomavirus (HPV); >100 types; often asymptomatic; warts or condylomas (see Chapter 16) can be seen on the genitals; see link of 15 oncogenic typ es (such as 16, 18, 31, 45, and others) to cervical neoplasia. Scabies, pediculosis, eczema, tinea cruris, psoriasis, eczema, other types of dermatitis (see Chapter 16) Molluscum contagiosum, condyloma lata (syphilis), urethral prolapse, skin tags (perianal), and benign pearly penile papules (males) Rule out other STD ulcers; complement fixation. Biopsy; colposcopy; cytology (Pap smear); molecular diagnostic modalities (in situ hybridization, dot-blot [ViraPap/Vira Type]), Southern blot and PCR. 736 737 HIV/AIDS (human immuno- acquired virus/ deficiency immuno- deficiency syndrome) Sexually acquired enteric infections Pinworms Pediculosis pubis HIV-1 in the United States; HIV-2 in other places such as West Africa; tr ansmitted via sexual behavior but also intravenous drug use and breast-feeding; half of new cases in U.S. occur to those under age 25; over 50 million humans are infected globally, with 30 million deaths due to HIV/AIDS. Mainl y seen in homosexuals with oral to anal or oral to oral sex; organisms noted include Shigella spp., Giardia lamblia, Entamoeba histolytica, and Campylobacter jejuni; can lead to enterocolitis or proctitis; some have no symptoms. Pinworms travel to the vagina and cause intense pruritus, especially at night; can be sexually acquired; see Chapter 20. Infestation of lice (Phthirus pubis) on pubic hair as well as p erineal and axillary hair; also seen in eyelashes; intense pruritus can develop, leading to mild to severe skin excoriations; often sexually acquired but also spread via fomites (bedding or clothes). Broad differential; acute retrovir al syndrome of HIV/AIDS develops within first few weeks after infection and presents with fever, malaise, skin rash, and lymphadenopathy Differential diagnosis of proctitis and enterocolitis Tinea cruris, chemical vaginitis, candidiasis Scabies, tinea cruris, chemical vulvitis HIV antibody testing (HIV-1, HIV-2): enzyme immunoassay (EIA) as screening test; confirm with Western blot (WB) or IFA (immuno fluorescence assay); plasma HIV RNA Stool culture and stool exam ination for bacteria and parasites Stool examination; cellophane tape test Pubic hair examination using a hand lens to see the adult form and/or the eggs (“nits”). (Continued) [...]... covered The clinician should remind the patient of the steps of the procedure and the reason for the examination The table’s stirrups should be in proper position Ask the patient to place her heel into the stirrups, and then ask her to slide down to the edge of the table such that her buttocks are slightly over the edge, providing reassurance that she will not fall The table may be slightly elevated and the. .. positive-result curve to the right of the threshold) is the probability of detection of a positive result, while PFA (the % area under the negative-result curve to the right of the threshold) is the probability of a false-negative result The % area under the positive-result curve to the left of the threshold is the probability of missing a positive result Increasing the threshold will decrease PFA and... result The curve on the right shows possible test values for a known (by a gold-standard test) positive result, while the curve on the left shows possible test values for a known negative result d is the difference between the mean values for positives and negatives; the variance is the same for the two results For a particular threshold value PD (the % area under the positive-result curve to the right... their bodies and feel uncomfortable with allowing others to view their genitals and breasts Demystify the female genitalia by allowing the adolescent to take part in the examination One can do this by having a mirror that the patient can hold and view her genitalia while the clinician is performing the examination Obtaining knowledge of the internal and external genitals and their function allows the. .. threshold values (The x axis is actually 1 minus the specificity, or the probability of a false alarm.) The upper-right corner represents 100 percent sensitivity and zero specificity, whereas the lower-left corner is the point of zero sensitivity and 100 percent specificity A perfect test has an ROC curve that passes through a point in the upper-left corner of the graph that corresponds to 100 percent sensitivity... your index finger in the vagina and the middle finger into the rectum Repeat the maneuver from the bimanual examination This component should not be neglected, especially in the evaluation of abdominal pain or in assessing a retrodisplaced uterus This maneuver also allows palpation of the uterosacral ligaments, cul-de-sac, and the adnexa Synthesizing a Diagnosis TABLE 21–7 lists the clinical high points... bimanual examination by lubricating the index and middle fingers of one of your gloved hands Allow the lubricant to drop to 742 Chapter 21: The Gynecology System and the Adolescent your fingers to avoid contamination From a standing position, introduce one finger and then, if able, the second finger into the vagina Abduct the thumb, and with the other hand press downward on the lower abdomen Palpate the. .. remove the finger Once past the sensitive urethra, turn the speculum horizontal, and tilt toward the rectum Slowly open the speculum blades, allowing the cervix to come into view Secure the speculum in an open position that allows the clinician to obtain any needed specimens Obtaining the Papanicolaou smear consist of acquiring endocervical cells by placing the longer end of the wood scraper in the cervical... include the transformation zone at the squamous-columnar junction Remove and place the specimen onto a glass slide Next, obtain ectocervical cells by placing the endocervical brush inside of the cervical os Roll it between your fingers (thumb and index) 360 degrees Remove the brush, and roll the brush against the glass slide You may use the previous slide that contains the endocervix specimen or another... Place the slide into an alcohol solution or apply the special fixative Alternatively, the provider may obtain a liquid-based cytology by placing the specimens directly into preservative Inspect the vagina on withdrawal of the speculum slowly making note of color, inflammation, discharge, or ulcers As the speculum clears the cervix, release the lock on the speculum, close and withdraw, reversing the insertion . and then, if able, the second finger into the vagina. Abduct the thumb, and with the other hand press downward on the lower abdomen. Palpate the cervix, uterus, and either side of the fal- lopian. take part in the examination. One can do this by having a mirror that the patient can hold and view her gen- italia while the clinician i s performing the examination. Obtaining knowl- edge of the. it over the middle fin - ger; remove the finger. Once past the sensitive urethra, turn the specu- lum horizontal, and tilt toward the rectum. Slowly open the speculum blades, allowing the cervix