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Creative :. You can also ask the child to cough in order todistract her and cause her hymen to open. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently.

If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.

The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium.

Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques.

Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating.

The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.

If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse.

Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.

Referral should be made to a gynecologist with experience in pediatric gynecology. Rectoabdominal exam. After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine.

This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses.

The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement.

After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus.

Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors.

After your examination is complete, congratulate the child for her cooperationand bravery. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed.

Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect.

Philadelphia, PA, Raven-Lippincott, Blake J: Gynecologic examination of the teenager and young child. Obstet Gynecol Clin North Am ; Pediatrics ; Gidwani GP.

Approach to evaluation of premenarcheal child with a gynecologicproblem. Clin Obstet Gynecol ; Pokorny SF. The genital examination of the infant through adolescence.

Curr Opin Obstet Gynecol ; Capraro VJ: Gynecologic examination in children and adolescents. Pediatr Clin North Am ; Am J Obstet Gynecol ; Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls.

Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination.

The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases.

The history should include the quality of the discharge color, odor, presence of blood , hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions.

Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.

Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body.

Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation.

Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing.

Clinical manifestations includepruritus, vaginal discharge and odor, vaginal bleeding, dysuria, and vulvarredness and irritation.

Nonspecific vulvovaginitis. Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes.

Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies.

Specific vulvovaginitis. Vulvovaginitis also may be associated with aspecific infectious agent. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.

Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus.

It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact.

N gonorrhoeaerarely persists beyond the newborn period without symptoms. Thus, a positivevaginal culture should be considered evidence of sexual abuse in the child.

Likewise, C trachomatis rarely persists beyond age 2 to 3 years, and mostinfants and toddlers have been treated since birth with an antibiotic thatwould treat Chlamydia.

Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse. Thefinding of genital herpes type 2 is a strong indication of sexual abuse.

Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.

New onset of Trichomonas vaginitis in theprepubertal child is associated with sexual abuse. HPV is also verticallytransmitted and lesions may appear in the first few years of life.

However,new onset of genital warts in the older prepubertal child is associatedwith sexual contact. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse.

Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area.

Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs.

Adult pinworms maybe visible at night. Noninfectious causes of vulvovaginitis also are common.

Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. Vaginal orcervical polyps or tumors also can present with symptoms of vaginitis.

Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. Vulvarskin disorders are common, and often easily recognizable on exam.

Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. Seborrhea also is commonly found on the scalp,behind the ears, and in the nasolabial folds.

Children usually are asymptomatic,but they may present with secondary infection. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous.

Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.

Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. Lichen sclerosus may present as vulvar discomfort or pruritus.

It is characterized by atrophy of the vulvar skin, which causes the labiaand clitoral hood to appear thin, white, and parchment-like. The atrophymay distort the anatomy of the labia and clitoris.

Other findings includeecchymoses and "blood blisters," which often develop after mildtrauma such as riding a bicycle.

Other associations. Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious.

A month passed; we decided to drop the condoms because birth control and presumed lack of STDs. My boyfriend goes to get an unrelated check-up and somehow he has developed chlamydia.

I call my doctor in a panic, assuming I got it from him and need to get re-tested. He's freaking out. I'm freaking out.

My doctor says she'll get back to me ASAP. And when she does? I forgot to call you about your test results! They've been sitting on my desk for three weeks!

I'd also been to the gyno a few times but was always in excruciating pain to the point of tears each time. I saw a woman and had explained this to her before we started.

She was clearly in a rush, so she kind of waved it away and got started. I cried out when she inserted the speculum, and she told me to grow up.

I didn't go to the gyno again for something like six or seven years after that because I was so traumatized. Weight Loss. United States. Type keyword s to search.

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Then she forgot that she had already given me my HIV results and freaked out about looking them up again. I had sex for the first time after swimming and got bacteria vaginosis.

This fake clinic offered an STD test, which I did, of course. They told me that I had herpes simplex 1 and tried to convince me that I couldn't have sex with it even when I don't have a cold sore.

Then they showed me abortion pictures. I cried to my mom and never went back again. There's a lot that's been written about these fake clinics already, and they're all horrifying.

I was finally growing up and found a guy I really liked. A month passed; we decided to drop the condoms because birth control and presumed lack of STDs.

My boyfriend goes to get an unrelated check-up and somehow he has developed chlamydia. I call my doctor in a panic, assuming I got it from him and need to get re-tested.

He's freaking out. I'm freaking out. My doctor says she'll get back to me ASAP. And when she does?

I forgot to call you about your test results! They've been sitting on my desk for three weeks! The vulva and anus. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities.

If extensive labial adhesions are present, you maynot be able to adequately examine the hymen and vagina and will need toreexamine the child after she has successfully completed treatment withlocal hygiene measures and topical estrogen see Sidebar, "Common gynecologicfindings in the prepubertal girl".

Vulvitis and vulvovaginitis usually are characterized by vulvar rednessand irritation, which may be associated with vulvar discomfort, vaginaldischarge and odor, vaginal bleeding, dysuria, or pruritus.

Common causesinclude dermatologic conditions, infections, irritants, and lichen sclerosis. The atrophic tissue of the prepubertal vulva is easily irritated, whichcan lead to nonspecific vulvitis.

Harsh soaps, shampoos, bubblebath, poorhygiene, and tight or wet clothing bathing suits are common culprits. Chronic vaginal discharge, which can occur with a vaginal foreign bodyor vaginitis, also can lead to vulvitis, which is characterized by an erythematous,hyperpigmented, or hyperkeratotic line along the dependent portion of thelabia majora.

Treatment is the same as for labialadhesions. Lichen sclerosis also can present as vulvar discomfort or pruritus.

It is characterized by atrophy of the vulvar skin, which may distort theanatomy of the labia and clitoris, producing ecchymoses and "bloodblisters.

A patient with signs of trauma, such as abrasions, lacerations, or contusions,should be evaluated for suspected sexual abuse.

Viscous lidocaine and warmsaline for irrigation through an IV set-up may be helpful when examininga child who has an acute straddle injury and bleeding.

After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.

In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. Leukorrhea may be present.

The hymen and vagina usually can be seen adequately when a child is inthe supine position, with her legs flexed on her abdomen.

For girls olderthan 2 years, the knee-chest position also permits excellent visualizationof the vagina and cervix without instrumentation.

These procedures are usually performed under anesthesia. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.

Dealing with a foreign body. If on vaginal examination you visualizea foreign body, you may be able to remove it with a cotton-tipped applicatoror by lavaging the vagina with saline or warm water after anesthetizingthe introitus with viscous lidocaine.

Removal under anesthesia may be necessaryif a foreign body has become imbedded into the vaginal mucosa. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass.

Obtaining cultures. When a child has vaginal discharge or bleeding andthe source such as a foreign body is not obvious, obtain samples for cultureand saline preparation.

If you suspect candidal vulvovaginitis, obtain apotassium hydroxide KOH preparation; a Gram stain may be useful if thedischarge is purulent.

Remember that this procedure can be painful to achild if you use a dry cotton swab or do not perform the examination gently. A better way of obtaining specimens from the prepubertal child is to usea nasopharyngeal Calgiswab moistened with nonbacteriostatic saline.

Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin. If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort.

You can also ask the child to cough in order todistract her and cause her hymen to open. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently.

If you needmultiple samples, you can use a small feeding tube attached to a syringecontaining a small amount of saline to perform a vaginal wash and aspiration,or you can insert through the hymen a soft plastic or glass eyedropper with4 to 5 cm of IV plastic tubing attached.

The catheter is placed into the vagina, and the salineis injected into the vagina and aspirated. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium.

Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques.

Cultures for other organisms shouldbe done by placing the Calgiswab into a transport Culturette II with medium,or by sending the aspirated fluid to the bacteriology laboratory for directplating.

The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.

If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse.

Examination of the vagina under anesthesia may be necessary if culturesdo not identify a pathogen, the child has a persistent discharge or bleedingand adequate examination is not possible, or you suspect a foreign body.

Referral should be made to a gynecologist with experience in pediatric gynecology. Rectoabdominal exam.

After obtaining samples, perform a gentle rectoabdominalexamination with the patient either in stirrups or supine.

This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses.

The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement.

After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus.

Abdominal or upper pelvic masses that are palpable mayrepresent ovarian tumors. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors.

After your examination is complete, congratulate the child for her cooperationand bravery. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed.

Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect.

Philadelphia, PA, Raven-Lippincott, Blake J: Gynecologic examination of the teenager and young child. Obstet Gynecol Clin North Am ; Pediatrics ; Gidwani GP.

Approach to evaluation of premenarcheal child with a gynecologicproblem. Clin Obstet Gynecol ; Pokorny SF.

The genital examination of the infant through adolescence. Curr Opin Obstet Gynecol ; Capraro VJ: Gynecologic examination in children and adolescents.

Pediatr Clin North Am ; Am J Obstet Gynecol ; Vulvovaginitis and vaginal bleeding often are found on gynecologic examinationof prepubertal girls.

Labial adhesions, also common, usually are asymptomaticand are more likely to be noticed by a parent or found on routine pediatricexamination.

The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases.

The history should include the quality of the discharge color, odor, presence of blood , hygiene, medications, irritants such assoaps and bubble bath, anal pruritus, enuresis, the possibility of a foreignbody or sexual abuse, any recent infections, and a history of systemic ordermatologic conditions.

Questions about caretakers, behavioral changes,fears, and somatic symptoms may help to diagnose sexual abuse. As described in detail elsewhere in this review, the physical exam shouldinclude an inspection of the perineum, vulva, hymen, and anterior vagina.

Visualization of the vagina and cervix and rectoabdominal examination alsois necessary if a child has persistent discharge, bleeding, pain, or ifyou suspect presence of a foreign body.

Tables 1 and 2 list the differentialdiagnoses of vulvovaginitis and vaginal bleeding. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation.

Risk factors for vulvovaginitis in theprepubertal child include hypoestrogenism, which can lead to an atrophicvaginal mucosa; close proximity of the vagina and anus; lack of protectivehair and labial fat pads; poor hygiene; use of irritants such as bubblebath; and contact with nonabsorbent clothing.

Clinical manifestations includepruritus, vaginal discharge and odor, vaginal bleeding, dysuria, and vulvarredness and irritation.

Nonspecific vulvovaginitis. Nonspecific vulvovaginitis often is associatedwith an alteration in vaginal flora, which may be due to a change in theaerobic flora or overpopulation with fecal aerobes and anaerobes.

Vaginalcultures will reflect normal flora, including lactobacilli, Staphylococcusepidermidis, diphtheroids, Streptococcus viridans, enterococci, and enterics Streptococcus faecalis, Klebsiella species, Proteus species, Pseudomonasspecies.

Specific vulvovaginitis. Vulvovaginitis also may be associated with aspecific infectious agent. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.

Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus.

It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact.

Editor's note: Kelly Wallace is CNN's digital correspondent and editor-at-large covering family, career and life. She is a mom of two girls. CNN -- The tween who took the Internet by storm last year starring in the hilarious and empowering "Camp Gyno" ad , about a girl who is the first at her summer camp to get her period, is back.

Nearly 10 million video views later, Macy McGrail, now a sixth-grader, returns, but this time her focus is on middle school and the consequences of some very bad decisions her character makes along the way.

In a unique twist, year-old McGrail plays the character from tweenhood into adulthood. In the opening scene, we hear a few gunshots ring out and then see McGrail's character racing out of a motor home wearing heels and a leather jacket.

She hops into a car with a guy who looks like bad news, telling herself, "Look at me, 38 years old and I'm running out of this place in this dress to this moron.

We see her when she was six months pregnant at 24 and took back her partner, a serial cheater, before taking a drag on a cigarette. At 15, when her friend told her getting high was "awesome.

Period Power: Talking to girls about 'Aunt Flo'. Sure, it's a tad over the top, but don't you remember kids who went with the wrong crowd in middle school and never quite recovered?

The video, which I'd love to show my girls when they get closer to middle school, is a unique trailer for McGrail's father's new book "Surviving Middle School: An Interactive Story for Girls.

Dave McGrail said the book was in the works long before his daughter's viral fame, but the trailer was, in fact, inspired by that success.

The idea came from Tommy Henvey, a relative who is an executive creative director for the ad agency Ogilvy and Mather, during a holiday party about a year ago.

Replace the 'sex talk' with the 'tech talk'? The book, modeled around the "Choose Your Own Adventure" books McGrail enjoyed as a child, lets the reader decide what to do and tackles some pressing issues affecting today's tweens and teens, who are growing up in a digital age.

For instance, do you stick up for a female classmate from India who is being bulled in person and online by a mean girl who makes fun of her name and her Indian jewelry collection, or do you decide to stay out of it, knowing that if you speak up you might invite the attention of the bully?

Another choice readers of the book face centers on getting an Instagram account and becoming friends with a sixth grader in Ohio, who turns out not to be a sixth grader but a grown man.

Do you continue the friendship or do you cut things off once you learn the truth and start feeling a bit uncomfortable?

What parents can learn about the Internet from Kim Kardashian. The father of two Macy has a younger sister says he hopes his book and trailer will both entertain and spark conversation about issues affecting middle schoolers just as the "Camp Gyno" ad got people talking about menstruation and girl empowerment.

Chances are, your teen has sexted. As for Macy, life is pretty much back to normal after her "Camp Gyno" fame. Her classmates have for the most part been supportive, with the exception of some snickering by the boys from time to time, and she's now focused on middle school and continuing her acting career, said McGrail.

It'll probably be the beginning of her college essay as well," said her proud dad. Do you think the video about the consequences of bad decisions in middle school helps get the point across to tweens and teens?

Digital Life. Print Email More sharing Reddit. The "Camp Gyno" video took the Internet by storm, racking up 10 million views.

Girls Gyno Video

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