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  • An understanding of the anatomic and physiologic variations among various age groups is essential to managing childhood gynecological disorders. It is important to take a detailed history and remain compassionate toward the young female prior to and during the physical examination.
  • An external examination of the genitalia and specimen collection, if indicated, is often all that is needed for prepubescent patients. A standard speculum examination is indicated in those patients who are sexually active, those who have bleeding from trauma or a suspected foreign body.
  • Congenital vaginal obstruction may present as an abdominal mass or bulging mass at the introitus. In severe cases, urinary tract infection, obstructive uropathy, and/or septicemia may result from secondary infection of a vaginal obstruction.
  • Treatment of labial adhesions is usually not indicated if the patient is asymptomatic. If treatment is indicated for symptomatic relief of local inflammation and irritation, estrogen cream is the first line of therapy. Surgery is rarely indicated, but necessary if symptoms persist and become severe despite medical treatment.
  • Urethral prolapse occurs most commonly in prepubertal African American female patients. Therapy with estrogen cream has been reported to be successful to reduce swelling of urethral tissue. If symptoms persist despite medical management, surgery to excise the redundant tissue may be indicated.


The emergency physician will have encounters with infants, prepubescent children, and adolescents who present with gynecological disorders. The pathologic processes in infants and young children differ significantly from that of the adolescent female patients. It is important to have knowledge of basic anatomic and physiologic variations among various age groups, as well as be able to provide compassionate and quality care to young female patients. Additionally, it is very important to take a thorough history, including any irritants or medications a child may be using, as well as a careful review of the social setting in which the child inhabits.


Infant and Toddler


The female infant is under the influence of maternal estrogens for the first 8 weeks of life. As a result, the labia majora appears full and there is thickening and enlargement of the labia minora.1 Hymenal tissue stays thick, redundant, and elastic throughout infancy. The hymen tends to surround the vaginal orifice and appears circumferential2 (Fig. 95–1 illustrates the genital morphology). Estrogen levels continue to fall until about 1.5 to 2 years of age.1

Figure 95-1.
Graphic Jump Location

Developmental changes in gential morphology. (A) Infant: hymen circumferential and redundant. (B) Preschool through school age: rudimentary labia minora, thinner hymen. (C) Early puberty: labia minora develop and hymen thickens.


Younger School-Age Children (Ages 3–6)


As the estrogen levels reach their lowest levels between 3 and 9 years of age, the appearance of the female genitalia changes.2 The clitoris is less prominent and the labia become flatter.1 The hymen generally ...

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