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  • Congenital vaginal obstruction may present as an abdominal mass or bulge at the introitus.

  • Treatment of asymptomatic labial adhesions is not indicated. For symptomatic relief, use estrogen cream as the first line of therapy.

  • Urethral prolapse occurs most commonly in prepubertal African American females. Therapy with estrogen cream may reduce swelling of urethral tissue.

  • Obtain a pregnancy test in all postmenarchal patients.

  • Obtain a thorough sexual and menstrual history in all adolescent patients.

  • Screen all sexually active patients for sexually transmitted infections (STIs).

  • The diagnosis of ovarian torsion is clinical. Evidence of an abnormal or enlarged ovary on ultrasound, with or without Doppler flow studies, in addition to the physical exam can help with the diagnosis.

  • In patients with complex ovarian cysts, tumor markers (e.g., AFP, serum HCG, LDH, and CA125) may be helpful to rule out malignancy.

  • Treat most labial abscesses with incision and drainage; for Bartholin’s abscesses, insert a Word catheter.

  • Pelvic pain can be caused by gynecologic and non-gynecologic sources, so it is important to evaluate all possible etiologies

  • Conduct a gynecological examination (if amenable to it), wet prep collection, and investigation into STIs in patients with a complaint of vaginal discharge and/or pruritus.

  • Most cases of genital trauma are accidental straddle injuries; however, consider the possibility of sexual abuse.

  • If sexual abuse is suspected, contact child protective services (CPS).


Infancy (birth to age 2): The female infant is under the influence of maternal estrogens for the first 6 months of life. Breast buds may be present, the labia majora appear full, and there is thickening and enlargement of the labia minora.1 Hymenal tissue stays thick, redundant, and elastic throughout infancy. The hymen surrounds the vaginal orifice and appears circumferential.2 Estrogen levels fall within the first 6 months of life and continue to fall steadily until about 1.5 to 2 years of age.1

Toddlers and younger school-age children (ages 2–6): As the estrogen levels reach their lowest levels between 3 and 9 years of age, the appearance of the external female genitalia changes, although there is high degree of variability in the timing of these changes.2 The clitoris is less prominent and the labia become more flat.1 The hymen generally becomes thinner and may appear translucent, having a “crescentic” appearance as the hymenal tissue recedes from the anterior vaginal orifice. As a result of low estrogen, the vaginal pH during this time is alkaline.2

Older school-age children (ages 7–12): The labia continue to develop, the hymen thickens, and the vagina elongates to about 8 cm. The vaginal mucosa thickens during this time and the vaginal pH becomes acidic. A thin white vaginal discharge known as physiologic leukorrhea may be noted during this time.1,2

Adolescents (ages 12–21): The labia are well developed and the hymen ...

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