Circumferential hymen elasticity. A marker of physiologic maturity.

OBJECTIVE: To study the relationship between anatomic changes in the peripubertal female and sex hormonal maturation. STUDY DESIGN: Medical records were reviewed on virginal females whose first gynecologic examination occurred between ages 9 and 20 and who were examined at least twice by the same gynecologist. Speculum sizes at each visit were surrogate measures of circumferential hymenal elasticity, the anatomic change of interest. RESULTS: Mean ages at the two visits for the 35 patients were 14.6 and 16.7 years, respectively, with substantial overlap in ages between visits. Average Tanner breast and pubic hair stages and speculum sizes were greater at the second visit (P < .001). At first visit, age, Tanner breast and pubic hair stages, and time elapsed from menarche, thelarche and pubarche correlated positively with larger speculum sizes (P < .10). Change in speculum size between visits was associated with younger age and lower Tanner pubic hair stages at first visit and with increases between visits in age, body mass index and Tanner pubic hair stages. Larger changes were associated with shorter elapsed time between the first visit and menarche, thelarche and pubarche. CONCLUSION: Circumferential hymenal elasticity increases during adolescence. This anatomic change, the surrogate measure of which is specula diameter, can be used along with Tanner staging as a measure of physiologic maturity in adolescent women.

Long-term intravaginal presence of foreign bodies in children. A preliminary study.

The similar clinical features of childhood sexual abuse, isolated premature menarche and intravaginal foreign objects prompted a preliminary study of the anatomic features of intravaginal foreign objects in premenarchal females.

The genital examination of the infant through adolescence.

The genital examination of the young female is a relatively new procedure for many clinicians. It was not felt important until physicians became involved with the examination of survivors of childhood sexual abuse; from these examinations it is apparent that young females also have a broad array of genital conditions which need clinical evaluation and intervention. This review of the recent literature on the techniques employed by a variety of clinicians demonstrates the limitations placed on our knowledge of pediatric and adolescent gynecologic conditions by technical and psychosocial parameters.

Acute genital injury in the prepubertal girl.

In an effort to develop guidelines for the management of acute genital injuries in prepubertal girls, we categorized 32 cases by the object that allegedly caused the injury: straddle injuries, nonpenetrating injuries, penetrating injuries, and torque injuries. Using these categories and the anatomic features of symmetry and/or hymenal transection, we determined that the most dangerous injuries were the penetrating injuries that were symmetric and transected the hymen; in this series these were all the result of sexual assault. Future studies are needed to determine if these unique injuries can be managed with less physical and psychosocial trauma to the young patient.

Prepubertal vulvovaginopathies.

The vast majority of prepubertal gynecologic problems fall into three categories. The most serious category includes those "things that bleed": sarcoma botryoides, trauma (including sexual abuse), vaginal foreign objects, condylomata, urethral prolapse, and single organism vaginitis. Very rarely, the clinician will see precocious menarche, metastatic Crohn's disease, vascular vulvar lesions, and factitious cases. The next category contains entities that have an abnormal appearance: ambiguous genitalia, periurethral cysts of the newborn, hymenal variants, and agglutination of the labia and vulva. Rarely, an underlying skin disorder such as lichen sclerosus, seborrhea, or atopic vulvitis will be seen. The last and most bothersome category, distinguished by its symptoms of pruritus and discharge, includes the most common types of vulvovaginitis.

Child abuse and infections.

Although our understanding of sexually transmitted diseases in children is rudimentary, we cannot ignore the long-term consequences that the pathophysiologic process can have. This article reviews the role of the health care provider to the sexually abused child and discusses the documentation and treatment of sexually transmitted diseases.

Ultrasound examination of adolescent females with lower abdominal pain.

We evaluated pelvic ultrasound examination in adolescent females as an aid in the diagnosis of acute and chronic lower abdominal pain resulting from suspected gynecologic disease. Of 41 subjects, 35 (85.4%) had a final diagnosis of a gynecologic disorder. Pelvic ultrasound examination was positive in 19 of 35 (54.3%). Ten positive tests had relatively specific findings that supported (seven) or helped change (three) the initial clinical diagnosis. Nine positive tests had nonspecific findings that were consistent with (six) or helped change (three) the initial diagnosis. Twenty-one negative tests helped change the initial diagnosis (13); ruled out complications of acute salpingitis (five); or discriminated between alternative diagnoses (three). One test was falsely positive. Ultrasonography was most clearly cost-effective when surgery was being considered. We conclude that pelvic ultrasound examination may be a useful diagnostic adjunct in this type of adolescent patient.

Configuration of the prepubertal hymen.

Anatomically descriptive terms are required when one is asked to comment on the hymen of the sexually abused prepubertal child. Action descriptive terms such as virginal or ruptured relay no objective information. Biologic hymenal configurations can be loosely categorized by the amount and distribution of hymenal tissue surrounding the vaginal introitus: The terms fimbriated, circumferential, and posterior rim are proposed. Descriptions of 124 prepubertal hymens are presented, with discussion focusing on biologic configurations and the impact of trauma and hormones.

Postcesarean wound infection by Mycoplasma hominis in a patient with persistent postpartum fever.

Mycoplasma hominis was isolated in pure culture from a wound infection following delivery by cesarean section. The importance of recognizing this organism as a potential pathogen of the female genital tract is emphasized. Two commercially available isolation systems that allow the recovery of this organism are also described.

Atraumatic removal of secretions from the prepubertal vagina.

Adequate vaginal secretions for laboratory tests are difficult to obtain from the prepubertal girl. A simple atraumatic technique for obtaining several milliliters of vaginal secretions is described. This is extremely useful for the clinician evaluating the child with vulvovaginitis and/or possible sexual abuse.

Home birth: negative implications derived from a hospital-based birthing suite.

Our study of 390 patients enrolled in a birthing suite program revealed that antepartum or intrapartum problems allowed only 160 (41%) to actually give birth in the birthing suite. Antepartum complications included premature labor in ten (2.5%), premature ruptured membranes in 31 (8%), postdatism in 50 (13%), preeclampsia in 27 (7%), and diabetes mellitus in five (1.3%). Intrapartum complications included meconium in 62 (16%), arrest of labor in 64 (16%), oxytocin use in 85 (22%), and fetal heart rate decelerations in 28 (7%). Two hundred ninety-seven births (76%) were spontaneous. Forty-two low-forceps deliveries (10%), 12 mid-forceps deliveries (3%), and 39 cesarean sections (10%) were done in the traditional labor and delivery suite. Puerperal complications included one uterine inversion, two cases of placenta accreta, one rectovaginal fistula, and two requirements of blood transfusion. Neonatal morbidity included 22 low Apgar scores (7%), two shoulder dystocia, three cytomegalovirus infestations, and one lethal anomaly. Six infants had meconium aspiration, two with severe hypoxia. Any of these complications would overwhelm the patient in home birth. Intense prenatal screening may decrease some risk factors, but the intrapartum period was found to pose unacceptable risks for home birth in this population.