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Genitourinary symptoms in younger children

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TopicPaediatric Genitourinary Presentations
AuthorHelena Winstanley and Tara George
DurationUp to 2 hrs
Facilitator LevelST4 and above
Learner levelFY1 and above (can be adapted depending on the level)
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussion covering the key points and evidence including an optional practical session (10 mins) covering paediatric genital examination
  • Advanced session: (2 x 20 minutes) case discussions covering more complex areas, diagnostic dilemmas; advanced management and escalation
  • Quiz: (10 mins)
  • Infographic sharing: (5 mins) 5 take home learning points

We also recommend printing/sharing a copy of your local guideline
(if available) for sharing admission criteria.

Expectation is for the learners to have understood the basics before the session. They should be encouraged to listen to the podcast and/or read the article below.

General Paediatric Gynaecology – 20 minute podcast
https://www.emrap.org/episode/emrap2019/pediatricpearls

Gynecology for the Paediatrician
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791551/

PAEDIATRIC GENITOURINARY PRESENTATIONS: SUMMARY

Paediatric GUM is an area that has the potential to cause significant distress to
both parent and the child, it is often a clinical area in which clinicians feel
underskilled and potentially embarrassed or uncomfortable.

Parents or carers may be very worried about the possibility of sexual abuse and
Children and young people may feel anxious or embarrassed about discussing
their symptoms and having to undergo a physical examination.
Clinicians may be anxious due to (often) a relative lack of training in this area and
the potential sensitivity of the situation.

There are relatively few genitourinary symptoms – typically pain, discharge, bleeding
and itching. The majority of cases will be due to mild self-limiting conditions such
as vulvovaginitis but the clinician must always be aware of the possibility of more
serious problems such as a retained foreign body or sexual abuse.

The underlying cause varies between age-groups because children become
susceptible to specific conditions as they progress through childhood.

● Pre-pubertal girls have an oestrogen poor environment which leads to vaginal
tissue that is more friable and sensitive than that seen in pubescent/post-pubescent
girls. This makes them more susceptible to conditions such as vulvovaginitis.
● Sexually transmitted diseases – whilst sadly not unheard of in young children –
are much more common in teenagers and should be high on the list of differentials
in a young person who presents with gynaecological symptoms.
● Retained foreign bodies may occur in younger children exploring their bodies
for the first time or in teenagers who are starting to experiment sexually.
● Straddle injuries are usually seen in nursery/primary school aged
children – classically whilst attempting to climb out of a bath.
● Sexual abuse, whilst a comparatively rare cause of gynaecological symptoms
should always be considered at any age – bearing in mind this may present
differently in different age groups.

ASSESSMENT OF A CHILD PRESENTING WITH A GENITOURINARY PROBLEM INVOLVES:

● Using sensitivity and tact to elicit the history as always. However, we risk
perpetuating stigma, shame and embarrassment if we take the history in a
secretive or different way just because it involves genitalia. Care should be taken
wherever possible to allow the child/young person to tell their story independently
of the parents or carers. If there’s any possibility of abuse in the history, the right
person needs to be taking the first history as if there is any chance of a prosecution,
the child needs not to be retelling the story and compromising evidence (and also
minimising distress for the patient).

● Obtaining a comprehensive history including duration of symptoms, continence
issues, precipitating factors and not forgetting more subtle signs such as change
in behaviour.

● Exploring the concerns of the family who may be extremely anxious and come
with preconceived ideas surrounding the diagnosis.
● Examining the child/young person (with an appropriate chaperone) to look for
any obvious skin changes, discharge/bleeding or external signs of trauma. Aim
to examine the child just once with necessary senior/specialist staff present and
any equipment ready prepared in order to minimise distress. Appropriate use of a
parent’s lap and a play specialist are often invaluable.
● Considering the possibility of sexual abuse – including child sexual exploitation.

Referral for urgent assessment in secondary care should be considered if the child is:
● Presenting with a clear history of a retained foreign body
● Systemically unwell
● Actively bleeding
● Suspected of being maltreated.

Referral to the gynaecology team, if available, should be arranged (the urgency
depending on clinical judgement) if:
● There is a suspicion of a retained foreign body.
● A child has symptoms that have failed to resolve with conventional treatment.
● There is uncertainty about the diagnosis.
● Examination under anaesthesia is likely to be required.

A child aged 3-10 years who presents with soreness and itching to the vulva/vagina
is most likely to have vulvovaginitis. This can usually be safely managed in the ED/
UTC/primary care with advice and education for the child and family:
● Girls should be taught to wipe front to back after using the toilet
● Cotton underwear should be worn if possible
● Avoid wearing pants at night
● Salt water baths and nappy creams (eg Bepanthen or Sudocrem ) may be
helpful to ease the irritation
● Avoid bubble baths and sitting for a prolonged time in soapy water. Parents
should be encouraged to wash the affected area in plain water.

Underlying conditions such as constipation, UTI or threadworm infection should
be considered and treated where necessary. Vulval swabs may aid diagnosis of
a bacterial cause, most commonly group A strep but remember skin commensal
contaminants are common and the majority do not have bacterial infection..
Children whose symptoms are not resolving despite the above measures should
be referred to secondary care.

Specific conditions that may be covered in more detail, depending on time
available:

Vulvovaginitishttps://adc.bmj.com/content/archdischild/88/4/324.full.pdf

Straddle injurieshttps://www.rch.org.au/clinicalguide/guideline_index/Strad-
dle_injuries/

Retained foreign bodieshttps://www.childrens.com/specialties-services/con-
ditions/foreign-body

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634203/

Child sexual exploitationhttps://www.nspcc.org.uk/what-is-child-abuse/
types-of-abuse/child-sexual-exploitation/

Alysha is a very distressed six year old girl who attends A&E with her mother.
She has blood in her pants following an accident in the park.

How will you approach this case? What are your priorities?

Alysha is now calmer and is happy for you to proceed but would like something to make sure it doesn’t hurt.

What are your options?

What should you tell her?

How will you approach this case? What are your priorities?

Alysha is now calmer and is happy for you to proceed but would like something to make sure it doesn’t hurt. What are your options?

After your fantastic preparation, the examination proceeds easily and you determine that there is minor laceration in between at the posterior fourchette on the right. It is not actively bleeding, there is no suggestion of urethral/clitoral damage and it does not encroach on the introitus. What should you tell her?

Olivia, a 5 year old girl, is brought to the urgent treatment centre when her mother finds some yellow discharge with a streak of blood in her pants. Her mother has noticed she is ‘scratching her privates’ and is worried something might have happened to her at her new primary school.

What are the differential diagnoses in this case? How would you refine your diagnosis further?

A thorough history establishes that Olivia is systemically well but has been
complaining of itching for the past three weeks. Since going to school she is
no longer supervised to use the toilet and admits she only ‘sometimes’ washes her hands afterwards. On examination you find that the vagina and labia are erythematous with a small amount of discharge. There is also some evidence of excoriation around the anus.

Given these findings, what do you think is the most likely diagnosis?
What will you do now and what advice will you give to the family?

What are the differential diagnoses in this case? How would you refine your diagnosis further?

Given these findings, what do you think is the most likely diagnosis?
What will you do now and what advice will you give to the family?

Inez is a 6 year old girl who is brought to ED by her parents with a two month
history of vaginal discharge. They have seen the GP repeatedly and have been told that she is suffering from vulvovaginitis. Despite carefully doing everything their doctor recommended there has been no improvement in her symptoms and they are becoming increasingly frustrated.

How will you approach this case?
What are some of the differentials you will need to consider?

You manage to speak to Inez’s GP who confirms she has seen her a number of times. Initially she was treated for simple vulvovaginitis but as it failed to improve she has sent vaginal swabs and urine MC&S. The vaginal swab grew a mixture of bacteria so Inez received a course of antibiotics which resulted in only a temporary improvement.

What symptoms might suggest a retained foreign body?
How might you proceed now?

How will you approach this case? What are some of the differentials you will need to consider?

What symptoms might suggest a retained foreign body? How might you proceed now?

Gabriella is a 3 year old girl. She attends the ED with her mother. Her mother is distraught and tells you that Gabriella was at her grandparents’ house today while mum was at work. It’s the school holidays and several cousins are at the grandparents house today including Brandon, the 13 year old great nephew of Gabriellas’s stepgrandad who has never met Gabriella before. The grandparents rang her to pick up early as Gabriella would not stop screaming and was very very distressed after going inside to the toilet. Gabriella has told her mother that she doesn’t like Brandon and he hurt her today. Gabriella is sad and withdrawn clearly in pain but clearly heard to say “he putted his finger in my bum and I don’t like that”.

How would you feel if presented with this scenario?

What are you worried about?

What are your next steps in managing this child? Who will do this? What skills might you/they need?

Gabriella is likely to need a full child protection medical – what is your departmental
policy on this? How in practical terms do you arrange this?

How would you feel if presented with this scenario?

What are you worried about?

What are your next steps in managing this child? Who will do this? What skills might you/they need?

What is your departmental policy on this? How in practical terms do you arrange this?

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Question 4

Answer 4

Question 5

Answer 5


Please download our Facilitator and Learner guides

Authors

  • Dr Tara George. MBChB (Hons) Sheffield 2002, FRCGP, DCH, DRCOG, DFSRH, PGCertMedEd Salaried GP and GP Trainer, Wingerworth Surgery, Wingerworth, Derbyshire. GP Training Programme Director, Chesterfield and the Derbyshire Dales GP Speciality Training Programme. Out of Hours GP and supervisor, Derbyshire Health United. Early Years Tutor, Phase 1, Sheffield University Medical School. Mentor, GP-s peer mentoring service and Derbyshire GPTF new to practice scheme. External Advisor RCGP. Host Bedside Reading podcast. Pronouns: she/her When she's not doing doctory things Tara loves to bake, to read novels, run and take out some of that pent up angst in Rockbox classes.

    View all posts

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