Pediatric Primary Care (94 page)

J.  Education.

1.  Know signs/symptoms of progressive disease process.

2.  Ensure routine urinalysis remains part of well-child check so early evaluation and treatment can be done.

3.  Follow nonpathologic proteinuria annually.

4.  Close observation for pathologic proteinuria.

BIBLIOGRAPHY

Behrman RE, et al.
Textbook of pediatrics.
17th ed. Philadelphia, PA: W.B. Saunders; 2004.

Gearhart JP, Rink RC, Mouriquand PD.
Pediatric urology.
Philadelphia, PA: WB Saunders; 2010.

Johnson KB, Oski FA.
Oski's essential pediatrics.
Philadelphia, PA: Lippincott-Raven; 1997.

Oneil JA, Jr., et al.
Principles of pediatric surgery.
2nd ed. St. Louis, MO: Mosby; 2004.

Wein AJ, Kavoussi LR, Novick AC, et al.
Campbell-Walsh urology.
Philadelphia, PA: Elsevier; 2010.

CHAPTER 28

Gynecologic Disorders

Mary Lou C. Rosenblatt and Meg Moorman

I.  AMENORRHEA

A.  Primary: No episodes of spontaneous uterine bleeding by 16.5 years. Evaluate for delayed puberty if no secondary sex characteristics by 14 years.

B.  Secondary: After onset of menarche, absence of uterine bleeding for 6 months or time equal to 3 previous menstrual cycles. Regular monthly cycles not often seen until 1-2 years after menarche. Because evaluation of amenorrhea applies to all amenorrhea, not necessary to categorize workup as primary or secondary.

C.  Etiology.

1.  External genital anomaly: androgen insensitivity (46, XY).

2.  Internal genital anomaly:

a.  Vaginal agenesis.

b.  Imperforate hymen.

c.  Transverse vaginal septum.

d.  Agenesis of the cervix.

e.  Agenesis of the uterus.

f.  Gonadal dysgenesis.

3.  Hypogonadotropic hypogonadism:

a.  Stress.

b.  Weight loss or gain.

•  Obesity.

•  Eating disorders.

•  Competitive athletics.

•  Familial (ask ages of menarche for mother, sisters).

•  Drugs (phenothiazines, oral contraceptives, medroxyprogesterone acetate (Depo Provera), illicit drugs).

•  Environmental changes (such as going away to college).

4.  Pregnancy.

5.  CNS tumor.

6.  Pituitary gland infarct, irradiation, surgery.

7.  Adrenal gland tumor, disease.

8.  Chronic diseases.

9.  Hypo- or hyperthyroidism.

10.  Autoimmune oophoritis.

11.  Ovarian failure, tumor, irradiation, or surgery.

12.  Polycystic ovary syndrome (PCOS).

13.  Asherman's syndrome (history of uterine surgery)

D.  Occurrence.

1.  Primary: 3 out of 1000 girls have menarche after 15.5 years.

2.  Secondary: Most common reason is pregnancy. Also consider stress, weight changes, eating disorders.

a.  8–10% of 14–18-year olds report missing 3 consecutive menses in past year.

E.  Clinical manifestations.

1.  May have no signs or, depending on cause, may be specific signs, such as wide-spaced nipples, web neck, short stature of Turner syndrome, obesity, acanthosis nigricans of PCOS, or wasting of anorexia.

2.  Evaluate galactorrhea/amenorrhea for prolactinoma and empty sella syndrome.

F.  Physical findings.

1.  Physical exam to rule out nonreproductive system problems.

2.  Plot height and weight looking for Turner syndrome, obesity, anorexia; explain need for genital exam.

3.  On external exam check for patent hymen.

4.  A cotton Q-tip can determine the length of the vagina.

5.  A one-finger, vaginal–abdominal or rectal–abdominal exam may determine the presence of a cervix and uterus.

6.  Estrogenized vaginal mucosa is pink.

7.  A pelvic exam for sexually active teens to identify normal organ structure. Clitoromegaly is seen in the presence of excess androgens.

G.  Diagnostic tests.

1.  Testing indicated in stepwise progression based on history and physical exam.

2.  If any concern about sexual activity, obtain pregnancy test. Keep in mind admitting sexual activity may be difficult for some teens.

a.  Negative pregnancy test: Follow stepwise progression again, starting with thyroid-stimulating hormone (TSH) and prolactin.

b.  Pelvic ultrasound to look at pelvic structures may be needed.

c.  Vaginal maturation index can be obtained to evaluate estrogenization of vagina.

d.  Progestational challenge checks endogenous estrogen levels and competency of outflow tract.

H.  Differential diagnosis.

1.  See Etiology.

I.  Treatment.

1.  Cause of amenorrhea determines treatment.

J.  Follow up.

1.  Determined by the cause and treatment.

2.  Referral may be needed in cases of anatomic or chromosomal abnormality, CNS tumor, eating disorder, or specialized management.

K.  Complications.

1.  Infertility may result from some causes of amenorrhea, making it important to listen to patient's questions and concerns and to offer emotional support.

L.  Education.

1.  Offer information relevant to the cause and treatment of the individual's diagnosis.

II. CHLAMYDIAL INFECTION

A.  Etiology.

1.  An obligate intracellular bacterial agent with at least 18 serologic variants.

B.  Occurrence.

1.  Most common sexually transmitted infection (STI) in United States with high rates among sexually active adolescents.

C.  Clinical manifestations.

1.  Causes urethritis, cervicitis, epididymitis, salpingitis, perihepatitis, endometritis, reactive arthritis.

2.  Can lead to acute and chronic pelvic inflammatory disease (PID).

3.  Incubation varies; about 1 week.

D.  Physical findings.

1.  May be no symptoms for males or females.

2.  Females: mucopurulent vaginal discharge, hypertrophic cervical ectopy, abdominal tenderness.

3.  Males: penile discharge, abdominal tenderness, testicular tenderness.

E.  Diagnostic tests.

1.  Tissue culture.

2.  Nucleic acid amplification: highly sensitive from cervical, urethral, rectal, vaginal swabs, or urine.

F.  Differential diagnosis.

1.  Other STIs, such as gonorrhea.

G.  Treatment.

1.  Recommended regimens:

a.  Azithromycin 1 g one dose PO, OR

b.  Doxycycline 100 mg PO bid for 7 days.

c.  See Centers for Disease Control and Prevention (CDC) guidelines (see Bibliography) for alternative regimens or treatment guidelines for PID.