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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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EMQ	1502
SBA	2115

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ESSAY 146 - ADOLESCENT GYNAECOLOGY

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		Posted by vijaya L. Sat Feb 12, 2005 05:43 am
Persistent vaginal discharge in a young girl can be of considerable distress for the parents and the girl, because sensitive issues like sexual abuse, substance abuse and sexual activity at an young age are involved. Great care would be taken while obtaining history to avoid emotional upset. She would first be asked about her general health status as chronic diseases like diabetes and renal disease can increase the susceptibility for any infection. Then she would be asked about her menstrual status as premenstrual vagina is at risk of infections due lack of acidity produced by vaginal estrogen. Then sexual history would be asked. The girl can be given a chance to consult alone for some time and confidentiality should be assured unless the history is suggestive of abuse and needs reporting for her own safety. Maximum effort would be made to convince her to talk to the parents. Substance abuse would also enquired about as both are related problems. Even though foreign body insertion is commoner in younger girls this history would make treatment simpler. On examination apart from noting the signs of puberty and looking for the signs of substance abuse like intravenous injection marks, local examination is done to look for signs of abuse like excoriations and swabs are taken from vagina, urethra and rectum to identify chlamydia, gonorrhoea or any other organisms. As adequate treatment of these infections is necessary to protect the reproductive system. Consultant should be involved and proper documentation is necessary if abusive relation ship is suspected. Apart form the swabs, X ray and examination under anesthesia are considered if foreign body is suspected. Screening for other STDs and GUM clinic referral should be discussed for contact tracing and appropriate treatment. Infective discharge is treated with appropriate antibiotics. Estrogen cream is useful in case of premenarchal status to improve the local immunity. Counseling offered incase sexual abuse or substance abuse are suspected. Written information containing the numbers of the relevant social organisations and support groups is provided. She would be explained about the contraceptive methods. Condoms are protective against STDs but they are partner dependent. COCPs and POPs are very effective but require compliance. Depoprovera is very good but for the controversy about the probable reduction in the bone mineral density. Followup visits are arranged with GP or a family planning clinic to ensure the compliance with contraception .
		Posted by narmin B. Sat Feb 12, 2005 08:30 am
The management of an offensive discharge in a 14 year old girl depends on the causative agent and therefore a detailed history, examination and investigation are required in order to identify the cause. Taking a detailed history is necessary. Duration of discharger and its characteristics use or change of soaps, deodorants should be asked as they can cause allergic reactions and secondary infection. Menstrual periods and use of tampons should be enquired because a retained tampon can be the cause of infection and persistent discharge. Systemic medical condition such as diabetes and prolonged use of antibiotics is another cause of persistent vaginal discharge. Sexual activity is also very important as she may have a sexually transmitted disease, however the girl may be reluctant to answer this question in the presence of her parents and an interview without presence of parents may be necessary. Another possibility which always should be considered is possibility of a sexual assault. Taking history with regard to this issue is not easy and need skill and experience. There is also a possibility of genital tract malignancies and symptoms such as weight loss, rapid swelling of abdomen should be asked. A general examination is required to assess general health and look for hygienic problems. An abdominal examination may reveal an abdominal mass. Internal examination is not necessary or not justified due to virginity. However an inspection of external genitalia is required to look for signs of dermatitis with secondary infection. Also there may be old or new bruises in the genital area which may be due to sexual assault. A low vaginal swab can be taken for culture and sensitivity test. In the presence of an abdominal mass an abdominal ultrasound scan is required to assess the characteristics and possible origin of the mass. Examination under anaesthetic may be necessary to look for foreign body and their removal. Rarely taking a biopsy may be required for suspected malignancy. Treatment of the condition is dictated by the findings of history, examination and investigations. Basic hygienic measures, a course of systemic antibiotic for secondary infection and reassurance is all that is necessary in some patients. If she is prepubertal atrophic vaginitis and secondary infection is possible and use of local oestrogen cream can be helpful. In the event of systemic disease such as diabetes, it must be ensured that the condition is under control. Infection must be treated with appropriate antibiotics and in the case of sexually transmitted diseases referral to genitourinary clinic is mandatory for full investigation, treatment and contact tracing. A difficult situation is the possibility of sexual assault. In these cases consultation with a senior and experienced colleague is necessary. Also there may be a need for legal action. Genital tract tumours should be removed surgically with least possible damage to reproductive organs. Thorough documentation is essential especially in cases where there is possibility of sexual assault, since the notes may be referred for medical or legal reasons. Follow ?up appointments should be arranged to ensure the cure, although occasionally treatment can be difficult. Referral to other specialities such as dermatologist should be considered in these cases.
		Posted by Sarwat F. Sat Feb 12, 2005 11:06 am
Persistent vaginal discharge in adolescence is a distressing condition not only to the girl but also for her parents. It is important to manage the condition carefully so as not to cause further distress to the family especially if there is suspicion of sexual abuse Management will include history, examination, investigations and treatment. Careful and sympathetic approach is required and patient may need to be interviewed alone as sexual abuse may be present. In the history it is important to ask about the history of vaginal discharge, for how long she is having this discharge. Any associated complaint like abdominal pain, fever, nausea, vomiting, dysmenorrohea, dysperunia, and any associated pruritus. Sexual history is asked including number of sexual partners. She is asked about the method of contraception if any she is using. Hisory of drug abuse is also important. Menstrual history is asked including the use of tampons. In the examination it is important to check blood pressure, pulse, and temperature and general hygiene of the patient. Then abdominal examination is done for abdominal tenderness. Finally on vaginal examination careful inspection is required to check for any bruises in view of sexual assault or abuse or threadworm infestation as scratches around anal region may be present. Gentle pelvic examination is done to check for tenderness on movement of cervix and the uterus and adnexal tenderness. Investigations will include High vaginal swab for culture and sensitivity and additional swabs from urethra and endocervix for gonorrohea and Chlamydia. Ultrasound may be needed to check for any pelvic mass as Pelvic examination may be difficult in this age. Probable diagnosis in this case include pelvic inflammatory disease, trichomonas vaginitis, thread worm infestation, foreign body like retained tampon, dermatological conditions like lichen sclerosus, atopic or contact allergy and sexual abuse. Regarding PID, Treatment will depend on the severity of the condition whether she can be managed as outpatient or inpatient. If the general condition and vital signs are stable she can be managed as an outpatient and antibiotic doxycycline and metronidazole are given for 14 days. Inpatient antibiotic treatment will include ceftriaxone followed by doxycycline iv or per orally BD and metronidazole three times daily. Treatment continued for 14 days. For severe disease her condition is stabilized by admitting her and parenteral antibiotics are administered. Surgical treatment will be required for severe cases and in the presence of pelvic abcess. It is important to review the case after 72 hrs of antibiotic treatment in case of outpatient management. Contact tracing is also required and partners should be screened for infection with Chlamydia and gonorrohea by referring to genitourinary medicine clinic. After treatment patient will be counseled regarding future contraception that barrier method is protective against PID and combined pills are also protective. Threadworm infestation can be treated with antihelminthics and patient is educated regarding hygienic measures. Similarly for trichomoniasis, metronidazole treatment is given. In case of a foreign body it is removed gently and this may require some sedation or rarely examination under anaesthesia. Broad spectrum antibiotic treatment is also given after removal of foreign body For dermatological conditions which are less likely as patient has offensive discharge, patient is advised to avoid contact with allergic material like certain brands of soaps. In severe cases help with a dermatologist may be required. In case sexual abuse is suspected, help with appropriate gynaecologist or paediatrician with experience in management of such cases is sought. Police and social worker may be required to be involved in case of management of sexual abuse. Proper documentation will be required in view of legal issues. It is important not to be judgemental at this stage as parents may become resentful at the thought of being accused of negligence. Support in the form of referral to various support groups will be provided. Regular follow-up with GP is ensured.
		Posted by Iman B. Sat Feb 12, 2005 12:40 pm
A detailed history is necessary to identify the patients last menstrual period, and time of first menarche, this will give an idea on whether the vagina is oestrogenised and so protected or not. A history of medical disorders which may cause debilitation as diabetes, chronic cardiac illness, previous cancer(leukaemia or lymphoma) TB, or cystic fibrosis, to establish if she has an increased risk of acquiring infection. The patients eating habits are asked about(for possible anorexia) Time alone with the patient away from the parents should be sought, and patient should be asked about sexual contact/s or abuse. Upon taking history an idea as to the patient?s mental capacity may be elicited, (increased possibility of insertion of foreign body, or abuse) General examination should include weight of patient, her body mass index, and presence or absence of secondary sexual characters. Perineal examination, and a swab is taken from the discharge and sent for culture, if the hymen is intact, if patient sexually active and permission by the patient is given an internal examination for forgotten tampon, a high vaginal swab and cultured, a cervical swab for gonorrhoea. Ultrasound or X ray if suspected foreign body Urine analysis for infection and to check for diabetes. Full blood count to exclude possible anaemia Screen for sexually transmitted diseases, trichomonas vaginalis, Chlamydia, syphilis, gonorrhoea, herpes I and II, and HPV. Any chronic illness should be controlled with referral to internist. Foreign body is removed if present. Personal hygiene explained to patient and information papers on sexually transmitted diseases given to patient if sexually active, their prevention, and explanation of barrier contraception, and its significance in decreasing STDs. Psychotherapy if anorexia nervosa. The results of culture and screen, and treat the patient and her contacts if sexually transmissible disease.
		Posted by Nibedita R. Sun Feb 13, 2005 07:32 am
Symptoms of offensive vaginal discharge may be psychologically distressing for the girl and also for the parents. A very sensitive and empathic approach, good communication and adequate time allowance can build a rapport and gain confidence. A detailed history should be obtained keeping the possibility of sexual abuse in mind. History of discharge, such as colour, amount, duration and associated odour and itching should be obtained. Intense itching may be indicative of either candida infection or thread warm infestation. Blood stained discharge may be indicative of foreign body inside vagina or rare possibility of malignancy. Frothy greenish discharge is indicative of trichomonas infection in a sexually active girl. General history including diabetes, broad spectrum antibiotics and steroids, which may cause candida infection. Use of chemicals like cosmetics and spermicide gel may cause allergic dermatitis. Menstrual history and contraceptive use should be obtained. High dose oestrogen containing pill may cause infection due to candida. She may be reluctant to give sexual history in front of parents. Tactful questionnaire and adequate privacy may help to obtain sexual history and history of substance or sexual abuse. Pelvic pain, dyspareunia and dysmenorrhoea when associated with offensive discharge in sexually active girl, indicates PID. Urinary and bowel symptoms should be obtained, as UTI can present with PID and amoebiasis may cause vulvo-vaginitis. In a suspected case of sexual abuse, consultant gynaecologist should be involved and history and examination notes should be properly documented as legal issue is concerned. Explanation of examination procedure should be discussed and consent for examination should be obtained. General examination may reveal anaemia and cachexia, which may be indicative of malignancy (rare). Gentle abdominal examination may reveal tenderness in lower abdomen indicative of PID. Inspection of the external genitalia may reveal vulval oedema and erythema suggestive of candida infection. Scratch mark may be found due to pruritus from thread warm infection. Signs of injury may be detected in sexual abuse. Any discharge from introitus should be sampled and sent for culture sensitivity. If she is sexually active, swabs collected from endo-cervix, uretha and anal canal, before pelvic examination and sent for examination (to detect PID due to chlamydia or gonococcal infection) and HVS for other infections. Pelvic examination may detect adnexal mass, tenderness and cervical excitation in PID. If she is virgin, and history suggestive of malignancy, a P/R examination can be carried out to assess pelvic organs. Inspection of the vagina can be done using a nasal speculum or paediatric laryngoscope. Foreign body if detected should be removed and sent for examination. If malignancy is suspected should be examined under G/A by a consultant gynaecologist at an early date and biopsied. USS is recommended if a pelvic mass is suspected. X ray of pelvis is of use if radio-opaque foreign body is suspected. Discharge due to non-specific vulvo-vaginitis, should be treated with barrier cream and proper hygiene such as cleaning vulva after micturation and defaecation. Use of cosmetic and chemicals should be avoided. Genital infection should be treated with appropriate antibiotics according to the sensitivity report. Fungal infection can be treated by Nystatin pessaries or systemic Fluconazole tabs. If, PID is confirmed, she should be referred to GUM clinic for treatment and for screening of other STDs. Contact tracing should be done. Screening of partners and treatment can reduce chance of re-infection. Counselling on PID and its consequences and should supported by written information. Barrier contraceptive use should be stressed. In sexual abuse, referral to appropriate support group allowing her to be treated and counselled. Psychological counselling involving a psychiatrist may be required in extreme depression.
		Posted by Abdul Aziz S. Mon Feb 14, 2005 06:21 am
Vaginal discharge is a distressing condition, both for the girl and her parents. Great care must be taken in handling such a sensitive problem. Adequate time must be given to establish rapport and build up confidence. First step is to obtain a careful history. Amount, duration, color of discharge, any associated itching and blood stained discharge should be enquired. White curdy discharge may be due to candidal infection ,greenish discharge due to trichomonal infection. Itching could be due to threadworm infestation. Blood stained discharge, though rare could be due to malignancy. If the girl is menarchal, history of use of tampons should be taken, as retained tampon could be a cause of infection and discharge. History of drug or sexual abuse should be obtained, bearing in mind that the information given may be inconsistent. But may point to possibility of STI like gonorrhea, herpes, HIV.Pt may be seen alone to get information about her sexual activity and number of sexual partners. A recent change in bathing soap, underwear or other agents, which may cause allergic reaction, must be excluded. Although sensitive, it must be ensured that the pt is well aware and takes good care of personal hygiene.Hist of medical illnesses such as diabetes, which may predispose tocandidal infections, should be taken. General examination should make note of signs of drug abuse or child abuse. Abdominal examination done for any tenderness in the lower abdomen, or palpable abdominopelvic masses.local exam would include examination of vulva-for marks of itching, excoriation due to sexual abuse. If discharge seen at introitus, swabs taken. Hymen should be checked for any tears. Vaginal examination done using nasal speculum, or paediatric laryngoscope or vaginoscope. If foreign body is found it should be removed under anesthesia. PR examination done to assess any masses bimanually. Consultant should be informed if signs of sexual abuse noted. All findings should be documented. Investigations would include culture and sensitivity of swabs taken .USG if any mass found. X-ray abdomen to identify presence of any radio opaque object in vagina. Treatment would depend upon identification of positive findings on culture; accordingly antibiotic or antifungal treatment may be given. If STI are detected on cultures, pt should be referred to support groups, contacts traced and treated with the pt. Nonspecific vulvovaginitis may be treated by barrier creams and observing proper personal hygiene. If the pt is sexually active she should be advised to use barrier contraception. If PID is diagnosed, it should be actively treated and pt should be informed of its long-term consequences. This would ensure compliance to treatment.
		Posted by Sonali G. Tue Feb 15, 2005 12:41 pm
Persistent offensive vaginal discharge is a distressing condition for this young 14 year old girl. It should be approached very sensitively and tactfully especially if sexual abuse is suspected. Aim is to diagnose the cause after excluding sinister causes and to treat according to etiology. Causes could be due to infectious, allergies, foreign body, sexual abuse or rarely carcinoma. History regarding duration of the discharge and its relation with the periods is to be enquired. Physiological discharge will be copious during ovulation getting thicker and scanty during luteal phase, but it wont be offensive. Nature of the colour of the discharge is also asked for. Greenish discharge is seen with trichomonas vaginalis. Dirty greyish discharge leaving stains on the clothings is seen in bacterial vaginosis and white thick curdy discharge which usually sticks around vulva and vagina may be candiasis. Complaints of itching around perianal region can be due to thread worm. History of any allergies to soap / cosmetics or recent change in soaps should be enquired. Her sexual history or history regarding sexual abuse should be asked very tactfully especially if her parents are accompanying her. On examination, abdomen is palpated for any mass or tenderness. If she is virgo intacta internal examination is avoided, pervulval examination is done to look for any signs of sexual abuse or obvious infection. If she is sexually active, perspeculum examination is done and high vaginal swab and endocervical swabs are taken for chlamydia gonorhhoea or other infections.. Cervix is examined to look for for any tumour (sarcoma botyroids) which is very rare. Internal examination is done to look for cervical excitation and bilateral adnexal tenderness (as seen in PID). This is also done to rule out any adnexal tumor which can present with vaginal discharge but very unlikely in this age group. Further investigations are conducted on the basis of clinical findings. Ultrasound scan pelvis is done if any tumour mass or foreign body is suspected. Vaginal secretion pH>5 with fishy odour and whiff test on addition of KOH and presence of clue cells on microscopy suggest bacterial vaginosis. Presence of myecelia like organism suggests thrush. If foreign body is suspected, especially in case of virgo intacta, examination under anaesthesia is done with paediatric laryngoscope and foreign body removed at the same time Treatment depends on the cause. Candidiasis is treated with antifungal treatment in the form of clotrimazole whether orally or vaginally. Bacterial vaginosis is treated with metronidazole and trichomoniasis with metronidazole. In cases of Chlamydia or gonorrhoea, contact tracing is done with referral to GUM clinical and treatment of both the partners. Avoidance of soap or other allergen will get rid of allergies. Mebendazole is given for worms. Appropriate referral and management is done in case of suspected malignancy. In any suspicion of sexual abuse , responsible authorities are informed. Thus the management in this young girl requires sensitive and systematic approach.