Pediatric and Adolescent Gynecology Emergencies

Educational Objectives

The goal of this program is to improve the diagnosis and management of pediatric and adolescent gynecologic emergencies. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize signs of chronic gynecologic conditions in pediatric and adolescent patients presenting to the emergency department with acute symptoms.
2. Interpret diagnostic tests and imaging studies for gynecologic emergencies.
3. Develop evidence-based treatment plans for pediatric and adolescent patients with gynecologic emergencies.

Summary

Acute pelvic pain: young patients who report to the emergency department (ED) with abdominal pain, nausea, and vomiting are often not asked about contraceptive use, sexual history, or exposure to pregnancy or sexually transmitted infection (STI); ask about the nature of the pain (ie, cyclic vs noncyclic); frequently, patients' and parents' histories contradict one another; ask about fever and gastrointestinal (GI) or genitourinary (GU) symptoms; perform an abdominal examination; vulvar examination can be performed without stirrups, ie, in frog-leg or knee-to-chest position or sitting on their mother’s lap; pulling downward and outward on the labia majora allows for visualization of, eg, foreign bodies and the hymen (ie, patent, septate)

Imperforate hymen: the vulva appears red and atrophic prior to puberty; several hymenal variants exist; a large bluish bulge at the introitus indicates blood behind an imperforate hymen (may be misinterpreted as an endometrioma or adnexal mass); children may tolerate pain for several months (≤1 yr) before presentation to the ED; acute cyclic pelvic pain may indicate Müllerian duct anomalies; ultrasonography (USG) and magnetic resonance imaging (MRI) help in diagnosis

Obstructed hemivagina with ipsilateral renal agenesis (OHVIRA): patients continue to have menstrual periods; OHVIRA is characterized by cyclic pelvic pain; it is a genetic, multifactorial, syndromic condition; the Müllerian and renal systems develop together; this is a chronic issue that presents with acute symptoms; practice mindful care to avoid traumatizing the patient; if in doubt, reassure the patient and obtain additional imaging before proceeding with surgery; some patients have a thick transverse septum that balloons above the sacral promontory instead of into the vagina; such instances require stepwise and more complex care than a simple hymenotomy; different obstructive variations exist

Treatment of hematocolpos: suppress menses and provide pain relief; a Foley catheter may need to be placed while the body reabsorbs the blood; disrupting native tissue leads to stenosis in ≤80% of patients; it is important not to perform drainage, perforate the dilated structure, or perform surgery without a clear understanding of the patient’s anatomy; infants with imperforate hymen and mucocolpos often require no treatment other than ensuring they are able to urinate

Ovarian torsion: symptoms — include abdominal pain, nausea, and vomiting; USG may appear normal; patients may be discharged from the ED with high stool burden and given laxatives; imaging may show a follicular ring sign that mimics polycystic ovarian syndrome (PCOS); ovarian torsion is associated with edema, bleeding, and a twisted ovary and tube; follicles may appear like a pearl necklace on USG; computed tomography (CT) and MRI may show a whirlpool sign; red flags — waxing and waning pain despite normal examination and imaging, nausea, and vomiting; the diagnosis is made using laparoscopy; the composite score created by the Division of Pediatric and Adolescent Gynecology at Cincinnati Children's Hospital Medical Center is used for premenarchal and menarchal patients; often, one ovary has a higher volume even without cysts; the adnexal ratio is calculated by the radiologist using USG; ≈25% of patients with composite scores >4 have torsion; negative laparoscopy rates ≤50% are acceptable as treatment is performed at the time of diagnosis; the goal is to prevent loss of a young girl’s ovary; paratubal cysts — may torse without compromising blood flow to the ovary; surgical detorsion is required; immediate cystectomy is not recommended for large cysts associated with torsion (detorsion is still required); reassess after 6 wk; hemorrhagic corpus luteum cysts frequently resolve on their own

Tubo-ovarian abscess (TOA): may occur in young individuals who have never been sexually active; symptoms — include severe abdominal pain, nausea, and vomiting; patients may have prodromal symptoms before developing a fever; TOAs in young individuals are not necessarily associated with STIs; they can result from a sore throat or GI infection (eg, Norovirus); the pathogens travel to the GU system from, eg, the blood, respiratory, or immunologic systems; bimanual examination is not required; these infections are commonly polymicrobial and are treated with intravenous broad-spectrum antibiotics; interventional radiology drainage is useful; Crohn disease or ulcerative colitis may present with TOA

Common findings: a hemorrhagic corpus luteum is benign; simple follicular cysts and hemorrhagic cysts are common in young individuals; endometriosis may occur in young individuals; differential diagnosis of abdominal and pelvic pain includes, eg, appendicitis, inflammatory bowel disease, musculoskeletal, somatization, psychosocial, sickle cell crisis, and acute intermittent porphyria; a social worker or adolescent medicine consultation may be needed to have difficult conversations in a confidential manner, especially if parents are not engaged

Abnormal bleeding: patients with heavy bleeding may faint in the shower (Vagal response); young individuals are unlikely to have enough years of estrogen exposure for, eg, polyps, adenomyosis, fibroids, malignancy, or hyperplasia; they have an immature hypothalamic-pituitary-ovarian axis; abnormal bleeding may also be iatrogenic if contraceptive pills are not taken regularly; heavy bleeding may lead to anemia and need for blood transfusion; ≈33% of patients have a bleeding disorder, most commonly von Willebrand disease; management — 20 mg medroxyprogesterone acetate (Provera) 3 times daily for 3 days followed by 4 times daily for 21 days, then discuss long-term strategy; test for bleeding disorders after the acute phase has been managed; von Willebrand factor levels <50 IU are concerning in patients with heavy bleeding; tranexamic acid (TXA) is recommended over aminocaproic acid (Amicar; requires drinking a high volume of liquid and tastes bad); TXA can be used with oral contraceptives (OCPs)

Early diagnosis of PCOS: anovulatory bleeding may indicate PCOS; ask about androgenic symptoms, eg, excessive hair growth or acne on the back and chest; test free testosterone; treatment that includes estrogen reduces sex hormone binding globulin

Straddle injury: occurs as a result of a fall injury; skin separation may occur from the impact; injury may lead to large hematomas; place some thick pads or towels and close the child’s legs to apply pressure; sedation may be required for small children with active bleeding and pain; obtain a relevant history; social workers or abuse teams may need to be consulted; avoid speculum examination in awake patients (retractors may be more useful than a speculum in the operating room); accidental trauma commonly injures the anterior and lateral aspects of the vulva, while abuse commonly injures the posterior vulva; red flags for abuse — posterior lesions with a second-degree tear similar to an episiotomy; management — vulvar lacerations ≥4 cm in length or depth, or any actively bleeding lesion, need repair; vulvar hematomas are managed conservatively (most are nonexpanding); use ice packs, bed rest, and place a Foley catheter for urination; educate patients on how to dilute urine; reassure the family that these injuries heal well; estrogen may be prescribed for healing but is not necessary; hematomas also resolve quickly

Aphthous ulcers in the vulva: large and extremely painful; they differ from herpes lesions in that they are often necrotic and coalesce to form “kissing ulcers” (previously called Lipschütz ulcers); often preceded by a viral syndrome; the most common etiology is Epstein Barr virus; hospital admission may be required to manage pain, and patients may require a Foley catheter; they heal well; recurrent ulcers may be caused by rheumatologic disorders (eg, Behcet disease) and may occur after COVID-19 (infection or vaccination)

Questions and answers: OCPs — may be started at menarche; they do not stunt growth; hormonal birth control helps prevent ovarian, uterine, and colon cancer, and may help prevent thyroid and pancreatic cancer; parents who have children with disabilities may wish their children not to have periods; setting realistic expectations is helpful; 35 μg ethinyl estradiol is adequate to replace endogenous estrogen, eg, for bone density; 50 μg can be used for breakthrough bleeding or for patients taking seizure medications; imaging is used to rule out adrenal tumors in patients with PCOS and elevated dehydroepiandrosterone sulfate (DHEA-S); ovarian granulosa cell tumor — causes rapid temporal balding, voice change, and increased testosterone; painful periods vs pathology — ≈85% of women have primary dysmenorrhea; if patients do not respond to nonsteroidal anti-inflammatory drugs plus hormonal treatment, refer to a subspecialist for consideration of endometriosis

Readings

Cizek SM, Tyson N. Pediatric and adolescent gynecologic emergencies. Obstet Gynecol Clin North Am. 2022;49(3):521-536. doi:10.1016/j.ogc.2022.02.017; Fei YF, Lawrence AE, McCracken KA. Tubo-ovarian abscess in non-sexually active adolescent girls: A case series and literature review. J Pediatr Adolesc Gynecol. 2021;34(3):328-333. doi:10.1016/j.jpag.2020.12.002; Hartwick Das KJ, Hood C, Rutenberg A, et al. Pediatric and adolescent obstetric and gynecologic encounters in US emergency departments: A cross-sectional study. Ann Emerg Med. 2023;81(4):396-401. doi:10.1016/j.annemergmed.2022.10.001; Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol. 2018;48:28-39. doi:10.1016/j.bpobgyn.2017.09.009; Moufawad G, Giannini A, D'Oria O, et al. Obstructed hemivagina and ipsilateral renal anomaly syndrome: A systematic review about diagnosis and surgical management. Gynecol Minim Invasive Ther. 2023;12(3):123-129. Published 2023 Aug 10. doi:10.4103/gmit.gmit_103_22; Ragni MV, Machin N, Malec LM, et al. Von Willebrand factor for menorrhagia: A survey and literature review. Haemophilia. 2016;22(3):397-402. doi:10.1111/hae.12898; Sartor RA, Lawson A, Moncada-Madrazo M, et al. Vulvar aphthous ulcers in perimenarchal adolescents after COVID-19 vaccination: A multicenter case series. J Pediatr Adolesc Gynecol. 2023;36(3):268-272. doi:10.1016/j.jpag.2023.01.003; Wolfe M, Rose E. Pediatric and adolescent gynecologic emergencies. Emerg Med Clin North Am. 2023;41(2):355-367. doi:10.1016/j.emc.2023.01.006.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tyson was recorded at the 10th Annual Cedars-Sinai Update in Obstetrics and Gynecology Conference, held March 6, 2024, in Los Angeles, CA, and presented by Cedars-Sinai Medical Center. For information on upcoming CME activities from this presenter, please visit cedars.cloud-cme.com. Audio Digest thanks the speakers and Cedars-Sinai Medical Center for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.50 CE contact hours.

Lecture ID:

OB711101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.