Pediatric emergency medicine trisk 1543 1543
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FIGURE 79.2 A: Girl in the frog-leg position for the examination of the external genitalia. B:
Girl in the knee-chest position with exaggerated lordosis and relaxed abdominal muscles. The
examiner can inspect the interior of her vagina by gently separating her buttocks and labia,
using an otoscope without an attached speculum for illumination.
Precocious Puberty
Precocious puberty is characterized by cyclic bleeding with or without associated
breast development (thelarche), pubic hair growth (adrenarche), or accelerated
linear growth in girls less than 8 years of age. Always consider possible exposure
to exogenous feminizing hormones (e.g., creams or medications containing
estrogen). An ultrasound may be considered to identify an abdominal mass such
as an endocrinologically active ovarian tumor or cyst affecting the gonads. A
careful examination should also be performed to assess for a central nervous
system mass, symptoms/signs of hypothyroidism, blood or coagulation disorders,
or the presence of unilateral café-au-lait spots that may suggest McCune–Albright
syndrome. The evaluation for precocious puberty is rarely emergent and best
referred to a pediatrician and/or pediatric endocrinologist.
Foreign Body
Although a chronic, foul-smelling discharge is often considered the hallmark of a
vaginal foreign body, many girls have intermittent vaginal bleeding or scant
vaginal discharge. Direct inspection of the vaginal vault using the frog-leg or
knee-chest position ( Fig. 79.2B ) usually reveals the foreign body easily. While
the most common foreign body—toilet paper—is not radiopaque, pelvic
ultrasound may be useful when toy parts, crayons, or coins are suspected. If a
foreign body is strongly suspected but cannot be seen, vaginal irrigation often
successfully flushes out the foreign body. Instill normal saline via gravity using a
Foley catheter and a 50-mL syringe with the plunger discarded. Application of
2% viscous lidocaine to the introital tissues reduces discomfort and the majority
of children tolerate the procedure well. An examination under procedural sedation
or general anesthesia with a pediatric gynecologic specialist is sometimes
