Infancy (birth to age 2): The female infant is under the influence of maternal estrogens for the first 6 months of life. Breast buds may be present, the labia majora appear full, and there is thickening and enlargement of the labia minora.¹ Hymenal tissue stays thick, redundant, and elastic throughout infancy. The hymen surrounds the vaginal orifice and appears circumferential.² Estrogen levels fall within the first 6 months of life and continue to fall steadily until about 1.5 to 2 years of age.¹

Toddlers and younger school-age children (ages 2–6): As the estrogen levels reach their lowest levels between 3 and 9 years of age, the appearance of the external female genitalia changes, although there is high degree of variability in the timing of these changes.² The clitoris is less prominent and the labia become more flat.¹ The hymen generally becomes thinner and may appear translucent, having a “crescentic” appearance as the hymenal tissue recedes from the anterior vaginal orifice. As a result of low estrogen, the vaginal pH during this time is alkaline.²

Older school-age children (ages 7–12): The labia continue to develop, the hymen thickens, and the vagina elongates to about 8 cm. The vaginal mucosa thickens during this time and the vaginal pH becomes acidic. A thin white vaginal discharge known as physiologic leukorrhea may be noted during this time.^1,2

Adolescents (ages 12–21): The labia are well developed and the hymen is thick with a pale pink appearance. The vagina is typically an adult length at 10 to 11 cm, with an acidic pH. Physiologic leukorrhea may be noted depending on the timing of the menstrual cycle.^1,2

A successful examination of the premenarchal child requires adequate lighting and an environment in which the child feels safe, relaxed, and as comfortable as possible. Address any concerns or fears the child may have, especially in cases of sexual assault. Assess the stage of sexual development by examining the breasts and genital region externally, looking for any indication of puberty^3,4 (Table 100-1). Utilize a standard speculum examination for adolescent patients who are sexually active or bleeding from trauma. In prepubertal girls, typically only external visualization is needed. The frog-leg position allows easy visualization of the genitalia and may be performed with the child in the mother’s lap. The vaginal introitus can be visualized using the labial traction technique, performed by grasping the labia with the thumb and forefinger and gently pulling the labia toward the examiner² (Fig. 100-1,² examination techniques). A rectal examination may be useful if an abdominal mass is suspected. An alternative position is the knee–chest position in which the child lies with her knees pulled to her chest on the examination table, supporting her weight on her knees, with her buttock elevated.² Labial traction can be utilized in this position as well.

Consider an internal examination for vaginal bleeding, discharge, suspected foreign body, or suspected tumor. In prepubertal girls, consider performing the internal examination under general anesthesia using various instruments such as a vaginoscope, cystoscope, hysteroscope, or endoscope with irrigating properties.¹

If vaginal discharge is present, collect the specimen from the vaginal introitus with a swab moistened with normal saline to test for Gram stain, culture, and wet mount preparation. In a very young or uncooperative child, use a large bore intravenous catheter to flush 1 to 2 mL of saline for further studies.⁴ After initial fluid collection, irrigate the vagina with larger amounts of saline to wash out small foreign bodies.¹ Collect specific specimens for suspected sexual abuse (e.g., cultures of Neisseria gonorrhoeae and Chlamydia trachomatis, and slide preparations for Trichomonas). (See Chapter 144, Sexual Abuse.)

Disorders of infancy and childhood are listed below. In addition, Table 100-2 describes causes of prepubertal vaginal bleeding.

VAGINAL DISCHARGE AND BLEEDING

The newborn girl is affected by circulating maternal estrogens; thus it is common to see white, clear mucoid, or occasionally bloody discharge from the vagina. Transient discharge should subside after approximately 2 weeks of age as maternal estrogen levels in the neonate decline, so only reassurance is required. Initiate an evaluation if discharge or bleeding persists beyond this time period.^5,6 (See Chapter 103, Vaginitis.)

CONGENITAL VAGINAL OBSTRUCTION

Up to 7% of girls will have an anatomic abnormality in their reproductive tract.⁷ Of the anomalies that cause vaginal obstruction, the two most common types are an imperforate hymen or a vaginal septum. A transverse vaginal septum is thought to result from failure in canalization of the vaginal plate at various levels. A longitudinal vaginal septum is a result of failed fusion vertically as the vagina canalizes, and may form as a non-obstructive or obstructive type. An imperforate hymen is a remnant of the urogenital membrane. Other obstructive lesions may include lower vaginal atresia, whereby the lowest part of the vaginal plate fails to meet the urogenital sinus, resulting in a foreshortened vagina that does not meet the introitus. Other lesions, such as cloacal malformation and persistent urogenital sinus, result from an interruption of the normal differentiation of the hindgut. The vaginal plate and sinovaginal bulbs subsequently do not develop in the case of cloacal malformation, and the upper vagina and rectum enter the urogenital sinus.^5,6 These lesions sometimes lead to functional obstruction of normal mucoid secretions and cause hydrocolpos (distension of the vagina), or hydrometrocolpos (distension of the uterus and vagina).^8,9

Congenital vaginal obstruction can present at variable times during infancy and childhood. Hydrocolpos in the newborn period may present as an abdominal mass or a bulging mass at the introitus.^2,8,9 On rare occasions, vaginal obstruction can lead to recurrent urinary tract infections, obstructive uropathy, and renal failure secondary to compression by the mass. Rarely, an abscess can occur and requires emergent drainage.^8,9 An undiagnosed imperforate hymen may present at puberty as primary amenorrhea and intermittent lower abdominal pain that worsens every month. On physical examination, a bluish bulge due to the hematocolpos may be seen at the introitus.

Obstructive types of vaginal septae, lower vaginal atresia, and imperforate hymen are treated with surgical correction. Surgical drainage of hydrocolpos or hydrometrocolpos is necessary to relieve the obstruction, but not imperative in the prepubertal period as it is best to delay definitive reconstruction until the adolescent years.^8,9

LABIAL ADHESIONS

Labial adhesions, also known as labial agglutination, usually begin posteriorly and extend superiorly toward the clitoris, often leaving a small opening anteriorly. There is usually a thin white line or demarcation that represents the fused portion, known as the raphe.¹ The prevalence is 1.8% to 3.3% in 1- to 6-year age group, with a peak incidence in the 13- to 23-month age group.^10,11 A suggested etiology is an estrogen deficiency in the prepubertal period and inflammation that results in thinning of the superficial mucosal layers.^1,12