Good Practice in Pediatric and Adolescent Gynecology

256 Pages·2018·5.66 MB·English

by  Anna Maria Fulghesu (eds.)

Good Practice in
Pediatric and
Adolescent Gynecology
Anna Maria Fulghesu
Editor
123
Good Practice in Pediatric and Adolescent
Gynecology
Anna Maria Fulghesu
Editor
Good Practice in Pediatric
and Adolescent
Gynecology
Editor
Anna Maria Fulghesu
Department of Obstetrics and Gynecology
University of Cagliari
Cagliari
Italy
ISBN 978-3-319-57161-4 ISBN 978-3-319-57162-1 (eBook)
https://doi.org/10.1007/978-3-319-57162-1
Library of Congress Control Number: 2017954378
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Preface
This book is a very useful text to consult when a specific gynecological problem
affects a child or a young girl who needs your help.
This text is focused on a special time of women’s lives when the prevention of
sexual and reproductive problems is very important, and it is aimed at clinical pedia-
tricians and gynecologists. Each author is an expert scientist in the field, a member
of the Italian Society of Gynecology of Childhood and Adolescence (SIGIA), and
every chapter reports the most up-to-date knowledge. The text has a strong practical
relevance, and represents the guidelines of this scientific society.
The order of the chapters follows the age of girls from infancy, with genital mal-
formations, vulvovaginitis, to puberty, studying delayed puberty and postpubertal
gonadal failure.
Menstruation disorders, such as dysmenorrhea, heavy menstrual bleeding, men-
strual irregularities, eating disorders and polycystic ovary syndrome, are studied in
depth in individual chapters.
The prescription of contraceptives and the diagnosis and treatment of ovarian
cysts are specifically tailored to the adolescent age.
Sexual mutilation and abuse are also dealt with, and how to prevent, diagnose,
and treat the most frequent sexually transmitted diseases.
Finally, pregnancy in adolescence, which represents a difficult clinical responsi-
bility for gynecologists because of the high frequency of pregnancy-related disor-
ders, is described.
Happy reading!
Cagliari, Italy Anna Maria Fulghesu
v
Contents
1 Vulvovaginitis in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Cristina Vezzani, Gilda Di Paolo, Terryann Spagnuolo,
and Gabriele Tridenti
2 Delayed Puberty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Metella Dei and Francesca Pampaloni
3 Diagnosis and Treatment of Genital Malformations in Infancy
and Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Tiziano Motta and Chiara Dallagiovanna
4 Gonadal Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Maria Francesca Messina and Alfonsa Pizzo
5 Dysmenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Gabriele Tridenti and Cristina Vezzani
6 Dysfunctional Uterine Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Tiziano Motta, Antonio Simone Laganà,
and Salvatore Giovanni Vitale
7 Menstrual Disorders in Post-menarcheal Girls . . . . . . . . . . . . . . . . . . 117
Francesca Pampaloni and Pina Mertino
8 Eating Disorders in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Vincenzina Bruni and Metella Dei
9 Diagnosis of Polycystic Ovarian Syndrome in Adolescence . . . . . . . . 143
Anna Maria Fulghesu, Cristina Porru, and Elena Canu
10 R ecommendations for the First Prescription
of Hormonal Contraception in Adolescence . . . . . . . . . . . . . . . . . . . . . 161
Floriana Di Maggio and Gilda Di Paolo
11 O varian Cysts in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
M. Chiara Lucchetti
12 F emale Genital Mutilations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Lucrezia Catania, Omar Abdulcadir, and Jasmine Abdulcadir
vii
viii Contents
13 Sexual Abuse and Genital Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Maria Rosa Giolito, Giulia Mortara, and Monica D’Amato
14 Sexually Transmitted Diseases in Adolescence . . . . . . . . . . . . . . . . . . . . 211
Gilda Di Paolo
15 Pregnancy in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Gabriele Tridenti and Cristina Vezzani
About the Author
Anna Maria Fulghesu is a medical doctor specializing in obstetrics and gynecol-

ogy. As researcher of Obstetrics and Gynecology, from 1988 until 2000, she worked
in the Department of Obstetrics and Gynecology at the Sacred Heart of Rome
(Policlinico Gemelli), and since 2000 in Cagliari as Associate Professor at the
Università degli Studi. She is founder and is responsible for the Outpatient Service
of Pediatric and Adolescent Gynecology (PAG) in Calgliari. At the same hospital,
she has been involved in the Sexual Abuse Service in Childhood and Adolescence.
As an invited speaker, she has taken part in several national and international events.
As a teacher, she has given her services on many courses for medical doctors and
health caregivers. She has herself organized several courses on PAG, including six
national day courses. Author of more than 100 published scientific papers, she is
also a referee for several national and international scientific journals and she is a
member of the following scientific societies:
– International Federation of Infantile and Juvenile Gynecology (FIGJI)
– Società Italiana di Ginecologia dell’Infanzia e dell’Adolescenza (SIGIA, Italian
Society of Gynecology of Childhood and Adolescence): executive board mem-
ber since 2013.
ix
Vulvovaginitis in Childhood 1
Cristina Vezzani, Gilda Di Paolo, Terryann Spagnuolo,
and Gabriele Tridenti
1.1 Introduction
Vulvovaginal complaints account for 80–90% of outpatient pediatric gynecologic
visits [40]. Most cases may be attributed to vulvovaginitis but other less common
conditions, such as vulvar diseases or vulvar manifestations of systemic disease,
should be taken into account. Rare causes of vulvovaginitis have to be considered
especially when symptoms are recurrent or not responsive to standard treatment. In
this chapter, the causes, manifestations, and management options of vulvovaginitis
in childhood will be reviewed. Furthermore, common vulvar diseases affecting chil-
dren were outlined, since their knowledge is essential for differential diagnosis. The
prepubertal child is particularly susceptible to vulvovaginitis for anatomic, physio-
logic, and behavioral factors: absence of hair and minimal labial development; close
proximity of the vagina to the anus; physiological hypoestrogenism which causes
atrophic genital mucosa; neutral pH and unbalanced vaginal flora; absence of cervi-
cal mucus; and lack of antibodies [1]; furthermore, children’s tendency to have poor
local hygiene and to explore their bodies increases the risk of developing this condi-
tions. Germs may easily reach the genital area as a result of contiguity from the
rectum, urethra, or the surrounding skin. Diffusion of bacteria from the upper
C. Vezzani, M.D. • G. Tridenti, M.D.
Department of Obstetrics and Gynaecology, Santa Maria Nuova Hospital-IRCCS,
Reggio Emilia, Italy
e-mail: [email protected]; [email protected]
G. Di Paolo, M.D. (*)
Pediatric and Adolescent Gynecology Service, Department of Gynaecology and Obstetrics,
Santo Spirito Hospital, Pescara, Italy
e-mail: [email protected]
T. Spagnuolo, M.D.
Studio Madreperla, Pescara, Italy
e-mail: [email protected]
© Springer International Publishing AG 2018 1
A.M. Fulghesu (ed.), Good Practice in Pediatric and Adolescent Gynecology,
https://doi.org/10.1007/978-3-319-57162-1_1
2 C. Vezzani et al.
airways is also possible through autoinoculation and occasionally hematic spread
[2]. Obesity, diabetes, anatomic anomalies, and use of antibiotics may play a role in
facilitating vulvovaginitis.
1.2 Etiology
Vulvovaginitis are easily classified into two groups on the basis of etiology [3]
• Nonspecific
• Specific
Nonspecific vulvovaginitis refers to vulvovaginal irritation without an identifi-
able pathogen, accounting up to 25–75% of all cases of vulvovaginitis in children
[4]. Symptoms may often be caused by irritative-allergic reaction to topical or food
agents, nickel, or by poor perineal hygiene. Vaginal cultures are usually negative or
positive for skin flora/anaerobes/enteric organism [5]. However, in many cases eti-
ology cannot be found.
Specific vulvovaginitis are caused by specific pathogens. It has been reported
that infective vulvo vaginitis were found in one-third of young girls presenting with
vulvovaginitis [6]. Infectious may be caused by bacterial agents, pinworms, viruses,
and sexually associated pathogens.
Knowledge of the normal vaginal microflora in prepubertal age is an essential
prerequisite for definition of the pathogens of the lower genital tract and will limit
the overtreatment of non-pathogens (lactobacilli, diphtheroids, alpha-hemolytic
streptococci) [7].
It has been reported that some microorganisms, other than those traditionally
considered part of normal flora, can be isolated from vaginal culture of girls without
symptoms (Escherichia coli, Candida, Staphylococci, enterococci, Streptococcus
viridans, Streptococcus agalactiae, Corynebacterium, Proteus Mirabilis,
Pseudomonas aeruginosa). As these organisms are present in healthy prepubertal
girls, their growth in culture is not diagnostic [8]. Many of those bacteria may spread
from skin or bowel and may act as opportunistic pathogens and cause infection
only when the child has a temporary immune system depression. Escherichia coli
and Candida may be present in vaginal flora, respectively, in 8 and 4% of asymp-
tomatic patient populations [7]. Clinician should consider that Candida infection is
unlikely unless the girl has predisposing factors: recent antibiotic use, diabetes mel-
litus, immunodeficiency syndromes, poor perineal aeration, inflammatory skin con-
ditions such as diaper dermatitis, seborrheic dermatitis, and atopic dermatitis [9].
Escherichia coli and other enteric opportunistic microorganisms typically spread
from intestinal tract after pinworm infestation or poor hygiene or dysfunctional
intestinal disorders. Staphylococcus aureus may cause opportunistic skin infections
which may appear as impetiginous, bullous, or suppurative.
The non-sexually transmitted pathogens responsible for vulvovaginitis are repre-
sented by respiratory pathogens such as group A beta-hemolytic Streptococcus