Table Of ContentGYNAECOLOGICAL DISORDERS
OF INFA NTS AND CHILDREN
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GYNAECOLOGICAL DISORDERS
OF
INFANTS AND CHILDREN
--- CHRISTOPHER J. DEWHURST
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r) -,,-.-· M.B., F.R.C.S. (ED.), M.R.C.O.G.
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Reader in Obstetrics and Gynaecology in the University of Sheffield.
Honorary Consultant Obstetrician and Gynaecologist in the United
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Sheffield Hospitals and the Sheffield Regional Hospital Boartl
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CASSELL · LONDON
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CASSELL & COMPANY LTD
35 Red Lion Square · London WCI
and at
MELBOURNE • SYDNEY • TORONTO · CAPE TOWN
JOHANNESBURG • AUCKLAND
© Christopher J. Dewhurst 1963
First published 1963
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TO MY MOTHER
for all she has done for me
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PREFACE
The gynaecological disorders of childhood have received surprisingly little attention in medical
literature. This omission would be easier to understand if the diseases which occurred were the
same, in miniature, as those which are apparent in increasing numbers in later life; but they are
not. The commonest conditions of the adult are seldom seen, if at all, whereas other disorders,
such as those concerned with doubtful sex or with certain congenital malformations, belong more
to childhood than to any later period. Even those disorders which arise both in children and in
adults show important differences in their aetiology, or, in their clinical features, in these two
periods of life. Perhaps the most obvious explanation for the comparative neglect of the subject
is that these little patients are not always seen by gynaecologists but are treated by paediatricians,
paediatric surgeons, urologists and others, thus presenting little opportunity for the study of the
subject as a whole.
I have had thls last point very much in mind whilst writing this book, which is intended for
anyone who may be called on to see or to treat these diseases in children. Where the problems
concerned impinge upon other specialties in the paediatric field I have tried, first, to give a general
view of the subject before presenting the gynaecological aspects, in which I have included more
detail than in the chapters dealing with the more exclusively gynaecological lesions; it is my hope
that in this way I may help those who are not gynaecologists but who may be required to deal
with some of these problems. With several disorders, particularly those which occur around
puberty, it has been ~cessary to go over some of the ground covered by the standard gynaeco
logical textbooks; where this has been unavoidable I have stressed the features whlch are most
prominent or most important as they arise in younger patients. In dealing with the less common
conditions, whlch are seldom referred to in textbooks and about which any information is
difficult to obtain, I have included many references to other published works, in order to provide
as much helpful material as possible for anyone confronted with a similar problem. In one chapter,
dealing with bladder exstrophy, it has been possible, almost for the first time, to concentrate on
the gynaecological aspects of a condition which previously presented such grave surgical problems
as to overshadow other facets of the case: with the progressive advance of modern surgical treat
ment these associated probl~ms may now receive greater consideration. A chapter has been
included on chromosoma~~~1:3#_ormalities in gynaecology, since these conditions have so rapidly
assumed added importancet:D espite the title of the book, one chapter has been devoted to
pregnancy and labour in the very young.
Clearly, I could never have had the opportunity of studying some of the problems dealt with
here without the wholehearted co-operation of many people. In particular, I wish to record my
indebtedness to two of my colleagues, Dr. R. R. Gordon, Consultant Paediatrician with the
Sheffield Regional Hospital Board, and Mr. R. B. Zachary, Consultant Paediatric Surgeon with
the United Sheffield Hospitals, with one or other of whom were seen many of the patients dis
cussed here. I have received the greatest assistance from both and I am deeply grateful for it.
Many other colleagues have graciously allowed me access to their clinical material; in this
respect I wish to thank Mr. L. B. Patrick, Professor C. S. Russell, Mr. D. H. Lees, Mr. Tom
Smith, Dr. C. G. Paine, Mr. H. Jordan Malkin, Mr. F. J. P. O'Gorman, Mr. R. L. Lunt, Dr.
A. J. N. Warrack, Mr. F. A. L. da Cunha, Professor R. S. Illingworth, Dr. J. L. Emery, and Dr.
••• Preface
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Walter Calvert. Dr. C. E. Blank has patiently guided me through the maze of chromosomal
abnormalities; Mr. J. A. Neilson, M.A., LL.B., has given me considerable help with the legal
aspects of puberty and early marriage; and Miss S. A. Knight has supplied much of the info rma
tion on the backgrounds of very young mothers. Dr. D. W. Warrell has kindly read the manu
script and provided many helpful suggestions.
My thanks are extended also to the nursing staffs of the Children's Hospital and of the
children's wards of the City General Hospital, Sheffield, who have given me so much assistance
and have so cheerfully tolerated my constant intrusions into their wards. .
Several authors and the edit6rs and proprietors of journals have graciously given me per. .
mission to reproduce material previously published elsewhere: I should like to acknowledge the
help of Dr. C. N. Armstrong, Mr. Arthur C.H. Bell, Dr. J. B. Brown, Mr. J. K. Craig, Miss
ft.
Bessie Dodd, Dr. John B. Erich, Dr. Magnus Haines, Professor T. N. A. Jeffcoate, Dr.
Jordan, Dr. F. I. Mitchell, Dr. M. J. Levell, Dr. C. G. Paine, and Dr. C. W. Taylor, as well as
that of the Journal of Clinical Pathology, Journal of Obstetrics and Gynaecology of the British
Commonwealth, The Lancet, La Presse Medicale, Proceedings of the Royal Society of Medicine,
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Proceedings of the Staff Meetings of the Mayo Clinic, and Zentralblatt fur Gyniikologie. I am '
also indebted to Messrs. J. & A. Churchill Ltd. for permitting me to reproduce Fig. 59.
The drawings are the work of Mr. R. F. Lane, with whom it has, again, been a pleasure to
co-operate: the photographs have kindly been prepared by Mr. Joseph Larway of the Photo
graphic Service of the United Sheffield Hospitals, Mr. G. Lowndes and Mr. L. Reeves of the
Photographic Service of the Sheffield Regional Hospital Board, and by Dr. C. J. Moss, a dis
tinguished amateur: I record many thanks to them all. The text has been typed and checked by
Mrs. J. S. Fox and Mrs. M. Hartley-Smith, for whose help in this and many other ways I am most
grateful.
Lastly, I wish to express my thanks to Cassell & Company who have so wfilingly co-operat¢
at all stages of the preparation of this book. · ,._~
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Ranmoor, Sheffield. C. Dr.E.c. WH . " ·· ,. ~··
1962.
CONTENTS
CHAPTER PAGE
l 1
ENDOCRINOLOGY, ANATOMY AND PlIYSIOLOGY
JI 17
VULV0•V AGINITIS
III
OTHER VULY0-VAGINAL DISORDERS: LABIAL ADHESIONS; LICHEN
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SCLEROSUS; VAGINAL FOREIGN BODIES
IV 32
GENITAL TRACT OBSTRUCTION
V THE ECTOPIC URETER 41
VJ GYNAECOLOGICAL ASPECTS OF BLADDER EXSTROPHY 47
VII 60
CONGENITAL ANO-RECTAL DEFORMITIES IN GYNAECOLOGY
VIII 70
THE CHILD OF DOUBTFUL SEX
IX 93
CHROMOSOMAL ABNORMALITIES IN GYNAECOLOGY
X 105
TUMOURS OF THE GENITAL ORGANS
XI NORMAL PUBERTY 120
XII 125
PRECOCIOUS SEXUAL DEVELOPMENT
XIII DELAYED PUBERTY 137
XIV Loss;
OTHER PUBERTY DISORDERS: EXCESSIVE MENSTRUAL DYSMENOR-
RHOEA; OBESITY )45
XV 149
PRECOCIOUS MOTHERHOOD
CHITfAl{ANJAN SJ~\· \~ \f)AN f(1LLEGE.
of Ob~tetric~ G_:: ,llul·,gy ,tnd
Child Health
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»t!D~,MORIAL LIBRARY CCH CSSC CN~ CN
11.
CHAPTER ONE
ENDOCRINOLOGY,
ANATOMY AND PHYSIOLOGY
Gynaecological disease is seen less often in infancy and childhood than in later life. This can be
explained on a basis of the functional state of the genital organs, which, in the child is so different
from that in the adult; this, in tum, is concerned with the different endocrine backgrounds of
these two periods of life.
For some years after birth, the pelvic organs are stimulated only by general growth factors,
such as those of the pituitary and thyroid, which affect the rest of the body. To complete their
development it is necessary for the genitalia to receive a much greater stimulus from the sex
hormones; without this influence the reproductive organs would never achieve the complete
functional development characteristic of the normal adult state. For much of the childhood
period, however, the amount of these various hormones c.irculating in the body is very small and,
in normal girls, is insufficient to exert any significant influence on the genital tract. The first few
days of life are an exception, for then the baby's blood stream contains an appreciable amount
of the maternal sex hormones, in most cases sufficient to produce transient but distinct clinical
features (Fig. I) which will be discussed later. After this period of sex-hormone influence, the
genitalia remain in a quiescent state for some years, during which only slow growth takes place,
and this, to a smaller extent than in most other organs. The reproductive organs lie inert, their
activity dormant; they are capable of response to the appropriate endocrine stimulus should this
be applied, but under normal circumstances none is forthcoming, and they remain in their resting
state.
This phase of inactivity then becomes disturbed, and from the age of nine or ten years on-
wards gradually increasing amounts of the sex hormones can be detected in the urine until adult
levels are attained and maturity of the genital organs is reached. This period of growing up is
attended by most important changes; at first at a physical level, with the appearance and growth
of the secondary sexual characteristics and the onset of menstruation, and later at an emotional
level, with the awakening of sex consciousness.
At any time during the first fourteen, fifteen, or sixteen years of the girl's life disorders of the
genital organs may arise. The particular diseases encountered show little similarity to the common
gynaecological conditions seen later and are concerned closely with the special features of
anatomy, physiology, and endocrinology characteristic of these early years. These special features
will therefore be considered more fully, and since the activity of the sex hormones is so important
in determining the growth and development of the genitalia, the endocrine aspects of the child
hood period will be considered first.
THE SEX HORMONES
Much has been written about the sex hormones in women of reproductive age, in women after
the menopause, and in men, compared with which the output of similar work in children is
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