Clinical protocols in pediatric and adolescent gynecology PDF
Preview Clinical protocols in pediatric and adolescent gynecology
Cover Page i CLINICAL PROTOCOLS IN PEDIATRIC AND ADOLESCENT GYNECOLOGY Page ii This page intentionally left blank. Page iii CLINICAL PROTOCOLS IN PEDIATRIC AND ADOLESCENT GYNECOLOGY Sally E.Perlman MD, Steven T.Nakajima MD, and S.Paige Hertweck MD Department of Obstetrics, Gynecology and Women’s Health University of Louisville School of Medicine, Louisville The Parthenon Publishing Group International Publishers in Medicine, Science & Technology A CRC PRESS COMPANY BOCA RATON LONDON NEW YORK WASHINGTON, D.C. Page iv Published in the USA by The Parthenon Publishing Group 345 Park Avenue South 10th Floor New York, NY 10010 USA This edition published in the Taylor & Francis eLibrary, 2005. To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk. Published in the UK by The Parthenon Publishing Group 23–25 Blades Court Deodar Road London SW15 2NU UK Library of Congress CataloginginPublication Data Data available on request British Library Cataloguing in Publication Data Perlman, Sally E. Clinical protocols in pediatric and adolescent gynecology 1. Pediatric gynecology—Handbooks, manuals, etc. 2. Adolescent gynecology—Handbooks, manuals, etc. 3. Generative organs, Female—Diseases—Diagnosis—Handbooks, manuals, etc. 4. Medical protocols—Handbooks, manuals, etc. I. Title II. Nakajima, Steven T. III. Hertweck, S.Paige 618.9′2098 ISBN 0203493397 Master ebook ISBN ISBN 0203623665 (OEB Format) ISBN 1842141996 (Print Edition) Copyright © 2004 The Parthenon Publishing Group No part of this book may be reproduced in any form without permission from the copyright holders, except for the quotation of brief passages for the purpose of review. Page v Contents Preface vii Dedication viii 1. Ambiguous genitalia (intersex disorder) 1 2. Amenorrhea 10 3. Bartholin’s abscess 19 4. Breast abscess 21 5. Breast anomalies 24 6. Breast asymmetry 27 7. Breast mass 30 8. Cervical mass 34 9. Clitoromegaly 36 10. Condyloma acuminatum 40 11. Contraception 44 12. Depression 54 13. Dysfunctional uterine bleeding (DUB) 57 14. Dysmenorrhea 65 15. Eating disorders 68 16. Emergency contraception (ECP) 77 17. EMLA® use, topical anesthetic 81 18. Endometriosis 83 19. Female circumcision 92 20. Genital trauma 95 21. Gynecologic examination 98 22. Hemangioma of vulva 119 23. High risk behaviors 121 24. Hirsutism 123 25. Hymenal anatomy (normal and abnormal) 131 26. Labial abscess 142 27. Labial adhesions (labial agglutination) 145 28. Labial asymmetry/hypertrophy 147 29. Labial/vulvar mass 150 30. Lichen sclerosus 155 31. Menstruation 157 32. Menstrual management of the mentally limited patient 159 33. Molluscum contagiosum 162 34. Nipple discharge 167 Page vi 35. Obesity 170 36. Oncology patients and gynecologic issues 180 37. Operative care 184 38. Osteoporosis 190 39. Ovarian/adnexal torsion 192 40. Ovarian cysts 196 41. Ovarian masses and tumors 204 42. Pap testing 211 43. Pelvic inflammatory disease (PID) 222 44. Pelvic pain 229 45. Polycystic ovarian syndrome (PCOS) 238 46. Pregnancy 243 47. Premature ovarian failure (POF) 249 48. Premenstrual dysphoric disorder (PMDD) 253 49. Premenstrual syndrome 257 50. Prolactin disorders 262 51. Puberty 267 52. Radiologic imaging for gynecologic conditions 284 53. Rape 287 54. Sexual abuse 292 55. Sexual activity 303 56. Sexually transmitted diseases (STDs) 309 57. Substance abuse 329 58. Toxic shock syndrome (TSS) 334 59. Tubal mass 337 60. Turner syndrome (TS) 345 61. Urethral prolapse 349 62. Urinary tract infection (UTI) 351 63. Uterine masses 354 64. Uterovaginal agenesis/androgen insensitivity 357 65. Vaginal bleeding in the prepubertal patient 360 66. Vaginal tract anomalies 362 67. Vulvar nevi 370 68. Vulvar ulcers 372 69. Vulvovaginitis 380 Page vii Preface The Pediatric Adolescent Gynecology (PAG) program at the University of Louisville was founded by Dr. Joseph S.Sanfilippo and has been one of the premier training programs in this specialty since its inception in 1990. It has trained fellows including Drs Hertweck and Perlman, as well as residents, medical and nurse practitioner students in all of the primary care (Pediatrics, MedPeds, and Family Medicine) specialties as well as those of Gynecology and Reproductive Endocrinology. This book provides a comprehensive review of all of the common and less encountered PAG problems that patients present to us on a daily basis, both in the ambulatory as well as the surgical setting. This is not just a review but also more a basic handbook on how to assess these problems quickly and efficiently, enabling the clinician to determine and execute a management plan. The book is designed to be an easy to follow howtoguide for the most simple to the most complex problem. We completed a review of the literature, combined it with our clinical experience and placed the information in a bulleted text format with helpful photographs, figures and algorithms to assist both the student and the practitioner more easily care for the PAG patient. Hence, in this text, the reader will find diagnostic and treatment methodology for the most simple PAG problems such as vulvovaginitis and labial adhesions; for common issues like menstrual disorders and contraception; and for rare and more complex disorders such as Turner syndrome and ambiguous genitalia—with everything inbetween. We are grateful to Parthenon Publishing for recognizing the need for such a textbook. We are appreciative of the technical support as well as medical editing Leta Weedman has provided. We thank Drs. Pam Clark, Jacqueline Sugarman, Charles Maxfield, Dennis O’Connor (Pediatric Surgical Associates) and Claire Templeman for their expert review. We are indebted to our colleagues, especially our fellows and partners in the Department of Obstetrics and Gynecology and Women’s Health for covering some of our clinical duties so that we could complete this book in a timely fashion. And finally to our assistants, especially Laura LukatCoffman, thank you for your constant support and for making it possible for us to get through our days in the allotted time. Page viii Dedication We dedicate this book to our families who allowed us the privilege of putting our experience on paper and gave us the encouragement to be the physicians that we are today. Page 1 1 Ambiguous genitalia (intersex disorder) DEFINITION Anatomic variation of the external genitalia making sex determination difficult Characterized by clitoromegaly and labial fusion Most cases present in the newborn, not in the adolescent EVALUATION This is a medical and social emergency in the newborn 75% of these cases have lifethreatening salt wasting nephropathy that if unrecognized can cause hypotension, vascular collapse, and death (1) First priority: ensure electrolyte/endocrinologic abnormalities corrected • Check serum electrolytes (2) Second priority: establish the most probable cause • Inform parents of spectrum existing between virilized and feminized genitalia (3) Postpone making a gender assignment • Reassure parents: ‘You have a healthy baby, but the external genitalia are incompletely developed and tests are necessary to determine the sex’ • Refer to the infant as ‘the baby’ rather than a boy or girl • Instruct parents on how to deal with grandparents, sibs, babysitters and others who might note the child’s genital appearance (e.g. ‘The baby is different but normal and when the child is older he or she and the doctors will do what seems best’)
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