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GYNAECOLOGICAL DISORDERS OF INFA NTS AND CHILDREN • ..- UJfll'ARAf\TJAN SE\'<\ S:\DAN COTJLuG I '4 , ' ,t -,s&;·• -• fll Oh. ., t p t n· ,s <7· \ na·<.·c• lnt.' v n, I .i:. E \.,,. r . ~ .,% > <~ t\ "' hilli H~altb i ........ • • I I ~ • \ ' ~ ('r,!, , ' ~. , ~;· • & (, ' i ,1 ' • ""'+ >,,.J; ., • • ' r • • t , '• > . • , , • -·- •> 'I, . ,,, ·- , 5 .,. .l . . > , ,· : , '· ' " . ~, •• ,, , .,. ·, •· • ' • GYNAECOLOGICAL DISORDERS OF INFANTS AND CHILDREN --- CHRISTOPHER J. DEWHURST - ---- ,. - r) -,,-.-· M.B., F.R.C.S. (ED.), M.R.C.O.G. -· Reader in Obstetrics and Gynaecology in the University of Sheffield. Honorary Consultant Obstetrician and Gynaecologist in the United • Sheffield Hospitals and the Sheffield Regional Hospital Boartl -- , ...,.. - CASSELL · LONDON • 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 C, I D 5 I I .. , . . . ' • h .: ,,',.•. ., l..; ~e· .• tr.;.. .. . 0 ~<~. , ~ . ' • • • I . , .. V . •t~-.-1.., . .. , • TO MY MOTHER for all she has done for me I' -: .rl T1 -J t'. f ' "., r r ~ 11. 1' r l. f- ' Jnd oiu~•-· .,1, , 11, , 1,..1..,v • • v•, ,~ <:hlld Health , f ' ' ', ....... ' . . • \ ,.. • •A • .. • , , I ' , 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 Vlll 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, .. • 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. · ,._~ ~ , .... . t:!;: -~ ~ t. 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 24 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 \ ' . ~- ~-J. ' ·zt. »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 I\IDblRA MEMORIAL LIBRARY cc.H cssc CNCRC CAL·Zl