Pay special attention to anatomic and pathophysiologic differences in the child. The usual cause of genital trauma during childhood is an accidental fall. This may create considerable and understandable anxiety in the child and parent. In perimenarchal girls, the vagina is 8 cm long, andthe vaginal mucosa and hymen are thicker. The child should be told thatthe examination will be similar to having her temperature taken or havinga bowel movement, and that a finger has a smaller diameter than a bowelmovement. Each adolescent is at a different stage of development, and the approach to the examination may require variations that fit her developmental stage . Cultures from the vagina indicate normal rectal flora or Escherichia coli. A gentle, patient approach is important when examininga prepubertal girl. Historically, these masses were surgically removed, often involving removal of the entire ovary. Dr. Ahmed Darwish - Pediatrics: General Examination - YouTube 0:00 / 15:07 Dr. Ahmed Darwish - Pediatrics: General Examination Dr. Ahmad Darwish 13.1K subscribers Subscribe 1.5K 114K views 5. With the child supine, begin your external examination by inspectingher external genitalia (Figure 5). Rectoabdominal exam. The most important technique to ensure cooperation is to involve the child as a partner. There is nothing specific about the symptoms or signs of childhood vulvovaginitis. However, many infants are infected with Chlamydia trachomatis during birth and remain infected for up to 2 to 3 years in the absence of specific antibiotic therapy. Watch the video to learn the differences between primary and second dysmenorrhea and how to diagnose and treat endometriosis. Considerable effort should be devoted to gaining the childs confidence and establishing rapport. Vulvarskin disorders are common, and often easily recognizable on exam. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. This is to help girls understand that there is a doctor dedicated to their reproductive health. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. If you still cannot locate a hymenal opening, the child mayhave an imperforate hymen or vaginal agenesis. A hand lens or otoscope often is helpful. The first aspect of the pelvic examination is evaluation of the external genitalia ( Fig. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. In this video, Stephen Scott, MD, MPH, emphasizes the fact that pain originates from nerve signaling and uses this understanding to help him identify the source of pain and its cause. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. Diagnosis can befacilitated by performing the tape test: press a piece of cellophane againstthe child's perineum in the morning, affix the tape to a slide, and examineit under the microscope for the characteristic eggs. You might have a pelvic exam as part of your regular checkup. The most common gynecologic condition of children is vulvovaginitis . In some cases, however,it is helpful to spend time alone with the child during the interview, andto ask whether she prefers to be alone for the examination. This is especiallyimportant in girls who have persistent vaginal discharge, bleeding, or pelvicpain because it often is possible for an examiner to express vaginal discharge,palpate a foreign body, and detect masses. The classic symptom of pinworms (Enterobius vermicularis) is nocturnal vulvar and perianal itching, the treatment for which is the anthelmintic agent mebendazole. The lesions are often mistaken for bacterial cellulitis or lesions associated with other viral infections, such as herpes simplex virus. A pelvic exam usually lasts only a few minutes. Philadelphia, PA, Raven-Lippincott, 1998, 2. Inspect her for pubic hair and note the condition of the urethra,size of the clitoris, any signs of estrogenization, configuration of thehymen, and perineal hygiene. An adolescent gynecology exam is done to help make sure that your reproductive organs and system are healthy. When this intervention fails, there should be greater suspicion of bacterial colonization; in this case a reasonable approach is the use of broad-spectrum oral antibiotics such as amoxicillin or trimethoprim/sulfamethoxazole given for 10 to 14 days. You can also ask the child to cough in order todistract her and cause her hymen to open. Examination of the vulva, hymen, and anterior vagina by gentle lateral retraction (. Signs of priorabuse can include hymenal remnants, scars, and hymenal transections. Usingthis position and an otoscope head for magnification and light, you willbe able to visualize the lower vagina, and usually the upper vagina andcervix, in 80% to 90% of prepubertal girls.3. Etiologic Factors of Premenarcheal Vulvovaginitis, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty, Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures, Reproductive anatomy: Gross and Microscopic Clinical Correlations, Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management, Malignant diseases of the ovary, fallopian tube, and peritoneum, Neoplastic diseases of the vulva and vagina, Primary and secondary amenorrhea and precocious puberty, Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa, Anal incontinence: Diagnosis and Management. Tricia Huguelet, MD, Chief of Pediatric and Adolescent Gynecology, describes the typical presentation of hymen imperforations in adolescents and young adults, as well as obstructing and non-obstructing mllerian anomalies. In noncooperative children, treatment should not be withheld if a specimen cannot be collected and empiric treatment may be started., many techniques have been described for attempting to collect a specimen, including the use of a very slim urethral Dacron swab moistened with nonbacteriostatic saline (used for collection of male urethral cultures). Most episodes of childhood vulvovaginitis are cured solely by improved local hygiene. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. This conveys an unhurried approach. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. In this video, Veronica Alaniz, MD, provides guidelines for examining and understanding genital lacerations and hematomas resulting from vulvovaginal trauma, including blunt trauma or straddle injury and penetrating. The child should be instructed to void with her knees spread wide apart (even while facing the toilet to improve urine draining) and taught to wipe from front to back after defecation. What is it? In a microperforate hymen, it may be difficult to identify an opening.To establish its presence, try squirting a small amount of warm water orsaline with a syringe or angiocath, placing the girl in the knee-chest position,or probing with a small urethral catheter, feeding tube, or nasopharyngealCalgiswab moistened with saline or vaginal lubricant (Figure 8). Childrens Hospital Colorado providers are faculty members of the University of Colorado School of Medicine. The vulva and anus. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. This is a difficult decision and is based on the extent of the childs anxiety in relation to the severity of the clinical symptoms. While the ulcers generally resolve on their own and most patients never experience another outbreak, about 25% will have subsequent occurrences. In preadolescent girls, both benign and malignant ovarian tumors are usually unilateral. Topics for the pediatric nurse practitioner to be aware of. Videos : Exams. Usually, it is related to menstrual cramps, though many other conditions can cause it, including endometriosis, a painful disease in which uterine tissue grows outside the uterus. Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. They may be discovered by means of a flashlight or by dabbing of the vulvar skin with clear cellophane adhesive tape, ideally before the child has arisen in the morning. Before puberty, the girls reproductive organs are in a resting, dormant state. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . Capraro VJ, Capraro EJ: Vaginal aspirate studies in children. Your doctor checks your vulva, vagina, cervix . The history shouldassess the child's growth and development; signs of puberty such as breastdevelopment, axillary hair, pubic hair, growth spurt, and leukorrhea; genitaltrauma; vaginal discharge; and a history of foreign body insertion. They schedule and bill separately for their services, and are not employees of the Hospital. Help me decide. Afterthe newborn period, the average size of a normal clitoral glans in a premenarchalchild is 3 mm in length and 3 mm in transverse diameter.4 Inprepubertal girls, the vaginal mucosa and perihymenal tissue will be moreatrophic and appear thin and red. Chemicals that may be allergens or irritants, such as bubble bath, must be discontinued, and harsh soaps and chemicals should be avoided. Office evaluation of the child and adolescent. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 12.3 ). Group A streptococciand Shigella are the most common causes. After you have examined the external genitalia, you should visualizethe vagina if the child complains of discharge or bleeding that may be vaginalin origin, or if you suspect a tumor, ectopic ureter, or vaginal foreignbody.6 In premenarchal girls, the vagina is 4 to 5 cm long withthin, red epithelium. The quantity of discharge can vary greatly, from minimal to copious. Have the child resther head to one side on her folded arms and support her weight on bent knees,which are six to eight inches apart. Different positions for performing a gynecologic examination on a child. The evaluation of childrens gynecologic problems involves considerations of physiology, psychology, and developmental issues that are different from those of adult gynecology . "Pelvic Exam Variations" by Michael Hughey, MD has been added to 18 collections. Learn Peds Genitourinary 04 Genital Exam Intro from UBC Learn Pediatrics on Vimeo. Procedures such as vaginoscopy can be used for the diagnosis of gynecologic conditions in prepubertalgirls. Vaginal bleeding is also associated with vulvovaginitis. Introduction to the Basic Pelvic Exam. Obtaining a history from a child is not an easy process. 4:40. Forunusually persistent cases, it is appropriate to prescribe a 10-day trialof antibiotics (amoxicillin, amoxicillin-clavulanate, or a cephalosporin)or occasionally a two- to three-week course of an estrogen cream. Diagnose this skin lesion with newest Stanford 25 video and topic. Management is dictatedby the diagnosis: antibiotics and hygiene measures for infectious vulvovaginitis,surgical repair of trauma if necessary, biopsy of polyps or suspected tumors,removal of foreign bodies, further investigation for sexual abuse if itis suspected by exam or history or if condylomata are found, sitz bathsand estrogen cream for urethral prolapse, and further investigationinto the etiology of precocious puberty. Buyers also reviews treatment options, including menstrual suppression, with a focus on key counseling points to help patients and families decide which method is best for them. If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. Gynecologic Examination with Pap Smear. 25:50. Adolescents often come for examinations with the preconceived idea that it will be very painful. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. Change gloves, lubricate the rectum, and then gently . The typical location is the anterior vaginalwall near the cervix. Event marketing. During the exam, your doctor will check your vagina, uterus, and ovaries. 11 mins, 28 secs. Therefore, a positive culture from the vagina ina 5-year-old requires reporting and evaluation for child sexual abuse. A patient presents with foot pain and these chronic findings? These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. Those in middle or late adolescence (aged 15 to 19 years) may be more accepting of the idea of an examination and more likely to cooperate with the proper counseling and in the appropriate setting. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. New patient encounter videos allow you to practice your clinical reasoning skills and review for exams. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. Show Transcript. The film opens with a woman sitting in an office of a physician. Thegynecologic examination of the prepubertal child can be challenging, butit can also be quite rewarding for a clinician who understands the uniqueanatomic and physiologic characteristics of a prepubertal child and approachesthe examination with patience, gentleness, and respect. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. Bates' Visual Guide features head-to-toe and systems physical exam videos completely reshot with an emphasis on clinical accuracy and patient care. This short 1958 educational film from the American Cancer Society shows how to perform a routine pelvic examination and cytologic test for the detection of cancer of the uterus. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. It is recommended that the examination start with the nongenital areas , such as listening to the heart and lungs; an abdominal examination and inspection of the skin should be performed. Includes menu so you can select the portion of the video most applicable to you. Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. So this is the scariest picture weve got! Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. Next, examine the child's vulva and anus, observingfor hygiene, erythema, excoriation, labial adhesions, signs of trauma, andanatomic abnormalities. Visualizing the hymen. Both parent and child should be instructed that the vulvar skin should be kept clean, dry, and cool and irritants should be avoided. Findingson genital examination are normal, however, in most girls with a historyof substantiated sexual abuse. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. After the newborn period, when the uterus is enlarged becauseof maternal estrogen effect, your examination should reveal a small, button-likecervix and uterus. A parent may stay in the room during the exam if the child does not mind ( Picture 1 ). Am J Obstet Gynecol1987;157:950, 6. EMANS is Chief, Adolescent Division, Children's Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston. The vaginal epithelium of the prepubertal child appears redder and thinner than the vagina of a woman in her reproductive years. Pokorny SF. Candidal infection is uncommon in prepubertal children unless there isconcomitant antibiotic use, diabetes, immunosuppression, or occlusive diaperuse. When indicated, both vaginoscopy and hysteroscopy procedures can be performed by a pediatric and adolescent gynecologist at Childrens Hospital Colorado. The vulvar skin of children may also be affected by systemic skin diseases, including lichen sclerosus, seborrheic dermatitis, psoriasis, and atopic dermatitis. Finally, pinworms may present as perineal or perianal pruritus, witherythema and often excoriations in the perirectal area. In some cases, nonspecific vulvovaginitis may be caused by carrying viral infections from coughing into the hands directly to the abraded vulvar epithelium. She reviews the services that the Program provides, such as inpatient and outpatient consults, fertility preservation services and reproductive healthcare, and how to request consultation. Gynecologic diseases are uncommon in children, especially compared with the incidence and prevalence of diseases in women of reproductive age. Making the examination a positive experience, ifpossible, therefore is critical.2. Pokorny SF, Stormer J: Atraumatic removal of secretions from theprepubertal vagina. In girls with persistent, purulent, or recurrent vaginal discharge, orthose with a suspicion of sexual abuse, obtain a wet preparation and culturesfor bacterial pathogens, C trachomatis, and N gonorrhoeae. The introitus will gape open with gentle pressure downward and outward on the lower thigh or undeveloped thigh or labia majora area ( traction ) ( Fig. The Stanford Medicine 25 program for bedside medicine at the Stanford School of Medicine aims to promote the culture of bedside medicine to make current and . The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. Examination of the Female Genitourinary System. Below is a collection of all our Stanford 25-generated videos also found throughout the website. Includes speculum and bimanual exams. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. What Stands in the Way of Bedside Teaching? When alone withan examiner, a child may disclose abuse or other concerns, and allowingher to be interviewed or examined alone may give her a greater sense ofcontrol and responsibility for her own health. Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Occasionally,a narrow vaginal speculum can be used in an older child who is well estrogenized.10,11. 12.2 ). The major factor in childhood vulvovaginitis is poor perineal hygiene. 1. The introduction of any instrument into the vagina of a young child takes skillful patience. Join Childrens Hospital Colorado pediatric experts for a virtual Were passionate about providing answers, treatment and care for the full range of female reproductive health concerns, from infancy through adolescence and into adulthood. Vulvovaginitis is the most common gynecologic problem in prepubertal girls. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. Your questions should address the onset of symptoms; the type,frequency and timing of discharge; associated bleeding, pain, or pruritus;foreign body insertion; perineal hygiene; recent infections in the patientor her family (such as streptococcal pharyngitis or pinworms); recent antibiotictherapy; masturbation; and a history of sexual abuse. Occasionally it is best to defer the genital examination until a second visit . Approach to evaluation of premenarcheal child with a gynecologicproblem. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . Common reasons to perform a rectal examination include genital tract bleeding, pelvic pain, and suspicion of a foreign body or pelvic mass . Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. McCann J, Wells R, Simon M, et al: Genital findings in prepubertalgirls selected for nonabuse: A descriptive study. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. N gonorrhoeaerarely persists beyond the newborn period without symptoms. Pokorny SF: Configuration of the prepubertal hymen. Bumps are usually a normal variant and are often attached to longitudinal ridges within the vagina. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. Children often cannot hold still for long intervals while instruments are being located. Uterine bleeding that is coming more often than every three weeks, lasting longer than seven days in a row, or resulting in excessive product use and frequent bleeding through clothes should be evaluated. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. Intestinal parasitic invasion with pruritus. The pathophysiology of the majority of instances of vulvovaginitis in children involves a primary irritation of the vulva, which may be accompanied by secondary involvement of the lower one-third of the vagina. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. Begin the procedure with relevant elements of the general pediatric exam,including height and weight and examination of the thyroid, neck, breasts,lungs, heart, and abdomen. The rash of atopic dermatitis is typically maculopapular, pruritic, anderythematous. Puberty produces dramatic alterations in the external and internal female genitalia, as well as the adolescents hormonal milieu. Girls should have their first gynecological exam between the ages of 13 and 15. After viewing, providers will be better able to counsel patients and their families on treatment methods as well as provide them with updated resources on this topic. The entire exam takes about only 5 minutes. Visualization of the introitus is better achieved using the previously described traction and the Valsalva maneuver than separation because it gives a deeper view of the structures and partial visualization of the vagina. Bacterial vaginosis during pregnancy may lead to increased risks for preterm birth, preterm delivery, and spontaneous abortion, according to new research in the Archives of Gynecology and Obstetrics. HPV is also verticallytransmitted and lesions may appear in the first few years of life. Slang terminology for speculums among teens includes the threatening label the clamp. Teens should be assured that although the examination may include mild discomfort, it should not be painful . Gidwani GP. A minor vulvar irritation may result in a scratch-itch cycle, with the possibility of secondary seeding because children wash their hands infrequently. 1 A vaginal self-exam is not the same as a vulvar examination. What questions should PNPs consider related to womens health? Children usually are asymptomatic,but they may present with secondary infection. You can use this section to discover where and how this . Tell the child that the examination willnot hurt, and if you are going to use instruments, that these tools areall specially designed for little girls.1Let the child look atand touch the instruments to be used, such as an otoscope or a hand lens.When talking with parents, it is important to carefully explain that thechild's hymen will not be altered in any way by the examination, becausemany parents do not fully understand the anatomy of the vagina and hymen.Basic diagrams of the anatomy may be helpful. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. Many gynecologic conditions in children may be diagnosed by inspection . However, young children can help define their exact symptoms on direct questioning. The vagina of a child lacks glycogen, lactobacilli, and a sufficient level of antibodies to help resist infection. Forpersistent cases, prescribe a one- to three-month course of a low-potencytopical steroid preparation, such as hydrocortisone 1% or 2.5%, followedby careful hygiene and use of emollients. In this age of reliable access to ultrasonography, the internal genital examination to evaluate the uterus and ovaries can be performed with the assistance of sonography , often sparing the child from a rectal or pelvic examination. Older childrencan be placed in adjustable stirrups (Figures 1 and 2). This can be accomplished without the insertion of any instruments. Children are not skilled historians and will often ramble, introducing many unrelated facts. Sometimes doctors do pelvic exams if they think there's a problem. For a small childwho is fearful of the exam, it may be best to have the mother sit on thetable in a semireclined position (feet in or out of stirrups) with the child'slegs straddling her thighs (Figure 3). In this video, the Director of the Fertility Preservation and Reproductive Late Effects Program, Leslie Appiah, MD, discusses the prevalence of reproductive late effects and female risk stratification based on age and therapy doses. Systemic illnesses that can cause vulvovaginitis include measles, varicella,scarlet fever, mononucleosis, Kawasaki disease and Crohn's disease. Female Urethral Catheterization Male Urethral Catheterization Female Genital Exam Male Genital Exam Don't forget to watch the Why Urology video! There will also be an extra sheet you can use to cover yourself. Bacterial causes include group A, b-hemolyticStreptococcus, Haemophilus influenzae, Staphylococcus aureus, Branhamellacatarrhalis, Streptococcus pneumoniae, Neisseria meningitidis, and Shigella.Sexually transmitted infections include Neisseria gonorrhoeae, Chlamydiatrachomatis, herpes simplex virus, Trichomonas, and human papillomavirus.It is important to note that these organisms also can be vertically transmittedat birth and herpes can be transmitted by nonsexual contact. From Blythe MJ, Thompson L. Premenarchal vulvovaginitis. Emans SJ, Woods ER, Flagg NT, et al: Genital findings in sexuallyabused symptomatic and asymptomatic girls. PCOS occurs due to a complex interaction of genetic and environmental factors can affect the menstrual cycle, hair growth, skin, weight and the ability to have children. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). Thefinding of genital herpes type 2 is a strong indication of sexual abuse.Coexisting primary oral and genital herpes type 1 may occur in young children,but a finding of type 1 in the genital area alone should prompt an evaluationbecause this is more likely to be acquired by abuse.14Trichomonaswill rarely cause symptoms in the newborn period and spontaneously resolveswith waning of estrogen levels. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. A handheld mirror may help in some instances when discussing specifics of genital anatomy. Urethral prolapse often resolves after treatmentwith topical estrogen cream twice daily and sitz baths, but surgical excisionmay be required if there is necrosis. From AccessMedicine. Sometimes doctors do pelvic exams if they think there's a problem. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Obtaining a history from a child is not an easy process. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. These minor accidents result in injury because the genital tissues in children, without estrogen, are very thin and easily traumatized. At the end of the examination, use your fingerto "milk" the vagina and assess for discharge or, very rarely,polypoid tumors. Obtaining cultures. This chapter considers gynecologic diseases of children from infancy through adolescence. She should be allowed to visualize and handle any instruments that will be used. If the bleeding is unexplainedor you suspect a foreign body or tumor and the vagina cannot be fully visualized,an exam under anesthesia by a gynecologist is necessary. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . These exams may be done as part of a yearly check-up for teenagers or young adults, however, you may need them sooner or . In this video, adolescent gynecologist Eliza Buyers, MD, reviews the pathophysiology and diagnosis of PCOS in adolescent patients. This video demonstrates how to perform a comprehensive pelvic examination, including an examination of the external genitalia, a Papanicolaou test to screen for cervical dysplasia, a bimanual exami.
pediatric pelvic exam video
You can post first response comment.