General Medical Information

Normal Appearance and Values in the Examination of the Prepubertal Female Genitalia

Andrew S. Cook

A recent study by McCann details the normal values and appearance of the prepubertal female genitalia. Ninety-three nonabused girls 10 months to 19 years old were examined using the three examination techniques described. Examination of the prepubertal external female genitalia in the supine position (both traction and separation) yielded a greater incidence of positive findings than did examination in the knee-chest position. Labial adhesions, posterior fourchette raphe, and midline avascularity of the posterior fourchette are common findings, whereas isolated vascularity and friability of the posterior fourchette are uncommon. Vestibular erythema, periurethral bands, and follicles are seen in a significant portion of patients. The majority of the labial adhesions were less than 2 mm in length. The authors believed that these small adhesions accounted for the midline avascularity with traction (supine or knee-chest) and bleeding with further traction.

Labial adhesions, which probably are related to the hypoestrogenic state of the prepubertal female, usually are asymptomatic and do not require treatment. Most labial adhesions will resolve spontaneously with puberty. The patient may present to the physician as a result of maternal concern that the daughter has vaginal agenesis. The inferior half of the hymen is occluded by labial agglutination in 8% of 1-year-old children. Treatment is required if the labial adhesions impede urination or drainage of vaginal secretions. Application of an estrogen cream b.i.d. to the adhesion line should be performed by a parent for 2 weeks, then once a day at bedtime for another week or two, until there is complete resolution of the labial adhesions. Gentle traction on the adhesion line at the time of estrogen application is required. Subsequent application of an ointment (e.g., Vaseline) for a couple of weeks or months may help to prevent adhesion reformation.

All patients in the study by McCann had a hymen present. A crescent-shaped hymen was the most commonly observed hymenal shape, followed by the concentric hymen. The septate-, cribriform-, and imperforate-shaped hymens were rarely seen. Redundancy of the hymenal membrane was reduced and, as a result, visualization of the hymen was increased with the supine traction and knee-chest examination techniques.

The significance of a hymenal notch or cleft is dependent on both the location and extent of the lesion. Hymenal notches located between the 5 and 7 o’clock positions are considered suggestive of previous abuse or trauma. Superior and lateral notches should be considered normal and are found in 35% of newborns. Longitudinal intravaginal ridges are a normal finding. These can be found in all four quadrants of the hymen and may extend from the hymen into the vagina. Several studies suggest that less than 1 mm of hymenal tissue at the inferior rim (6 o’clock position) in prepubertal girls is evidence of prior abuse. Difficulty in obtaining accurate measurements may limit the usefulness of this finding.

The colposcopic transhymenal diameters were measured using the three different examination techniques in preschoolers (2 years to 4 years 11 months), early school age (5 years to 7 years 11 months), and preadolescent (8 years to Tanner II). On average, the transhymenal diameters increased with the age of the child. The greatest vertical transhymenal diameters were measured with the supine traction technique; the largest horizontal diameters were seen with the knee-chest method.

The percentage of the introitus that was covered by the hymen varied over a wide range and was dependent on the examination technique. Eighty-four patients were examined using the three examination techniques described. The ability to visualize the cervix was highly dependent on the examination technique used. The cervix was seen in 58 patients (69%) with the knee-chest examination technique, but it was seen in none of the patients using the supine traction or separation techniques.

Normal findings in nonabused children can include perianal redness, smooth areas, venous engorgement, skin tags, and hymenal ridges, bumps, tags, bands, and anterior notches.