Question

There is a lot of discrepancy when it comes to examining genitalia in the pediatric population. What have you witnessed in your clinical setting regarding both male and females? For example, do they document the Tanner stages? What is recommended, and how do you think you will practice? At what age will you ask the parent to stay in the waiting room?

Answer 1

In recent years, there has been increasing interest in adolescent health.Stage of puberty is also valuable in the assessment of various health outcomes in adolescents. The hormonal changes associated with puberty can impact both on physical and mental well-being

The examination of an infant, toddler, or child should ideally be performed in the presence of a parent or guardian; if the parent's presence may interfere with the examination (eg, suspected child abuse), a chaperone should be present. The use of a chaperone for the examination of the anorectal and genital areas of adolescent patients should be a shared decision between the patient and the clinician after the clinician has explained the reason for the examination and described how the examination will proceed. The sex of the chaperone should be determined by the patient's wishes and comfort (if possible). If a patient is offered the use of a chaperone and declines, this should be documented in the report.

Among male patients, only 7.3% and 6.0% expressed a desire for a chaperone when being examined by a male and female practitioner, respectively. Among female patients, 26.8% desired a chaperone if they were going to be examined by a male practitioner when compared with 5.5% for a female practitioner.Around one-third of male and female patients indicated they would feel uncomfortable having a chaperone present and this did not vary by the sex of the practitioner .For female patients being examined by a male practitioner, the desire for a chaperone was associated with having had a previous cervical smear

The following practices are recommended for the genital examination of the paediatric patient.

1. All remarks of a sexual connotation must be avoided during the interview and examination.

2. Patients should not be touched on the genitals or breasts except as part of the physical examination. They should be advised before being touched.

3. If the child is not at ease with a genital examination, force should never be used. The reason for the procedure should be clearly explained to the parents and the child. If the child refuses to cooperate, the examination should be postponed, if it is not urgently required.

4. For infants and school-aged children, a parent or caregiver should remain close to the child throughout the physical examination. The child should be undressed as necessary and be allowed to dress as soon as the physical examination is completed. Examination of the genitalia should be performed if indicated, such as during the annual examination to check for normal development of the external genitalia, to look for endocrine anomalies, to check for physical signs of suspected abuse or if requested by the parents. It should be the last part of the physical examination.

   Girls can sit on the parent’s or caregiver’s lap in the supine frog-legged position. This allows for adequate visualization of the introitus and anus, and is less anxiety-provoking than other positions. The knee-chest position, where the child is on her hands and knees, allows for better views of the hymen and vaginal vault but may be frightening because the examiner is out of view. In boys, the lateral decubitus position allows for an adequate examination.

5. For older school children and adolescents, a parent or nurse should be present. The child should be allowed to dress and undress in privacy, wearing a gown for the examination.

   A Papanicolaou (Pap) test or a screening test for sexually transmitted diseases is indicated only if an adolescent is sexually active. Pelvic examinations are not a routine part of physical examination in teens who are not sexually active even if oral contraceptives are being prescribed.

   In cases of sexual abuse (particularly in young children), a vaginal examination under general anesthesia is often the least traumatic method of assessing injury, and it should preferably be done by an experienced gynecologist.

The Clinical Guidelines for the Management of Disorders of Sex Development in Childhood (2006) provide some general recommendations for the medical examination. These include suggestions for clinicians to remain calm, reassuring, and open, and to use the patient’s preferred gender terminology. The guidelines also recommend minimizing the number of health care professionals involved in a child’s care and the avoidance of repeated exams, in particular those which involve measurement. In addition, they suggest photographing genitals only when necessary and being meticulous about preserving confidentiality. In summary, these guidelines emphasize treating the child with humanity and care, and avoidance of imparting a message of stigma or “freakishness” to a child or their family.

We make the following recommendations: (1) information should be given to caretakers and youth before the appointment visit regarding what to expect during the medical visit and genital exam; this information should be provided in a nonauthoritative manner, allowing for open communication, questions, and concerns to voiced; (2) when appropriate, parents can be encouraged to talk to their children about the exam ahead of the appointment, with input from the team about appropriate communication; (3) physicians can be trained to provide reassurance about positive aspects of the exam, while maintaining full disclosure about all findings; (4) youth can be given control of various aspects of the exam to the extent possible, and encouraged to communicate with providers; (5) children should not be forced to participate in an exam if acute distress is too high; (6) efforts should be made to reduce the possibility of stigma and shame, which may entail asking permission for trainees to be present in a context that encourages a child and parent to deny consent if that is more comfortable, and reducing the number of specialists in the room to only essential participants; (7) youth and family distress should be assessed routinely with interventions tailored to the unique needs of the family (such as stress reduction and coping techniques)

As assessing pubertal stage is difficult, various studies have focused on a particular pubertal stage in girls (9, 10), namely age at menarche, which can often be determined retrospectively, but there is no easily obtained comparable measure for boys. This limits analyses to girls only, and to one measure of puberty. There are a number of factors that complicate the measurement of pubertal status, including the complex nature of the pubertal process, individual differences in the pattern of pubertal change, lack of precise measurement techniques, and problems with securing permission to use the most precise measure – clinical assessment. Children and their parents are less likely to consent to clinical assessment than to other forms of assessment, such as questionnaire-based approaches. Schools share that reluctance and, in addition, have concerns about the use, within schools, of pictures or photographs depicting the development of secondary sexual characteristics. Chronological age is not a reliable parameter for determining the biological characterisation of individuals. To assess levels of sexual maturity in growing children, many clinicians rely on physical examination.

Below are the common methodologies

1.Clinical (Gold standard) assessment Tanner staging from a physical examination of the adolescent is considered to be the gold standard measurement of pubertal stage. There are five stages, separately defined for boys and girls, determined by pubic hair growth for both sexes and breast and testicular development for girls and boy respectively. The five stages are summarised in the sexual maturation scale (SMS) – a set of photographs that those performing the assessment use to judge the stage that a young person has reached in relation to each of their secondary sexual characteristics.

2.Self-assessment It assesses secondary sexual characteristics using a series of photographs (used originally to guide clinicians in the gold-standard measurement) and it has been shown that the identification of these characteristics, using the scale, is related to endocrine changes, growth and other pubertal changes. While the photographic version of the SMS has been used for selfassessment, a line drawing version was produced to make it more acceptable to young people.The PDS is an interview-based continuous measure of pubertal development. It includes a series of questions about growth, body hair and skin changes. There are additional gender-specific questions, including facial hair and voice change for boys and breast development and menarche for girls. There are four response options: ‘not yet started, barely started, definitely started, seems complete’. The questionnaire does not contain any pictures or diagrams.

3 Growth: Serial measurement of height is the most frequently reported approach to assessing pubertal stage and can be used to identify both age at take-off and peak height velocity. There is also some evidence to suggest that height velocity correlates with secondary sexual characteristics –the SITAR method can be applied to growth in other parameters, such as foot length, and to the development of secondary sexual characteristics – breast, testicular and pubic hair development. The SITAR method produces three measurements representing differences in mean size and growth tempo and a measure of growth velocity.

4.Hormonal assessment : At the onset of puberty, there is an increase in the overnight pulsatile release of LH suggesting that early morning urinary LH, adjusted for creatinine, might be a way of discriminating Tanner stage in girls. Serum testosterone is aromatised to oestrogen in fat, and it is oestrogen that triggers growth hormone (GH) secretion in both sexes. Pulsatile GH secretion leads to increase in IGF-1 and insulin, which persist until around age 25 years when they begin to fall . Low dose oestrogen primes GH secretion, but high doses close epiphyses . Oestrogen levels in girls are less discriminatory in the early stages of puberty, even with good assays. Inhibin B is released from the ovary in pubertal girls, rising in early puberty. Inhibin A is slower to rise . Testosterone is low in girls, rising with puberty, but always remaining lower than levels observed in boys. For boys, testosterone rises throughout puberty with the steepest rise seen between stages 3 and 4.

  Leptin Leptin is an adipocyte hormone that is important in regulating energy homeostasis. Leptin interacts with the reproductive axis at multiple sites with stimulatory effects at the hypothalamus and pituitary, and inhibitory action on the gonads. Evidence is accumulating that leptin potentially affects the regulation of GnRH and LH secretion during puberty, pregnancy and lactation

5. Voice. The maturation of the human voice, as a function of age, is characterised by changes in pitch, loudness and a variety of tone qualities. In both sexes, the voice drops throughout childhood as the larynx grows. Voice breaking in boys usually occurs as a distinct event during late puberty due to the increased length of the vocal cords that follows the growth spurt of the larynx and represents a further non-invasive measure of pubertal timing. A rapid drop in voice occurs during CLOSER Resource Report: Review of methods for determining pubertal status Page 9 of 54 Tanner stages 3 and 4, usually around 12-15 years. The maximum change in the male voice takes place at puberty.

Clinical assessment still represents the gold standard for assessment. Assessment of growth in height or foot size was agreed to be a promising approach, albeit that there was relatively little evidence relating to foot growth.Self-assessment, while much easier to administer and possibly the only realistic method other than clinical assessment was seen as a rather crude method of assessment given the likelihood that it will only accurately categorise pubertal status to within one Tanner stage. Assessment of voice was seen a potentially promising approach, particularly given the availability of a free app to do this. However, the need for research to assess this, particularly given the likely differences in accuracy between boys and girls, is acknowledged. Hormonal approaches to assessment were seen as holding promise, but the need for repeated measures in each young person and the potential cost of assays, were seen as current barriers to their use in cohort studies. Since this is a rapidly changing field, it is possible that hormonal approaches might be more realistic methods of pubertal assessment in the future