Pediatric and adolescent gynecology has emerged as an important subfield in obstetrics and gynecology. Adolescence is defined as between the ages of 10 and 19 according to the WHO,1 and menarche typically begins in this period. Menstruation-related problems in adolescence are frequently encountered by primary physicians,2 but other pediatric gynecological diseases are less common and can be difficult to manage in patients at this age. Therefore, this study was conducted in order to characterize clinical gynecologic problems during childhood that primary physicians should be aware of.

We performed a retrospective analysis of all medical records of patients younger than ten years who visited the Pediatric and Adolescent Gynecology Clinic of Samsung Medical Center between 1995 and 2020. The medical records were reviewed individually to identify the date of the first appointment, age at referral, chief complaints, symptoms at presentation, clinical findings, and final diagnosis. Among 6,605 patients who visited the clinic, 642 pediatric patients younger than ten years, (i.e., younger than the average age of menarche in Korea)3 were enrolled in analysis of pediatric gynecologic concerns, excluding menstrual-related issues.

The chief complaints about the gynecologic problems varied among pediatric patients in this study (Fig. 1). The most frequent chief complaint was abnormal external genitalia, with absence of the vagina or imperforate hymen as the main concerns at presentation (n = 209, 32.6% of the study population). The second most encountered group of problems was infectious and inflammatory conditions of the vulva and vaginal area, with the primary symptom of increased vaginal discharge (n = 161, 25.1%). Other chief complaints in the clinic included abnormal findings on examinations requiring the further evaluation by gynecologic specialists, vaginal pruritus and spotting, trauma, and other incidental findings.

Among those who visited with concerns about genital abnormalities, the most frequently diagnosed disease entity was agglutination of the labia minora (n = 198). Vulvovaginitis was the second most common disease (n = 169), followed by problems regarding neoplasm, vaginal bleeding, and other miscellaneous reasons.

Gynecologic diseases in pediatric patients can be categorized into these groups: 1) congenital anomalies, which mainly involve an abnormal appearance; 2) vulvovaginal problems, including inflammatory or infectious conditions; 3) neoplasm; 4) vaginal bleeding; and 5) other miscellaneous conditions (Fig. 2).

Among the 642 patients who visited the clinic during the study period, 245 cases (38.2%) were referrals from primary care sources; 175 cases (27.4%) were direct outpatient clinic visits; 169 cases (26.3%) were referrals from the pediatric department; and the remainder were referrals from other departments, including emergency medicine, urology, and general surgery (Fig. 3).

This study describes the clinical characteristics of pediatric patients and presents a brief review of common gynecologic problems and the diversity of medical conditions that can be expected in a pediatric and adolescent gynecology clinic. Most patients presented with concerns about genital anomalies or vaginal discharge. Chief complaints of neoplasms and issues involving vaginal bleeding were subsequent reasons for referral to the clinic. Most patients were managed conservatively; only a few underwent surgical intervention. Referral from a primary physician, direct visits to the pediatric gynecologic clinic, and referral from the pediatric department were the most common sources of patient presentation.

Genital anomalies were the most frequent clinical manifestations associated with referrals; most of these cases were diagnosed as agglutination of the labia minora. Such conditions are mostly noticed incidentally by an infant’s caregiver during routine care or observed at a health check-up.4 Outpatient consultations are generally based on referrals from primary pediatricians based on the abnormal appearance of the genitalia or apparent absence of a vagina. Agglutination of the labia minora can appear in partial or complete form and is generally treated with estrogen cream twice a day for two weeks, followed by a once-daily application for the subsequent two weeks.5 The need for surgical adhesiolysis in pediatric patients is rare as the tissue is easily separated by estrogen application. After treatment, caregivers are asked to maintain good perineal hygiene to prevent recurrent inflammatory conditions of the vulva.

The second most frequently encountered medical condition was vulvovaginitis, one of the most common gynecological complaints in pediatric and adolescent patients.6 The vagina is close to the anus, and children often have difficulty maintaining anal hygiene, allowing fecal flora to be introduced into the vagina.7 The health of the genital region is closely related to personal hygiene, a lack of which can result in vulvovaginitis. If the condition does not improve in response to treatment, clinicians should suspect vaginal foreign bodies. These can cause continuous irritation of the vaginal canal, resulting in vaginitis. If a vaginal exam is required, the clinician should pay particular attention to hymenal injuries. The usual need for sedation mandates consultation with the parents prior to the vaginal examination. Inspection during the examination should be completed with lateral and downward traction to expose problematic areas.8 Foreign body removal should be performed with a careful approach to prevent genital or hymenal injuries. In our clinic, when a vaginal exam was required, general anesthesia was performed followed by vaginoscopy, and there were no cases of hymenal injuries.

In our cases, the pathogens causing vulvovaginal infections were identified by vaginal culture carried out with the catheter-in-catheter technique to carefully retrieve a sample without damaging the hymen or vulva. Treatment with antibiotics improved the symptoms. Patients with no specific pathogen identified were treated with conservative methods, such as sitz bathing and education to ensure proper self-hygiene.

Neoplasms in childhood are indicated mainly by non-specific clinical symptoms such as abdominal pain or distension. Generally, the incidence of ovarian neoplasm in childhood is 2.2/100,000.9 Most cases are referred to tertiary care centers for diagnosis and discussion of appropriate treatment options. In our study, ovarian cysts, including physiologic and functional cysts, were often found incidentally during examination.

Problems involving vaginal bleeding were the least common reason for outpatient visits to the clinic in children younger than ten years. Most patients who visited the clinic with vaginal bleeding had transient symptoms or were referred from the pediatric department due to suspected precocious puberty. Considering that the mean age of menarche in Korean girls is 13.0 years,3 problems with vaginal bleeding among children enrolled in this study were not commonly related to menstruation. In cases of suspected precocious puberty, clinicians should be aware of the available diagnostic tools, including hormone assays, ultrasound evaluation, and appropriate physical exams to assess breast development and the presence of pubic hair.

Among various pediatric traumas, the incidence of genital trauma is 0.6%.1011 However, since more patients visit the emergency department than outpatient clinics at tertiary hospitals, it is thought that there will be differences from our clinic’s data. When a genital trauma patient visits their primary care clinic, it is necessary to determine whether it is a contusion or laceration, and to decide whether additional treatment and referral are required.

Consultation for patients with Marfan syndrome is a unique feature of our clinic. The incidence of Marfan syndrome in Korea is 1.11–2.25/100,000 below 10 years of age.12 Our center provides treatment for height control in pediatric females with Marfan syndrome. Therefore, 4.5% of those who visited pediatric gynecology in our center had Marfan syndrome, which is an unusually large percentage. Most patients with a diagnosis of Marfan syndrome have extraordinarily tall stature and are referred from the pediatric department for growth regulation. Because patients with Marfan syndrome experience an extraordinary growth spurt when entering puberty, the pediatric department refers patients to our clinic before that acceleration of growth. Patients are closely monitored according to a growth curve and considered for treatment with appropriately timed high-dose estrogen.13 Based on our study published in 2021, starting hormone therapy before 10.6 years is most effective in limiting the growth spurt.14

The findings of this study illustrate the most frequent gynecologic clinical symptoms observed during pediatric period and are consistent with related studies published in the United Kingdom15 and by the European Board and College of Obstetricians and Gynecologists.1617 Most patients were referred from primary care and the most common symptoms were vulvovaginitis and labial adhesions. However, in contrary to previous studies, our study included only patients aged younger than ten and excluded pubertal patients, allowing us to focus on gynecological problems in the first decade of life.

This article is anticipated to provide valuable information for primary physicians who need to diagnose and manage common pediatric gynecologic problems. Determining the appropriate timing of treatment or referral is a key aspect of resolving pediatric gynecologic problems.