How to overcome discomfort with the genital exam

When parents discover something concerning in their child’s genital region, the next step is often a trip to the pediatrician’s office to determine whether the discovery is a result of sexual abuse or something else. To make the determination, clinicians will need to use a genital exam, which can be a source of discomfort for the clinician. In her presentation “Overcoming discomfort with genital exams” at the virtual 2020 American Academy of Pediatrics National Conference & Exhibition, Premi Suresh, MD, associate professor of pediatrics at the University of California, San Diego, offered guidance on how to prepare for exams, exam strategies, discussed common findings and what to do with them, with the focus on female genital exams.

Before discussing pre-exam strategies, Suresh addressed one of the main reasons why clinicians may be hesitant to perform genital exams, which is general discomfort with such exams. She recommended doing genital exams as routine health maintenance. Doing this will allow both clinician and patient to become comfortable with the exam, with the clinician incorporating the exam into the medical visit and the child learning that the genital area is just another area that requires regular examination to determine health. A routine exam can also provide anticipatory guidance to the patient from the physician.

When preparing for a genital exam, Suresh recommended reviewing female genital anatomy to be better able to note issues. For caregiver support during the exam, the child should choose who she wants with her during the exam or if she even wants a caregiver present, as some adolescent patients may not. If a caregiver is present during the exam, the person should be told to remain emotionally composed during the exam and to stay at the head of the examination table. Before starting the exam, the clinician should build a rapport, which includes clearly explaining what will occur during the exam and beginning the exam with the easy and noninvasive elements. Suresh said the clinician should ensure that there is a good light source and that swabs are available to take samples of any vaginal discharge for testing. She stressed that clinicians be careful to not swab the hymen in prepubertal girls as this will often end the exam due to pain.

During the exam, the patient should be draped appropriately. A frog leg position will typically work with prepubertal girls, but younger girls can be examined in the caregiver’s lap if it will help keep the child at ease. During the exam, the clinician should use techniques such as labial separation and labial traction. When documenting the exam, the clinician should note any relevant statements made by the patient. Any findings should be noted using a clock-face as reference. If possible, photos can be taken, especially if consultation may be needed for the patient. Common findings that are rarely, if ever linked to abuse, include redness labial adhesion, urethral prolapse, and lichen sclerosus.

Fortunately for patients and parents, many of the complaints that will lead to genital exams are normal findings or common conditions. In these cases, clinicians should be sure to reassure parents and patients. When a clinician is in doubt of the findings, Suresh recommended consulting with another clinician to clear up any confusion. Any disclosures of sexual abuse should be referred to the local child abuse service or agency. In cases of acute sexual abuse, the clinician must report the abuse immediately to law enforcement.