An Initiative of the Program for Bedside Medicine, Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. The second phase of the examination involves evaluation of the vagina . Older childrencan be placed in adjustable stirrups (Figures 1 and 2). Obstet Gynecol Clin NorthAm 1992;19:39, 10. A tape testmay be useful for suspected pinworm. So this is the scariest picture weve got! To successfully examine a child, one needs the cooperation of the patient, the parent, and a medical assistant. Approximately 20% of female children infected with pinworms (Enterobius vermicularis) develop vulvovaginitis. The dischargeis usually white and not malodorous, and wet preparation demonstrates multipleepithelial cells without polymorphonuclear cells. 0:31. The film opens with a woman sitting in an office of a physician. In this video, pediatric and adolescent gynecologist Veronica Alaniz, MD, discusses the indications, proper technique and risks of vaginoscopy and hysteroscopy. Most young children will prefer to have aparent--usually their mother--in the room at all times. Position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. Children often cannot hold still for long intervals while instruments are being located. Diagnosing and treating PCOS in adolescents. Breast budding is a reliable sign that the vaginal pH is shifting to an acidic environment. They may be discovered due to symptoms, during a routine physical exam or incidentally through imaging studies. The child's buttocks will now be heldup in the air and her back and abdomen will fall downward (Figure 4). An ectopic ureter can present as persistent wetnessor purulent discharge. Vaginal bleeding is also associated with vulvovaginitis. You can use this section to discover where and how this . Includes menu so you can select the portion of the video most applicable to you. They schedule and bill separately for their services, and are not employees of the Hospital. Approximately 75% to 85% of ovarian neoplasms necessitating surgery are benign, with cystic teratomas being the most common. Our specialists are nationally ranked and globally recognized for delivering the best possible care in pediatrics. Childrens clothing is often tight fitting and nonabsorbent, which keeps the vulvar skin irritated, warm, moist, and at risk for vulvovaginitis. The child is told to have her abdomen sag into the table. Excoriations are common, and lesions in other areas of thebody or a history of allergy or atopy may help in making the diagnosis.Psoriasis, scabies, and autoimmune bullous diseases also can present asvulvovaginitis. In: Emans SJ, Laufer MR, Goldstein DP, eds. Girls should have their first gynecological exam between the ages of 13 and 15. 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. Tailor your gynecologic examination to the presentingissue. The prepubertal vagina is narrower, thinner, and lacks the distensibility of the vagina of a woman in her reproductive years. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. Gynecologic Examination with Pap Smear. Viscous lidocaine and warmsaline for irrigation through an IV set-up may be helpful when examininga child who has an acute straddle injury and bleeding. Addressing the Youth Mental Health Crisis, Department of Pediatric and Adolescent Gynecology, Fertility Preservation and Reproductive Late Effects Program, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome, Insurance, billing and payment information. Many gynecologic conditions in children can be diagnosed by inspection alone. At the 44th National Association of Pediatric Nurse Practitioners Conference, guidelines for prescribing oral contraceptives were discussed. The bacteriology laboratory should plate the swabs on standardgenitourinary media, including blood agar, MacConkey, and chocolate media.If you send a culture for N gonorrhoeae and the results are positive, thelaboratory should identify the species unequivocally in a premenarchal girlbecause of the possibility of sexual abuse. The child should be warned that the rectal examination will feel similar to the pressure of a bowel movement. A nasal speculum or otoscope can also be used, but they are usually too short for older girls and thus are less than optimal. Vulvovaginitis: causes and management. The most common gynecologic condition of children is vulvovaginitis . Emphasize setting the stage to make the examinationa positive experience for your young patient. 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. While the light from the otoscope or ophthalmoscope is shone into the vagina, the examiner can evaluate the vaginal walls and visualize the cervix as a transverse ridge, or flat button, that is redder than the vagina. A complete examination includes inspection of the external genitalia,visualization of the vagina and cervix, and rectoabdominal palpation. Dr. Common indications for a pelvic examination in an adolescent are listed in Box 12.1 . The foundation of treating childhood vulvovaginitis is the improvement of local perineal hygiene. Volume 90% Video Chronic Pelvic Pain and Endometriosis: Part 2 Jeannette Lager, MD, describes a directed pelvic examination for chronic pelvic pain, including a general pelvic exam, Q-Tip test for vulvodynia, abdominal exam (including testing for Carnett's Sign), an exam of the pelvic floor muscles and an assessment of myofascial trigger points. N gonorrhoeaerarely persists beyond the newborn period without symptoms. There is also a video, which demonstrates a technique for doing a thorough female pelvic exam and a module for the male genital exam. Occasionally it is best to defer the genital examination until a second visit . Nonspecific vulvovaginitis. Vaginal burning, itching or foul-smelling discharge. Huffman JW, Dewhurst CJ, Capraro VJ: The Gynecology of Childhood andAdolescence. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women's health care. She should be allowed to visualize and handle any instruments that will be used. She also explains why it is important to check ferritin levels for iron deficiency and discusses the etiology of abnormal uterine bleeding, with most heavy menstrual bleeding in adolescents and young adults due to ovulatory dysfunction or inherited bleeding disorders. If the issue is vaginal discomfort, pruritus, ordischarge, the differential diagnosis includes nonspecific or infectiousvulvovaginitis, vulvar skin disease, lichen sclerosis, and presence of aforeign body. Whats the diagnosis? Much of the history must be obtained from the parents . The outer catheter serves as an insulator, and the inner catheter is used to instill a small amount of saline and aspirate into the vaginal fluid. By Jessica Annette Kahn, MD, and S. Jean Emans, MD. Beforeinserting the Calgiswab, allow the child to feel a similar swab on her skin.If the Calgiswab does not touch the edges of the hymen, it should causethe child no discomfort. The mostcommon foreign body encountered in prepubertal girls is a wad of toiletpaper, which appears as a small, gray mass. Finding the source of this pain in adolescent females and diagnosing the condition can also be particularly challenging. Office evaluation of the child and adolescent. Accidental genital trauma often produces extreme pain and overwhelming anxiety for the child and her parents. Learn how doctors should perform a bedside swallow evaluation! Menstrual bleeding in adolescents can be chaotic. When you give to Children's Colorado, you're helping us to reimagine children's health through patient care, education, research and advocacy. Hysteroscopy is performed in the operating room under general anesthesia. Vulvitis, or vulvar inflammation, can occur alone or in combination withvaginitis, or vaginal inflammation. Children's Hospital Colorado partners with NRC Health to gather star ratings and reviews from patients, residents and family survey data. These patients require immunology or rheumatology consultations to prevent more serious and chronic autoimmune conditions, such as Behcets syndrome. The extent of labial adhesions and associated symptoms are variable (seefigure "B"). Pay special attention to anatomic and pathophysiologicdifferences in the child. Seborrheicdermatitis is characterized by erythema of the vulva, often associated withyellow scales and crusting. This patient presents with chest pain. Many if not most of these conditions may eventually require an examination to determine the cause of the problem. Asking the child whether anyone hasever touched her in a way that made her feel uncomfortable often is helpfulin drawing out this information. Vulvovaginitis in children may also be caused by a variety specific pathogens such as group A or group B b-hemolytic streptococci, Haemophilus influenzae, and Shigella boydii ; Neisseria gonorrhoeae, Trichomonas vaginalis, and Chlamydia trachomatis may also be responsible in cases associated with abuse but are significantly less common. From AccessMedicine. Macleod's Physical Examination - Head, Eyes and Ears Examination - OSCE Guide 2017. Similar to their peers, they can experience problem periods, such as heavy and painful bleeding. Physicians may elect to treat the primary symptoms of vulvovaginitis for 2 to 3 weeks, realizing that on rare occasions they could be missing something more serious. Young girls should feel that they are participating in their examination , not that they are being coerced or forced to have a gynecologic exam. She also discusses the preferred diagnostic modality and when to consider surgery. Bacterial vaginosis during pregnancy may heighten risk of preterm birth, pregnancy loss. Affecting approximately one in every 4,500 newborn girls, Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome can be challenging to treat both medically and psychologically, due to the potential loss of fertility. What Is The Specific Cause of This Patients Clubbing? Educational demonstration of a head-to-toe physical exam, vaginal examination, bimanual examination and rectal examination (pelvic examination) of a female b. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination. Opening questions can include inquiriesabout the family structure and recent changes, school, friends (such aswhether she has a best friend), and the types of activities she enjoys.It is important to assess who cares for the child and to uncover--both fromthe parent and from the child--information about any history of sexual abuseor current concerns in that regard. In this video, Stephen Scott, MD, provides an overview of how to properly identify and manage NSGUs and the timeline for healing. 12 red rubber bladder catheter for the outer catheter and the hub end of an intravenous butterfly catheter for the inner catheter ( Fig. Often reassurance and sometimes delay until another day are the best approaches. This allows one to establish a rapport and mimics the traditional visits the child has with the pediatrician. They may ask for their mothers to be there, be fearful of the examination concept, and need more than one visit to achieve the goals of the visit. Early identification and treatment can lead to improved quality of life for individuals with PCOS and prevention of diabetes and cardiovascular disease. Pokorny SF. 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. Treatment of lichen sclerosus consists of eliminationof irritants, improved hygiene, application of barrier ointments, and administrationof oral hydroxyzine hydrochloride before bed to minimize scratching. Common Indications for Pelvic Examination in the Adolescent, Clinical Features of Children Presenting With Vulvovaginitis. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. Vulvovaginitis also may be associated with aspecific infectious agent. Urethral lesions alsoshould be considered. NSGUs are caused by an autoimmune response following a viral illness and are unrelated to sexual activity. Emphasize that the most important part of the examination is just looking and there will be conversation during the entire process. Medical Forensic Exam Videos Adult/Adolescent Sexual Assault Medical Forensic Exam This 58 minute video includes: History Taking Discussion of HIV Prophylaxis Full anogenital exam with evidence collection Demonstration of Foley catheter technique Demonstration of toluidine blue dye application Photography Pediatric History Taking This 63 minute video uses unscripted interactions with children . Blake J: Gynecologic examination of the teenager and young child.Obstet Gynecol Clin North Am 1992;19:27, 3. 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. Stanford 25 YouTube Channel Abdominal Examination Examination of the Spleen (Stanford Medicine 25) Percussion of the Spleen (Stanford Medicine 25) Diagnosis Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) with Carnett's Sign - Abdominal Pain Ankle Brachial Index Ankle Brachial Index (ABI) Test: How to Perform Venous Testing Bedside Ultrasound DR. KAHN is Assistant in Medicine, Children's Hospital, Boston, and Instructor in Pediatrics, Harvard Medical School, Boston, MA.DR. However, it is when the pain gets progressively worse and occurs outside the menstrual cycle, that it might be time to consider a pathological cause, such as endometriosis. Often the first awareness comes when the mother notices staining of the childs underwear or the child complains of itching or burning. The history and examination usually clinch the diagnosis of vulvovaginitisand vaginal bleeding, but selected laboratory tests such as culture arehelpful in some cases. An infant may be examined on her mothers lap. A gentle, patient approach is important when examining a prepubertal girl. After the history has been obtained, the parents and the child should be reassured that the examination will not hurt . The vagina will then fill with air, aiding the evaluation. If you suspect candidal vulvovaginitis, obtain apotassium hydroxide (KOH) preparation; a Gram stain may be useful if thedischarge is purulent. The importance of patient/family preference along with individualization based on medical history and treatment goals is reviewed. The relative size ratio of cervix to uterus is 2:1 in a child. This period of transition involves important physical and emotional changes. Physiologic leukorrheacan be confused with vulvovaginitis. For example, the physical presence of the mother often may facilitate examining a 4-year-old girl but may inhibit the cooperation of a 14-year-old adolescent. The atrophymay distort the anatomy of the labia and clitoris. There are no reported cases of congenital absence of the hymen. Change gloves, lubricate the rectum, and then gently . If vaginalcultures are not needed, lidocaine jelly can be used to decrease the child'sdiscomfort. After observing an increase in the rate of syphilis cases, the Cleveland Clinic Ob/Gyn & Womens Health Institute has partnered with the Center for Pediatric Infectious Diseases to evaluate the effectiveness of current testing strategies. Philadelphia, PA, WB Saunders, 1981, 5. Approach to evaluation of premenarcheal child with a gynecologicproblem. The most important technique to ensure cooperation is to involve the child as a partner. The vagina is 4 to 6 cm long , and the secretions in a prepubertal child have a neutral or slightly alkaline pH . This may create considerable and understandable anxiety in the child and parent. In this setting it may be helpful to use the extinction phenomenon, in which the examiner provides pressure on the perineum lateral to the introitus before insertion of the speculum. The hymen of a prepubertal child exhibits a diverse range of normal variations and configurations ( Fig. Many adolescent girls do not want other observers, such as mothers, in the examining room. Culture for N gonorrhoeae should be plated on modified Thayer-Martin-Jembecmedium. Speculums and instruments that might frighten a child or parent should be within drawers or cabinets and out of sight during the evaluation. After your examination is complete, congratulate the child for her cooperationand bravery. Typical findings are a maculopapular brightly erythematous rash withsatellite papules. HPV is also verticallytransmitted and lesions may appear in the first few years of life. A specimen for Chlamydia culture can be obtained by using a Dacron maleurethral swab and scraping the lateral vaginal wall gently. Vaginal foreignbodies, particularly wads of toilet paper, often are found in girls whohave a bloody, foul-smelling, or persistent vaginal discharge. Pinworms are another cause of vulvovaginitis in prepubertal children. A handheld mirror may help in some instances when discussing specifics of genital anatomy. 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. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders. Because the child lacks the labial fat pads and pubic hair of the adult, when a child squats, the lower one-third of the vagina is unprotected and open. 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. . We see more, treat more and heal more children than any hospital in our seven-state region. Intestinal parasitic invasion with pruritus. 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. In determining the diagnosis, it may be helpfulto inquire about persistently wet underwear, recurrent fevers, unexplainedUTI, and abdominal or lower back pain. The typical location is the anterior vaginalwall near the cervix. Most such traumas involve straddle injuries. What is it? This conveys an unhurried approach. Cultures from the vagina indicate normal rectal flora or Escherichia coli. The majority of childrens gynecologic problems are treated by medical , rather than surgical, means . All-New Assessment Videos! The medical history should be guided by the presenting complaint anddifferential diagnosis. She discusses how diagnosis requires both ovulatory dysfunction and hyperandrogenism, and she shares recommendations for PCOS treatment from lifestyle changes to possible medications. You canmodel for parents appropriate ways to discuss gynecologic issues with theirchild, and help parents and children understand the importance of discussingissues related to reproductive healthand sexuality during the prepubertalyears.1. The history is critical in terms of making a diagnosis, but it also providestime for you to establish rapport with the patient and elicit her understandingof her symptoms and expectationsof the visit. 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. Teens don't usually get pelvic exams. Patient has this new skin finding, what should you worry about? A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. Inspect the child's breasts and palpate themfor signs of puberty. 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. Not sure if you need urgent or emergency care? It is estimated that 80% to 90% of outpatient visits of children to gynecologists involve the classic symptoms of vulvovaginitis: introital irritation and discharge. A visit with a pediatric clinician is an ideal time to ensure that a teenager knows the correct information, has the opportunity to make certain contraceptive choices, and instill the knowledge that the pediatric office is a safe place to come for help. Abraham Verghese Asks: Why Are We Doing This Teaching? Examination of the Female Genitourinary System. In life-threatening emergencies, find the emergency room location nearest you. The device is commercially availableas the Pediatric Vaginal Aspirator from Cook Ob/Gyn (Spencer, IN.). This can be accomplished without the insertion of any instruments. Cleveland Clinic reexamines syphilis testing strategies after rise in cases. Discuss the results of the examination and your diagnosis andmanagement plan with the child and her parents after she is dressed. In the office setting, the examination should be limited to external inspection only; speculum exams should not be performed in pediatric patients. Health providers are the key source of accurate information on puberty and menstrual periods and can offer safe and effective treatment. Except for the cervix, any mass discovered on rectal examination in a prepubertal examination should be considered abnormal. 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. In the period surrounding the time of puberty, children often develop a physiologic discharge secondary to the increase in circulating estrogen levels. The vagina of a child is 4 to 5 cm long and has a neutral pH. A KOH preparationor Biggy agar culture is useful to rule out candidal infection. An exam of your child's genitals (JEN-ah-tuls) is done to check for possible disease, injury or abnormality. The classic symptom of pinworms is nocturnal vulvar and perianal itching. The major factor in childhood vulvovaginitis is poor perineal hygiene. Recurrent vulvovaginitis, persistent bleeding, suspicion of a foreign body or neoplasm, and congenital anomalies may be indications to perform a vaginoscopy and examine the inside of the vagina. For girls olderthan 2 years, the knee-chest position also permits excellent visualizationof the vagina and cervix without instrumentation.3 If necessary,an experienced examiner or pediatric gynecologist may use a small vaginoscope,cystoscope, hysteroscope, or flexible fiberoptic scope with water insufflationof the vagina to improve visualization. Clin Obstet Gynecol 1987;30:643, 7. An assistant pulls upward and outward on the labia majora on one side while the examiner does the same with the nondominant hand on the contralateral labia. Vulvarskin disorders are common, and often easily recognizable on exam. 1 A vaginal self-exam is not the same as a vulvar examination. You can establish rapport by asking about psychosocial issues that mayimpact on the child's presenting gynecologic complaint, including familydynamics and peer relationships. In addition to your doctor, there will be a nurse or an assistant in the room during . If youidentify a specific pathogen, appropriate antibiotic therapy is indicated,in addition to the measures previously described. In this. Labial adhesions do not require treatment unless they are symptomatic or voiding is compromised. Dr. Huguelet also reviews the basic embryology and treatment approach for these conditions and explains when the best time is to perform surgery. In this video, adolescent gynecologist Eliza Buyers, MD, discusses the management of abnormal uterine bleeding (AUB) in adolescent patients. Pelvic Exam The pelvic exam is a vital part of every woman's preventative care and is also important towards making a number of diagnoses when presenting with abdominal or pelvic complaints. The labia minora are thin, and the vulvar skin is red because the abundant capillary network is easily visualized in the thin skin. The vulvar and vaginal epithelium lack the protective effects of estrogen and thus are sensitive to irritation or infection . Vaginoscopy is a diagnostic procedure that can be used to evaluate the inside of the vagina and is recommended for girls who are too young for a speculum exam or cannot tolerate one. 4:40. Childrens Hospital ColoradoAnschutz Medical Campus13123 East 16th AvenueAurora, CO 80045. Pediatricians are uniquely qualified to perform an appropriate clinicalassessment because of their expertise in examining young children and knowledgeof many anatomic and pathophysiologic conditions specific to children. One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. Congenital anomalies, precocious development, and amenorrhea are covered in more detail in other chapters. The classic perianal figure eight or hourglass rash is indicative of lichens sclerosus with white patches and in some cases local trauma. Most young children can be examined in the frog-leg position; that is,supine with knees apart and feet touching in the midline. Am J Obstet Gynecol1987;157:950, 6. Specific vulvovaginitis. 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. New onset of Trichomonas vaginitis in theprepubertal child is associated with sexual abuse. 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. A parent or caretaker is usually present during the examination of ayoung child, and most children are comfortable with the parent sitting closeby or holding their hand. What Stands in the Way of Bedside Teaching? Last updated on April 26, 2013 @3:30 pm Feedback: How useful was the above information? The examination also allows a period of opportunity to counsel children, in an age-appropriate manner, about potential sexual abuse. This provider either practices in a department or specialty that we currently do not survey, or does not have at least 10 ratings in the last 12 months. These exams may be done as part of a yearly check-up for teenagers or young adults, however, you may need them sooner or . Obtaining a history from a child is not an easy process. If a child's symptoms are severe,a one- to four-week course of a moderate-potency ointment can be recommended,followed by a lower-potency preparation. Cultures for C trachomatis are recommended because of the possibilityof false-positive test results with indirect and slide immunofluorescenttests and insufficient data on tests that utilize polymer chain reactionand ligase chain reaction techniques. 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. 12.4 ). Although anovulatory cycles are common in the years after menarche, there are established norms and, alternatively, abnormal findings that require further investigation. 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 . Ovarian torsion should be managed conservatively with untwisting and preservation of the adnexa, regardless of the appearance. Other associations.Vaginal complaints also can be associated with masturbationor psychosomatic illness, or they may be factitious. This technique is generally successful in cooperative children unless there is a very high crescent-shaped hymen, in which case it is too difficult to shine the light into the small aperture of the vaginal introitus. 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. Pokorny SF. 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.
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