The Gynecologic Examination of the Prepubertal Child with Vulvovaginitis: Use of the Knee-Chest Position

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Abstract
Vulvovaginitis is a common complaint in the prepubertal child. The proximity of the vagina to the anus and the thin uncornified vaginal epithelium make the young child especially susceptible to vulvovaginal infection. Not only is hygiene often suboptimal in this age group, but pinworm infestations, bubblebaths, harsh soaps, and tight-fitting nylon tights can all contribute to the vulvar irritation. Because children are frequently sent to gynecologists, traumatized by a rectal examination as the first part of the evaluation, or sent for an x-ray of the vagina with the hope of excluding a radiopaque foreign body, we believed it would be useful to present our approach to the gynecologic evaluation of the prepubertal child in which the kneechest position is used for visualizing the vagina. METHODS The evaluation of a prepubertal child with vulvovaginitis in the Gynecology Clinic of Children's Hospital is done in the following order: (1) history; (2) inspection of the perineum with the child supine; (3) visualization of the vagina and cervix in kneechest position; (4) cultures; and (5) a rectal examination in girls with vaginal bleeding or abdominal pain. The knee-chest position (Figure) provides a particularly good view of the vagina and cervix without instrumentation. The little girl is asked "to lie on her tummy with her bottom in the air." She is reassured that the examiner plans "to take a look" but "will not put anything inside her." The child rests her head to one side on folded arms and supports her remaining weight on bended knees (6 to 8 in apart).

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