INTRODUCTION

Vaginoscopy refers to use of an instrument, other than a speculum, to visualize the vaginal canal. It is used most often for examination of children. The clinician should choose an instrument that will not damage the hymen or lower genital tract of the unestrogenized child. The anatomic integrity of the child's hymenal tissue is important from a cultural and forensic point of view: families often need to be assured the child will remain virginal; anatomic disruptions of the hymenal tissues are used as forensic evidence of childhood sexual abuse.

PREPROCEDURE ISSUES

Prior to insertion of any instrument into the vaginal introitus, the anatomic features of the hymen should be documented and the amount of estrogen effect on the child's tissues should be assessed. (See "The pediatric physical examination: The perineum", section on 'Females' and "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

Hymenal tissue with a high estrogen effect (newborns and peripubertal children) is better able to tolerate iatrogenic stretch without tearing than tissue with a very low estrogen effect (children three to eight years of age) [1]. A pediatric vaginal speculum should not be used in routine examination of the prepubertal child's vagina because there is a risk of traumatizing the hymen and vaginal walls, even if the child is under general anesthesia.

Vaginoscopy with an irrigating endoscope can be performed in the office or as an examination under anesthesia (see below). The site is determined by the child's ability to comply with instructions. Topical anesthetic is applied to the vulva approximately five minutes before inserting the vaginoscope [1]; the author uses a 2 percent preparation of viscous lidocaine. The author is more comfortable using a flexible irrigating endoscope for office procedures due to concern about inadvertent patient movement that might result in accidental injury. Patient compliance can be improved when the child is informed that she will be able to see what the doctor sees inside her body. A flexible scope can be bent toward the patient so she can visualize her lower genital tract or a video attachment with a monitor can be used.

INSTRUMENTATION

Historically, a popular technique for examination of a child's vagina involved the Cameron-Myers vaginoscope, which has interchangeable distal tubular structures of 0.7, 1.0, and 1.3 cm diameters (picture 1) [2,3]. This instrument was a modification of a veterinary otoscope [4,5]. The Killian nasal speculum has also been used for pediatric vaginoscopy [6]. Use of these instruments allows detection of large lesions and those that are a different color than the vaginal walls. However, if the lesion is accompanied by copious mucus or debris or is very small, detecting it with these instruments is difficult.