ABDOMEN AND GENITALIA

SILVERMAN TRANSCRIBED NOTES

ABDOMEN
LANDMARKS
Can be divided into 4 quadrants:
o Right-upper
o Left-upper
o Right-lower
o Left-lower
It can also be divided into 9 areas (3 horizontal,
3 vertical) using the Old English method
R
L
Epigastrium
Hypochondrium
Hypochondrium
R Lumbar/
Umbilicus
L Lumbar/ Flank
Flank
Hypogastric/
R Iliac
L Iliac
Suprapubic
INSPECTION
Contour normal full contour, flat, protuberant
Causes of fullness (5 Fs):
o Fat
o Flatus
o Feces
o Fluid
o Fetus
*considering frequency of teenage
pregnancy and obesity, even among
pediatric patients.
Abdominal distension - due to laxity
Causes:
o Rickets
o Celiac disease
o Hypothyroidism
Flat abdomen causes:
o Normal thin
o Malnutrition
o FTT
o Anorexia
*Diaphragmatic hernia in newborn
(normally full and convex) if flat it is DH!
Prune-Belly Syndrome
o complete absence of muscles of the
abdominal wall wrinkled appearance
o associated in:
Cryptorchidism
Hydroureter
Umbilical Hernia masses coming out of the
abdominal wall.

Masses in inguinal region

o Hernia
o Hydrocele
o Undescended testis
o Inguinal nodes
Epigastric pulsations
o May be normal in thin, excited
o Pulsations of liver
o Enlargement of R ventricle
Abdominal wall movement
o Normally moves with respiratory cycle
prominent during inspiration
collapsing during expiration
o Reversed in diaphragmatic paralysis
Collapse during inspiration
Prominent during expiration
o Diminished/absent with guarding Peritonitis
Peristaltic movement of intestine
o Patient is supine
o Observe using oblique light
o Visible normally in thin individuals
o Observe if excessive, observe direction
of wave
o Peristalsis of stomach visible over
LUQ in emaciated children with pyloric
stenosis
*waves are moving from LEFT TO
RIGHT particularly if baby is fed some
water.
o Peristalsis of Large Intestine over
lower quadrant and flanks
*waves RIGHT TO LEFT - due to
intestinal obstruction
Striae
o Purple
weight gain
Cushing syndrome
o Eventually becomes white
o Slate color Addisons disease
Blood vessels
o Distended veins in epigastrium IVC
obstruction
o Veins in periumbilical portal
obstruction
*demonstrated by pressing the vein with two fingers
held together and emptying the vein in both

directions by separating the fingers as pressure is

applied along the veins.
*then release one finger and see if the vein fills.
*in IVC OBSTRUCTION direction of blood flow is
from below upwards.

UMBILICUS
Defect/hernia
Drainage
Mass
At birth
o small defect of abdominal wall,
insignificant hernia
o usually <1 inch in diameter
Umbilical hernia - common in black (up to 7
years)
Surgical repair is indicated if associated with:
o Persistent urachus
o Skin over sac is thin & atrophic
Uncomplicated
Soft, reducible

Strangulated
Tense, irreducible

Omphalocele
o large hernia of the abdominal contents
into the base of the umbilicus
particularly due to poor abdominal
musculature
Discharge occasionally during neonatal period
o Watery (urine), purulent,
serosanguinous
o May be normal or be caused by:
Infected cord stump
Persistent urachus
Urachal cyst
Patent omphalomesenteric
duct
Cord
o Usually falls off in 6-18 days after birth
o Raw surface heals by 12-21 days
o Granulation tissue may persist
(granuloma)
Polyp
o With pedicle, opening
o Bright red, mucoid discharge
o May be a urachal or
ompahlomesenteric duct (assoc with
fecal or watery discharge)
o If there is an opening present, it is not
related to granuloma, but URACHUS
AND OMPHALOMESENTERIC DUCT.

PALPATION
an art
even cooperative patients tensed
crying tensed abdominal wall
cold pair of hands protective spasm tight
abdomen
Distraction helps to relax the abdomen:
o Engage in serious conversation
o Laughing and some jokes
o Flex hips and ask child to take a deep breath
o Ask patient to take deep breaths while
quickly palpating the abdomen
o In crying child, can be accomplished, wait
until the abdomen relaxes at the end of the
expiratory phase and palpate when the
child takes a deep breath
o In ticklish children, place your hand on top
of the childs with index finger overlapping
palpate using childs own hand except
your finger dip inside childs hand.
Tone of the abdominal wall
o Soft, firm, tense
o Hard intraabdominal pathology
o Masses:
LUQ liver
RUQ stomach,spleen
RLQ cecum, appendix
Flank kidneys
Firmness & tenderness:
o Board-like Peritonitis
o Diffuse
Chest disease, tetanus
o Localized
Mass, full bladder
o Very soft
Prune-belly syndrome
Pain in the abdomen
o Make sure the child has no area of pain
o Ask the child to point to where it hurts
and palpate the painful area LAST
o Palpation should NOT cause pain
o If (+) area of tenderness, note the:
Location
point of maximum intensity
Elicit rebound tenderness
o Rebound tenderness (peritoneal
irritation):
*Press firmly over one area
*If (-) pain, suddenly release and
remove the fingers
*(+) RT if there is tenderness upon
withdrawal of the fingers indicated
PERITONEAL IRRITATION.

Location of tenderness:
*Edge of liver Hepatitis
*RLQ - Duodenal ulcer
*LUQ - Splenic rupture
*LUQ, LLQ Ulcerative Colitis,
amoebiasis
*Loin - Perinephric abscess
*Diffuse Peritonitis
o Spastic bowel relieved by pressure
o Intra-abdo inflamm aggravate by
pressure
Pyloric Stenosis
*Best to examine after stomach is emptied
*Hold baby in relaxed position
*Give baby sugar-water before palpating
*May have to feed the baby clear liquids until
the baby vomits palpate the abdomen soon
after vomiting
*Flex the hip palpate the abdomen with the
other hand midway between the umbilicus and
costal margin along the lateral border of the
right rectus muscle
*Fingertips should be used with a kneading upand-down motion
o Mass is felt as a firm olive-like swelling
Appendicitis
*Often starts with a history of persistent but
vague, diffuse pain in the periumbilical area
*Soon localizes the RLQ
*Appendix may not be located in the classical
location, so S/Sx may vary
*Flank pain with appendix along paracolic
gutter
o S/SX:
Loss of appetite
Low grade fever
Change in bowel habits
*Constipation usual manifestation
*Diarrhea may occur in retrocecal,
pelvic appendicitis
o Classical finding: LOCAL POINT
TENDERNESS OVER THE INFLAMED
APPENDIX (McBurneys point)
*Between R ASIS and umbilicus
o If the appendix is along paracolic
gutter, tenderness is over flank or felt
only upon deep palpation
o Coughing aggravates the pain cause
the child to wince
o Perforated appendix
*Child is toxic and pale
*Grunting respiration

*Lies still
*Rigid with abdominal generalized guarding
*Absent bowel sounds
*Mass in RLQ in rectal or abdomen exam
Liver
o Normally located on the right side
o Size varies with age & size of child
o Size determined by palpation WILL BE
DIFFERENT in size determined by
percussion
o Size by Roentgenogram is most
accurate
o Technique:
*With patient lying supine (no pillow),
stand on right side (R-handed) and
palpate starting from LRQ moving up
*If liver edge is palpated, measure size
below the costal margin at the MCL
using a rule/tape
o Normal values below costal margin
0-6M
3-3.5 cm
6M-4Y
0-3 cm
4-10Y
<2 cm
10Y+
<1 cm
o Total height of the liver
*Upper border: percuss along the MCL
anteriorly with pleximeter finger held
parallel to ribs (heavy percussion); a
mark is made at ICS where dullness is
first noted
*Lower border: percussion is started at
the RLQ and gradually moved toward
the costal margin (light percussion)
o Vertical height between the two points
is now measured
o Palpate L lobe of the liver at the
epigastrium
*Important in the tropics where
amoebic abscess and portal
hypertension are common
o L lobe is more prominent in the above
conditions (AA, PH)
o Auscultate the liver
*Hepatic rub = perihepatitis, liver
abscess, leukemic infiltration
Spleen
o Normally located on the left side
o Not palpable unless it is enlarged 3x
normal
o If not palpable in supine position,
palpate in R lateral position (Shorts
maneuver)

*Patient lies on his R side

*Examiners L hand is place over the L
lower ribs on the Mid Sternal Line
pushing the spleen forward
*R hand is then used to palpate
o Start over RLQ proceed diagonally
toward LUQ
o Very large spleen may cross the midline
with the palpable edge on the R side
o The examiner can easily miss the edge
if palpation is done only the L side
o Castell Percussion sign for enlarged
spleen
*Patient is in supine position
*Percussion in the lower ICS on the
anterior axillary line should be resonant
(insp & exp)
*If (+) enlargement, percussion over
lower ICS is resonant during expiration,
dull during inspiration
o Auscultation of the Spleen
Splenic rub = perisplenitis
Other Intra-abdominal Organs & Masses
o Mass in RLQ:
Usually related to appendix
Cecal mass
Ovarian masses in female
Intussusception - Ill-defined
sausage-shaped mass over
RUQ
o RLQ is found to be empty
o Kidney palpation (difficult in obese)
Deep bimanual palpation
*Patient is supine, abdo relaxed
*Palm of one hand is posteriorly on
flank, pushing kidney forward
*Other hand is placed anteriorly below
the costal margin, pushing the abdo
wall back and upwards
*Felt best in deep inspiration
o Description of a mass:
Location
Upper and lower borders
Firm, hard, soft, cystic?
Is it midline, or cross midline?
Is it attached to abdominal wall?
Does it move with respiration?
Is it movable?
Is there a bruit, murmur, pulse?

PERCUSSION (FOR FLUID)

Normally sounds tympanic on percussion except
when percussed over solid organs (liver, full
bladder)
Highly tympanic = obstruction, paralytic ileus
Dullness over large abdomen = free fluid,
tumour
Methods to elicit signs of free fluid
Fluid wave
Shifting dullness
Patient is supine
Patient is supine
An observer
Finger is placed on
places the edge
flank parallel to
of their hand
midline
vertically on
An area of dullness is
midline of
percussed
abdomen
Ask the patient to roll
Examiner places
over and lie on the
palm on one side
opposite side of the
and taps with
percussed dullness,
fingers on the
while the examiner
opposite flank
keeps the pleximeter
finger in place
Percuss again after
the fluid has time to
settle at the
dependent position
(+) = fluid wave is
(+) = tympanic note over
created by tap
previously full area

Detecting very small amounts of fluid:

*Place in knee-chest position and percuss over
periumbilical area
*Normally NOT DULL

AUSCULTATION (BOWEL SOUNDS)

Bowel sounds
o Best heard along a diagonal line 6
inches long, starting 1 inch to the left
and above the umbilicus running
toward the RLQ
o Gurgling quality
Conditions:
Frequency, high-pitch = gastroenteritis
Metallic = early obstruction
Absent = paralytic ileus, late obstruction
Distant = ascites, peritonitis
Murmurs
o Listen all over abdomen especially over
loin/flank
Renal Artery Stenosis = systolic murmur

INGUINAL REGION

Common causes of swelling:

o Hernia
o Hydrocele
o Undescended testes
o LN enlargement
o Also describe whenever there are
fluctuations in size (spontaneous, related to
coughing or crying)
Hernia
o Indirect inguinal hernia is most common
o Direct & femoral hernia are rare
o More often in boys
o Bulge in inguinal area; extends into scrotum
o Enlarges & tenses when the child cries
o Becomes smaller when not straining, may
be reduced by external manipulation
o If it does not reduce, consider:
hydrocele of spermatic cord
incarcerated hernia
o To differentiate, palpate above hernia:
*(+) empty hernial sac above the mass
hernia + hydrocele
*(-) empty hernial sac above the mass, (-)
reducibility, (+) pain incarcerated
hernia
o Ovary may be palpated in the hernia sac
o Evidences of inguinal hernia, palpate and
compare with the other sides:
Silky texture (Thickened Cord)
hernia repair should not be
initiated on the basis of a silky
cord alone
Hydrocele
o Swelling of scrotum or along spermatic
cord
o Fluctuant size/alters in size if assoc
with hernia
o Gradually increases in size if there is
communication between the
processus vaginalis and hydrocele sac
o May transillunate, hernias do not
o Physiologic up to 3 months; fluid is
reabsorbed
o Pathologic after 4 months, associated
with indirect inguinal hernia
o Cystic mass along the inguinal canal in
girls hydrocele of the tunica
vaginalis (hydrocele of the canal of
Nuck)
o Suspect a testis in phenotypic female

Indirect Hernia
Bulge in inguinal
area.
Extends into
scrotum.
Crying

Not straining.
Reducible.
(-)

Hydrocele
Swelling of scrotum.
Physiologic up to
3months
Fluctuant if (+) hernia
If PV (processus
vaginalis) and
hydrocele connect
Irreducible.
(+)

Lymph Nodes
o Inguinal nodes:
Located along the crease
made by flexion of the hip
lateral to the inguinal canal
Normally may have palpable
inguinal nodes:
*Small to medium size
*Soft to firm
*Freely movable
*Tender
o Femoral nodes:
Located below line of the
inguinal ligament in the
femoral triangle in a vertical
direction
Not usually palpable

GENITALIA
MALE
MALE GENITALIA
Normal Penis, full term, new born
o Well-formed
o Average length is 4 cm
o Cylindrical (bent in aberrant location of
urethral opening)
o Urethra opening at tip
o Prepuce is easily retractable
Normal Scrotum
o Highly pigmented in the newborn
o Less pigmentation as the child grows
o Tests are located in the scrotal sac and
measure 1 cm in length
o Left is lower than right
o No enlargement upon
straining/coughing
o Secondary sexual characteristics start
during preadolescent period
On Physical Examination
o Undress completely
o Examine under good light
o Describe the:
Size and shape of penis
Prepuce
Urethral orifice
Size of scrotum
Color of scrotum
Testes & 2 sex characteristics
Penis
o Size is variable
o Enlargement may be a real increase or
appearance of enlargement due to
priapism
Real: precocious puberty,
CAH, CNS lesions, testicular
tumors
Priapism: sickle cell disease
o A small penis may be true hypoplasia or
only apparently small
o Apparently small: fat boys
o True hypoplasia: congenital
malformation, hypopituitarism,
Klinefelter
o Curved shape hypospadias
o Stiff, painful sickle cell crisis
o Phimosis (in prepuce) - preputial sac is
very narrow, unretractable

To test for phimosis:

Child is supine
Pick up fold of prepuce with
both hands and pull gently
upward
Normal: good tunnel is formed by
preputial skin and meatal opening is
visible
Urethral Orifice
Located at the tip of the penis
Hypospadia located on the
under surface; importantly
associated with:
Cryptorchidism
Hermaphroditism
Epispadia located on the
dorsal surface
Less common than
hypospadias
Assoc with bladder
extrophy
Should not have urethral discharge at
any age in a male. If (+) discharge,
consider:
FB (less common in boys)
Balanoposthitis
Gonorrhea
Reiter Syndrome

Scrotum
o Scrotal Sac normally converges at
base of penis on ventral side
o Shawl scrotum portions of the scrotal
skin come around the base over dorsal
aspect
associated with incomplete
masculinization or virilization
o First examine without touching
o Left is lower than right, but not larger
Abnormally large = swelling
Abnormally small = (-) testis
o Wrinkles over the scrotum
Distance between wrinkles is
narrower on the small side
compared to the large side
Undescended testes
o Ambiguous Genitalia if not felt
anywhere abdominal; a penis with
absent testis

o
o

o
o

o
o
o
o
o
o

Undescended Testis
*Palpate along the inguinal canal
between ASIS and pubic tubercle for
the testis
*Moisten the finger tips with liquid
soap and rub fingers gently bur firmly
on the inguinal canal from above
downward
*Plop = (+) testis
Large scrotum may indicate one of the
following:
Thickened skin elephantiasis
Hydrocele fluid in sac
Hernia intestines in scrotum
Large testis
Large epidydymis
Large scrotum that becomes small
when child lays down or is relaxed, and
enlarges from coughing or straining
hernia
Irreducible normal, testicular tumor
Hydroceles cannot be reduced
completely, but become smaller on
pressure
Normally darker than the rest of the
body
Red = inflammation, orchitis,
torsion
Blue lines = varicocele
Normally, not tender on palpation.
(+) tenderness inflammation,
torsion, strangulate/incarcerated
hernia
Lying down may appear higher
Siting, standing testes may descend
If (+) testicular mass along inguinal
canal, try to push this into the scrotum
Retractile testis = (+) descent
Undescended testis = (-) descent
Abdominal testis = testis is not felt
anywhere

o
o
o
o

o
o
o

FEMALE

Female genitalia
o Traumatic for children of any age
o Proper preparation and good
explanations are essential.
o Most finding can be observed on
inspection
o Have a female nurse or mother present

o
o

Have the child in mothers lap,

semirecumbent position (infant, child)
Feet are supported on examiners
knees
Place childs soles together to abduct
thighs
Grasp labia majora between thumb and
index and draw outwards exposing
labia minora, urethral meatus, vagina
Bimanual palpation - done cautiously
Finger cannot advance too far into
fornix very short
Newborn
Highly pigmented and
edematous in newborn esp in
breech delivery (newborn)
Older prepurbetal children
Labia minor have receded in
size
Glans clitoris is <3mm long,
<2mm wide
Hymen is interior to introitus
Vaginal mucosa is red, appears
thin
Introitus will gape open in
knee-chest position allows
to view vagina ang cervix;
Foreign Body maybe seen in
this position.
Points to be looked on female genitalia
(other than in newborn)
*Look for appearance and distribution
of pubic hair (secondary sexual
development) Tanners Stage
*Look at general hygiene, small,
staining of pants, lice if pubic hair is
present
*Urethral discharge is uncommon at
any age. May indicate mechanical
irritation:
tight panties,
FB
Masturbation
physiologic (2-3y before
menstruation)
inflammation
Look for cysts, caruncle, prolapse
Look for foreign bodies by separating
the labia, a common cause of vaginal
discharge and bleesing (intermittent,
bloody, foul-smelling discharge).
Bimanual palpation of the rectum is
needed to palpate the FB.

Look for discharge and characteristics.

*Blood (NB) estrogen withdrawal
*Blood (older) foreign body
*Blood (adol) menstruation,
sarcoma botryoides
*Watery local irritation, infxn
*Purulent gonococcal infxn
*White, cheesy candida infxn
Examine clitoris
*Large normal, precocious
*Small gonadal dysgenesis,
hypopituitarism
*If there is not tissue surrounding the
superior aspect of what appears to be
the clitoris unlikely a clitoris
Look for synechiae fusing labia in
prepubertal girls. Will always separate
spontaneously in association with
vaginal pH change in puberty.
Examine labia majora.
*Fused CAH
*Hypoplastic with large clitoris
Trisomy 18 syndrome
Look for an imperforate hymen
especially when uterus is enlarged.

Ambiguous Genitalia
Suggested by the presence of:
o Large clitoris
o Small penis
o Hypospadia
o Undescended testis
o Fuse labia majora
o Inguinal hernia w/ mass in female
infant
Investigation is prior to sex assignment
Intersexuality discrepancy between
morphology of gonads and external
genitals
Female pseudohermaphroditism
*XX female
*(+) ovaries
*Virilized External Genitalia
Male psudohermaphroditism
*XY male
*(+) testes
*ambiguous/female External Genitalia

ANUS & RECTUM

Examination of genitalia and anus can be
traumatic to a child
Best to examine in left lateral position
Inspection
o Location of anus
May be too far forward
May not have an opening
May open though a fistula
*Recto-urethral (male)
*Recto-vaginal (female)
o Parasites
Pinworms
tapeworms close to opening
o Fissure in-ano (+) fissure or cracks in the
mucocutaneous junction; due to:
Pinworms
Constipation
Eczema
mechanical irritation
o Painful fissures cause constipation and
blood in stool
o Nodular Lesions
Rectal tag
Polyps
Hemorrhoids
prolapse of rectum
ano-rectal absecess
o Small rectal tags are not clinically significant
o (+) rectal polyps look for mucous
membrane pigmentation PEUTZ JEGHER
SYNDROME
o Polyps are pedunculated & reddish
o Hemorrhoids
Uncommon
solid, dark protrusions
associated with vena caval or
mesenteric obstruction
o True rectal prolapse, seein in:
chronic diarrhea
amebic dysentery
cystic fibrosis
cough (pertussis)
severe worm infxn
o Anorectal abscesses are tender, warm,
indurated, or fluctuant
o Fistulae are uncommon in children,
sometimes open into vagina or urethra,
seen in:
congenital anomalies
UC
regional ileitis

o
o

Acquired fistula cause is due to abscess and

open into perianal skin
Probe can usuallu be introduced into the
fistula.

RECTAL EXAMINATION
Child in left lateral position
Better to use examiners little finger
Gloved index finger in older children
Finger cot should be greased properly
First, feel for sphincter tone:
o Tight = stenosis, anxious child
o Cannot be moved in = imperforated anus,
agenesis
o Does not grip the finger (absent or poor
spinchter tone)
Spinal Cord lesions
*myelomeningocele
*traumatic paralysis
Tenderness
o Anorectal abscess
o acute prostatitis
Fecal masses may be felt in the rectum
Empty = obstruction, megacolon (there is
sudden widening of ampulla proximal
to the line of agenesis of ganglia)
(+) Mass other than feces = may be a part of
the gut, pelvis, polyp, mass (do
bimanual palpation)
Bimanual Palpation
o Uterus (girls) and bladder (both sexes)
may be felt usually on the midline
o FB in the vagina or rectum may be felt
Remember:
Look at the face to see if whether there is
tenderness
Examine the stool obtained for ova,
parasite, blood
___________________________________________
ESGUERRA, WINSTON L.
3F