Genitalia

Inspect the external genitalia for ambiguity.

In the term male infant, the scrotum is relatively large and rugate. The foreskin of the penis is tight and adherent to the glans penis. Inspect the glans for the location of the external urethral meatus. Hypospadias is a condition in which the meatus is located in an abnormal ventral position, anywhere from the lower glans of the penis to the scrotum. It is important to detect hypospadias in the neonatal period because it represents a contraindication to circumcision; indeed, the penis may look partially circumcised, because in this defect, the foreskin usually does not cover the entire glans. Penile erections are common, often preceding the voiding of urine. The testicles should be descended into the scrotum or the inguinal canals. Palpate the testicles by a downward movement, which counteracts the active cremasteric reflex. Are any masses present? Hydroceles or hernias are common in newborns. A hydrocele, which can be transilluminated, should be monitored until the child is 6 months of age. If it is still present then, the hydrocele usually must be repaired. A hernia should be repaired as soon as possible.

In the term female infant, the labia majora should cover the labia minora and clitoris. There should be a fingertip space between the vagina and the anus. If not, the possibility of sexual ambiguity exists. A whitish vaginal discharge is common during the first few days after birth and is an effect of estrogen; the discharge may become bloody later in the first week from withdrawal of maternal estrogen. The examiner should inspect the urethral meatus and vaginal orifice by placing a gloved thumb and index finger on the child's perineum while pressing downward and laterally on the buttocks.

Sexual ambiguity in the newborn is both a psychologic emergency for the parents and possibly a medical emergency for the child. The most common cause is congenital adrenal hyperplasia resulting from 21-hydroxylase deficiency in a female infant. Affected children have a large clitoris or phallus and possibly fused labia but no palpable gonads in the labio-scrotal folds. The child should be assessed immediately with appropriate blood tests, because many infants with 21-hydroxylase deficiency manifest salt loss and can go into shock and die in the first week or two after birth.

*A canal in the fetus that connects the urinary bladder to the allantois.

In a male or female infant born vaginally after a breech presentation, the external genitalia are often erythematous and edematous as a result of the trauma related to the birth process.

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