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Assessment of Sexual Maturity Stages in Girls and Boys

American Academy of Pediatrics

Assessment of Sexual Maturity Stages in Girls

Introduction

Determining the degree of development of the breasts and pubic and axillary hair in girls is an essential part of the physical examination. Accurate staging provides an important basis for the management of certain clinical problems that may arise as the child grows. In addition, counseling regarding the expected timing and sequence of pubertal development depends on recording and understanding the stages of development.

The following material demonstrates how to assign the stages of secondary sexual development using the system described by Tanner.

Sexual Maturity Ratings

The system of sexual maturity rating presented in this manual is based on the work of Marshall and Tanner. This rating system has been used widely in studies around the world. Staging of sexual development was first described by Stratz in 1901 and included 4 maturity ratings for the breast. Reynolds and Wines added the fifth breast stage as part of their longitudinal study in the 1940s, which was then adapted by Marshall and Tanner.

It is helpful for examiners to be familiar with the classic sets of pubertal photographs. Because these sets lack details important for assessing certain features of sexual maturity, photographs or drawings produced for this manual of each breast, pubic, and axillary stage are also included.

Breast Palpation

Breast palpation is not part of Tanner staging. With the rise of the prevalence of overweight children, it is harder to determine true breast development by visual inspection. Therefore, accurate assessments of breast development or the presence of gynecomastia may require palpation.

It is important to note that there are no breast tissue sizes that correspond with specific Tanner stages with the exception of the breast "bud" in females. The use of palpation should be recorded in the clinical note and should not influence the visual assessment of stage.

The terms used in describing sexual maturity stages are as follows:

Definitions

Areola: the circular, darkly pigmented area of the skin surrounding the nipple

Mons: the rounded, fleshy prominence over the symphysis pubis

Papilla: the pigmented projection on the breast surrounded by the areola; also called the nipple

Pubis: the pubic bone, the junction of the anterior portion of the hip bones

Vellus: the fine hair that succeeds the lanugo over most of the body and persists until puberty

Examination Techniques

Breast and Pubic Hair

Tanner staging for the breasts and pubic area is performed as described below. Bras and panties must be removed or temporarily displaced for adequate assessment. There should be good lighting in the room.

The breasts are best examined with the patient sitting. The breast area should be adequately exposed for inspection from the front and side and at an angle. This is best done when auscultation of the heart is being performed. Be sure to note each breast separately.

Since Tanner staging is based on visual inspection only, palpation may not be routinely performed. Certain clinical factors may indicate the need for palpation. For example, in an obese girl, palpation would be needed to differentiate adipose tissue from true breast budding.

If palpation is required, it is best performed by using the second, third, and fourth fingers. The breast should be gently palpated on each side of the areola and then in a circular fashion. Breast tissue is felt as a discrete firm mass under the nipple, 1 cm or more in diameter.

The pubic area is examined with the patient in the supine position. The panties must be removed or sufficiently displaced to allow for clear visualization of the labia majora, where Stage 2 hair usually makes it first appearance. It is essential that lighting be bright, particularly when examining fair-haired girls. Stage 2 is easy to miss in these individuals.

Axillary Hair

Examine both axillae with the patient sitting or lying. Again, good lighting is important.

The Influence of Breast Type

Individuals vary in breast type from small or "flat" to very large. The influence of a girl's basic type on the assessment of the Tanner stage can cause confusion. The figure from the Reynolds and Wines study (p 17) depicts 4 different individuals, each in Stage 5 for breast development.

Assignment of Stages for Breast and Pubic Hair Development

It is important to be aware that breast and pubic hair development often take place at different rates, especially during the early stages. The breasts themselves may also be at different stages. Therefore, rating of one area should not influence rating of the other. Occasionally, the stages may be quite discrepant.

Breast Anomalies

Occasionally a child may present with unusual breast features. It is helpful to be familiar with these possibilities. Prevalence of these anomalies is unknown.

Anomalies include the following:

• Premature thelarche — Breast development that usually occurs between 6 months and 2 years, distinguished from pubertal development by the presence of a breast bud and absence of other pubertal signs; areolar changes are usually absent.

• Omission of stages of development — Some females appear to stop development at Stage 4, while others appear to go from Stage 3 directly to Stage 5.

• Absence of nipples (athelia).

• Accessory nipples (polythelia).

• Accessory breast tissue (polymastia).

• Asymmetric breast development (anisomastia).

• Absence of the breast (amastia).

• Underdevelopment of the breast (hypoplasia or micromastia).

• Hyperplasia (juvenile and adult types).

• Trunk breast — An unusual malformation constituting marked enlargement of the areola with herniation of the anterior parenchyma into it.

• Inverted nipple.

Pubic Hair Variants

There are few unusual features of pubic hair development.

• Premature pubarche — "Early" development of pubic or axillary hair.

• Premature adrenarche — This term is often used instead of premature pubarche to refer to the "early" appearance of sexual hair. Technically the term refers to early activation of the adrenal cortex, which can be shown by finding higher levels of dehydroepiandrosterone that, in turn, causes the growth of pubic and axillary hair.

• Stage "6" — Some females will develop hair on the lateral thighs or on the area ascending the midline above the mons; occasionally this may be termed Stage 6.

Assessment of Sexual Maturity Stages in Boys

Introduction

Observation of the development of genital and pubic hair growth in boys is an essential part of the physical examination. Accurate staging of the physical changes of sexual development provides an important basis for the diagnosis and management of certain clinical problems that may arise as the child grows and matures. In addition, counseling of patients and families regarding the expected timing and sequence of pubertal development depends on accurate physical assessment and understanding of the stages of development. Because gynecomastia is common among and of concern to adolescent boys, assessing breast tissue development may also be important.

The following material demonstrates how to assign the stages of the physical changes of pubertal development using the system described by Marshall and Tanner. We also describe the correct technique for measuring testicular size using orchidometer beads. Since the first (and most objectively measurable) outward sign of puberty in boys is usually testicular growth, it may be difficult to determine by visual inspection alone whether puberty has begun without using other methods for detecting the relatively subtle increase in testicular volume to greater than 3 mL. The prepubertal testis may vary in size from approximately 1 to 2 mL in volume; an increase to 3 or 4 mL is usually accepted as the beginning of pubertal development. While using orchidometer beads is not part of Tanner staging (the latter is based on visual inspection only), the orchidometer provides a fairly accurate and clinically feasible way of assessing the size of the testicles.

Sexual Maturity Ratings

The system of sexual maturity rating presented here is based on the work of Marshall and Tanner. This rating system has been widely used for decades in studies around the world. Various schemes for rating the stages of sexual maturity in males appear in medical literature from the 1930s on. After the publication of Marshall and Tanner's landmark paper on pubertal changes in boys, the use of the staging methodology defined in that paper became the standard. Genital growth and pubic hair growth are staged separately.

The terms used in describing sexual maturity stages and male anatomy are defined as follows:

Definitions

Areola: the circular, darkly pigmented area of the skin surrounding the nipple

Corpus spongiosum: the spongy body of the penis

Epispadias: the opening of the urethra on the dorsal surface of the penis

Glans penis: the conical expansion of the corpus spongiosum which forms the head of the penis

Gynecomastia: enlargement of the glandular tissue of the breasts in a male (Enlargement of the soft adipose tissue alone in the breasts of a male is called pseudogynecomastia.)

Hypospadias: the opening of the urethra on the ventral surface of the glans or on the shaft of the penis proximal to the glans

Linea alba: the fibrous band running vertically along the center of the anterior abdominal wall

Pubes: plural of pubis

Pubis: the region located over the pubic bone, just above the external genitals

Vellus: the fine hair that succeeds the lanugo over most of the body and persists until puberty

Examination Techniques

Staging of the physical changes of pubertal maturation in boys is somewhat more difficult than the staging of girls because it is primarily based on relatively subjective assessments of changes in genital size and scrotal skin characteristics rather than the more readily distinguishable changes in breast contour seen in girls. If the boy's physical development is not followed longitudinally, staging may be difficult when done at a one point-in-time examination, given that at any stage of development, there is at least a twofold range in testicular size in normal males of all ages. The range of normal for penile size varies as well. Another challenge is that genital development and pubic hair growth must be staged separately; therefore, it is important that the examiner not let his or her assessment of one feature influence the assessment of the other.

Anatomy: A Brief Review

Several features of male anatomy are important to understand in learning to assess genital maturation.

Scrotum

This fibromuscular sac contains a partial median septum that separates the pockets that contain each testis.

Testicular Size

Normal testicular volume ranges from 0.6 to 1.3 mL in early childhood. At sexual maturity testicular size ranges from about 11 to 22 mL in volume. On average, the ovoid adult testis is approximately 4 to 5 cm long and 2 to 3 cm wide. A volume of 25 mL is considered the upper limit of normal. The left testis usually hangs lower than the right, and the right testis is often slightly larger. The testes are covered by several layers of tissue. The epididymis is a soft comma-shaped structure that houses the spermatozoa. Its head sits along the top of the testis while the body and tail extend along the side of the testis to where it connects to the vas deferens. These structures add to the perceived size of the testis when visually inspected or palpated.

Penile Size

Stretched penile length ranges from about 3 to 7 cm in early childhood. The mature stretched penile length ranges from about 11 to 15 cm. Reynolds and Wines found that some boys have a regression in penile size after reaching Stage 5 in maturity. The true penile size may be obscured in the overweight or obese boy due to the prominence of the perineal fat pad.

Anomalies and Conditions That May Be Encountered When Assessing Pubertal Maturation in Males

Penis/Scrotum

Hypospadias: A congenital condition in which the urethral opening is located on the inferior (ventral) surface of the glans or shaft of the penis.

Chordee: Commonly associated with hypospadias, is the ventral curvature of the penis due to the presence of tough fibrous bands.

Epispadias: A congenital condition in which the urethral opening is located on the dorsal surface of the penis. This is much less common that hypospadias.

Micropenis: A stretched penile length of less than 2 cm at birth (defined as <-2.5 SD for age).

Adherent penis: Also known as webbing, results from the attachment of the scrotum to the ventral surface of the penile shaft. The penis may be small or appear to be small.

Position: In some adolescents the penis does not hang vertically, but may hang markedly to the left or right.

Testis

Size and position: The left testis is usually slightly smaller and hangs lower than the right.

Cryptorchidism: Undescended testis. The condition may be unilateral or bilateral. This must be distinguished from a retractile testis (see below). An undescended testis may reside anywhere along the developmental course of testicular descent, from the abdominal cavity to the upper scrotum. An undescended testis is often smaller than normal due to dysgenesis (abnormal development of the testis). An ectopic testis is a testis that is not located along the normal course of testicular descent, such as in the femoral area.

Polyorchidism: The presence of more than one testis on one or both sides of the scrotum. Triorchidism is the most common variant, but up to 5 testes have been reported.

Retractile testis: A testis that on examination is in a position outside the scrotum (or in the upper part of the scrotum) but that can be manually manipulated into the normal position in the scrotal sac. This is thought to be due to an exaggerated cremasteric reflex. These testes are more likely to retract when a cremasteric reflex is triggered by exposure to cold environmental temperatures, anxiety, or other factors. After puberty, a formerly retractile testis will continuously reside in a normal position in the scrotal sac.

Varicocele: The "bag of worms" scrotal mass caused by dilation of the spermatic vein due to the incompetence of valves in the vein. This usually presents as a painless bluish mass.

Hydrocele: A non-tender fluid-filled mass occupying the space within the tunica vaginalis or the processus vaginalis of the spermatic cord. The mass transilluminates.

Atrophy: A testis may atrophy as a result of testicular torsion or other insult or injury.

Hernias may present as scrotal masses. Very rarely, a prepubertal boy will present with a testicular mass from acute lymphobastic leukemia or paratesticular rhabdomyosarcoma. A normal to small penis and small firm testes may indicate Klinefelter syndrome.

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Excerpted from Assessment of Sexual Maturity Stages in Girls and Boys by Marcia E. Herman-Giddens, Carlos J. Bourdony, Steven A. Dowshen, Edward O. Reiter. Copyright © 2011 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
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