Vulvovaginitis in the Prepubertal Child

Vulvovaginitis is the most frequent gynecological disorder encountered in pediatrics. It is characterized by inflammation of the vulva/vagina and usually occurs secondary to infection related to bad hygiene.  The terms vulvitis, vaginitis, and vulvovaginitis are often used interchangeably to describe inflammatory conditions of the lower genital tract. 

Why is there an increased risk in prebubertal girls?

  1. The proximity of the vagina to the anus
  2. Lack of estrogen - leads to thinning of the vaginal mucosa
  3. Lack of pubic hair to protect the area
  4. Lack of labial fat pads

Clinical Presentation

  1. Vaginal discharge. May be white, yellow, green, and have a foul odor.
  2. Pruritis
  3. Dysuria
  4. Erythema 
  5. Bleeding
  6. Symptoms may be present for a long period before the child is brought in for evaluation and the acute onset of symptoms is often associated with an acute infection or abuse.

Important questions to ask during in your history

  1. Duration of symptoms
  2. Recent use of medications (e.g. antibiotics), perfumes and bubble bath
  3. Amount and color of discharge
  4. Any suspicion of abuse 
  5. Clothing worn
  6. Any recent respiratory infections

Physical Examination

  1. During the initial evaluation, an examination of the external genitalia with the child in a supine frog-legged position
  2. Examine the pharynx for evidence of past or current infection
  3. Closely examine the skin for any rashes or other skin abnormalities
  4. Check for any signs of sexual abuse

Etiology

  1. The most common cause is poor hygiene.
  2. There is an increased incidence in overweight girls, girls who wear tight leotards or bathing suits or underpants.
  3. Use of perfume soaps and bubble bath
  4. Foreign bodies- most commonly tissue paper
  5. Localized skin disorders
  6. Normal leukorrhea associated with the onset of puberty may be misdiagnosed as vulvovaginitis.
  7. Infectious
    1. Streptococcal pyogenes associated with throat infection and Staphylococcus aureus 
    2. Candida infection- associated with antibiotic use.
    3. Shigella
    4. Pinworms, scabies, lice.
    5. Discovery of Chlamydia trachomatis, N. gonorrhea, Trichomonas, and Herpes simplex should raise the suspicion of sexual abuse. Some of these may be transmitted from the mother, other family members, and caretakers by non-sexual means.

Diagnosis

1.     Usually no lab testing is required.

2.     If infectious etiology is suspected then appropriate gram stain, culture, prep, DNA PCR, etc. should be conducted

3.     If abuse is suspected, full STI panel should be obtained

 

Treatment 

  1. Most cases of vulvovaginits can be treated by 
    1. Improving hygiene- More frequent bathing and teaching proper front to back wiping.  Use of wet wipes instead of toilet paper may prove beneficial 
    2. Wearing loose fitting underpants made out of cotton. Avoiding tight clothing
    3. Daily bathing.  Allow child to soak in clean water for 10-15 minutes. Use soap to wash just before taking child out of bat.
    4. Avoid use of bubble baths, perfumed soaps, fabric softeners,
    5. If vulva area is swollen or tender, cool compresses can be used to relieve pain
  2. If the child has not improved with the above suggestions and mucopurulent discharge or other symptoms persist for more than 2 to 3 weeks, a 10 day course of amoxicillin or augmentin is recommended.
  3. May try topical antibiotics or low potency steroids
  4. If there is any suspicion of abuse, cultures should be obtained with the proper culture media to try to delineate a specific etiology.

Reference

  1. Vandeven, Andrea. and Emans, Jean. Vulvovaginitis In the Child and Adolescent. Pediatrics in Review. April 1993
  2. Shapiro,Robert et.al Neiseria gonorrhea Infections in Girls Younger than 12 Years of Age evaluatied for Vaginitis.  Pediatrics Vol 104 No.6 Dec 1999 e72
  3. Laufer MR, Emans JS.  Vulvovaginal complaints in the prepubertal child. UpToDate, www.uptodate.com.  July 16 2009