Vulvovaginitis

doi:10.1016/j.paed.2009.10.002

Paediatrics and Child Health

Volume 20, Issue 3, March 2010, Pages 143-145

https://doi.org/10.1016/j.paed.2009.10.002 Get rights and content

Abstract

The evaluation of vulvovaginitis, which is common in pediatric practice, depends on the pubertal development of the patient, keeping the possibility of sexual abuse in mind. Prepubescent girls are especially susceptible to vulvovaginitis because of anatomic and hormonal factors and because of their tendency to have poor local hygiene. If symptoms persist despite hygienic measures vaginal secretions should be investigated microbiologically and specific antimicrobial treatment prescribed accordingly. When the major complaint is of perineal pruritus, especially at night, empirical treatment with Mebendazole can be considered. In adolescents, who usually present with vaginal discharge, pruritus or dysuria, the pH of vaginal secretions should be tested and the secretions should be examined under the light microscope and sent for microbiological investigations. Physiologic leukorrhea is a common cause of vaginal discharge in adolescents. In the sexually active adolescent a complete pelvic examination with speculum should be performed including evaluation of endocervical specimen for sexually transmitted pathogens. Treatment is then directed at the specific cause. The diagnosis of one sexually transmitted disease necessitates investigation for others and treatment of the partner.

Section snippets

Definitions

Vulvar inflammation, vulvitis, may precede or accompany vaginitis, which is inflammation of the squamous epithelial tissues lining the vagina. The hallmarks of the former are irritation and redness of the vulva causing itching, pain and dysuria, whereas the major symptom of vaginitis is vaginal discharge. Usually patients suffer from concurrent inflammation of both the vulva and the vaginal tissues, namely, from vulvovaginitis. Vulvovaginitis is common in the pediatric practice. The differences

History

History should include questions about itching, discharge (colour, quantity, odour, consistency and duration), dysuria and redness. Other issues which should be discussed are: Perineal hygiene, exposure to irritants such as bubble baths and soaps, the possibility of a vaginal foreign body, the use of medications, underlying diseases, anal pruritus, recent infections in the child or family, and obviously sexual activity and use of contraception in the adolescent, who should interviewed alone.

Physical examination

The physical examination should look for evidence of chronic illness or dermatological disease and include determination of the pubertal stage. The genitalia should be inspected in the frog-leg supine position, with attention to the vulva, introitus, hymen and anterior vagina, including gentle lateral retraction of the labia as well as gripping of the labia and pulling anteriorly and laterally. Signs of inflammation or injury should be sought as well as the presence of a foreign body. For

Investigations

Vaginal secretions should be obtained for examination under the light microscope and for microbiological investigation in both the prepubertal and adolescent patient. The specimen can be collected with a saline-moistened swab or using a sterile newborn suction catheter carefully inserted 2–3 cm into the vagina. Vaginal fluid should be evaluated microscopically for epithelial cells, white cells, motile trichomonads, clue cells, and for hyphae or spores on a potassium hydroxide wet mount. A

Vulvovaginitis in the prepubescent girl

Vulvovaginitis is the most common gynecological problem in prepubertal girls. Factors that explain the increased susceptibility of children to vulvovaginitis include: The close anatomic proximity of the rectum; lack of labial fat pads and pubic hair; small labia minora; thin and delicate vulvar skin; thin, atrophic, anestrogenic vaginal mucosa; and children's tendency to have poor local hygiene and to explore their bodies. Most cases of vulvovaginitis are of nonspecific etiology. However in

Differential diagnosis & management

Girls suffering from vulvovaginitis should be treated with hygienic measures: Avoiding tightly fitting clothing or other irritants like harsh soaps to the vulva, front-to-back wiping after using the toilet, sitz baths and protective ointments. If symptoms persist vaginal secretions should be investigated and specific antimicrobial treatment prescribed according to microbiological results. Pinworms (Enterobius vermicularis) should be considered in girls whose major symptom is perineal pruritus

Vulvovaginits in the adolescent

Vaginal complaints in the adolescent are common, consisting mostly of vaginal discharge, pruritus and dysuria. The major causes of vaginal discharge in the adolescent are: Physiologic leukorrhea, vaginitis, cervitis and foreign body, mostly a retained tampon. In the case of a foreign body the discharge is usually foul-smelling and bloody. Physiologic leukorrhea, which typically starts before menarche and has a cyclic variation, is a whitish mucoid discharge resulting from the normal estrogen

Acute vaginitis

The three most common types of acute vaginitis are vulvovaginal candidiasis, bacterial vaginosis and trichomoniasis. In the non-sexually active teenager, candidiasis is the major cause of vaginal complaints and inflammation, most cases being caused by Candida albicans. The vaginal discharge is typically white, thick and curdy (“cottage cheese like”), without odour. It is accompanied by pruritus, dysuria and burning. The vaginal pH is lower than 4.5 and microscopic evaluation reveals hyphae or

Cervicitis

The sexually active adolescent presenting with vaginal discharge might be suffering from mucopurulent cervicitis, which is characterized by mucopurulent discharge from an inflamed cervix. It can be caused by Chlamydia trachomatis and Neisseria gonorrhoeae, by herpes simplex or by Trichomonas vaginalis. Additional symptoms include itching, irregular vaginal bleeding and dyspareunia. If there is lower abdominal pain pelvic inflammatory disease (PID) must be considered. In this serious consequence

References (0)

Cited by (3)

Gonococcal vulvovaginitis in prepubertal girls: Sexual abuse or accidental transmission?
2013, Archives de Pediatrie
La vulvovaginite est l’affection gynécologique la plus fréquente chez la fille prépubère. Elle peut être due à une bactérie sexuellement transmissible : Neisseria gonorrhoeae. Dans ce cas, un abus sexuel est systématiquement évoqué. Nous rapportons le cas d’une fillette de 5 ans chez qui un diagnostic de vulvovaginite à gonocoque avait été porté. L’examen clinique et l’interrogatoire de la fillette et de ses parents, réalisés par 2 pédiatres expérimentés, n’ont pas permis de mettre en évidence d’argument évocateur d’abus sexuel. Les 2 parents présentaient des signes évocateurs de gonococcie, une urétrite pour le père et une vaginite pour la mère. Après revue de la littérature, nous avons constaté que d’autres modes de transmission que la voie sexuelle étaient possibles : par voie manuportée et surtout par vecteur passif (linge de toilette, thermomètre rectal, …). Nous avons donc retenu une probable contamination accidentelle intrafamiliale pour notre jeune patiente. La connaissance de ces modes de transmission parait indispensable à l’évaluation, toujours difficile, de ces situations et à l’information le cas échéant des autorités judiciaires.
Vulvovaginitis is the most frequent gynecologic pathology among prepubertal females. An infectious cause is found in 30% of cases and is highly associated with the presence of vaginal discharge upon examination. Neisseria gonorrhoeae may be one of the causative agents. Since N. gonorrhoeae is a common sexually transmitted disease, sexual abuse should be considered in the pediatric setting. We report the case of a 5-year-old girl with N. gonorrhoeae vulvovaginitis. Her previous history, multiple interviews with the patient and her parents, and clinical examination showed no evidence or signs of sexual abuse. Both parents presented gonorrhea, urethritis for the father and vaginitis for the mother. The discrepancy between pediatric evaluation and the presence of a bacterium associated with sexually transmitted disease led us to consider other means of contamination. Previous studies have shown that other routes of transmission are possible but are often neglected. Hence, contamination can be transmitted by the hands or mostly through passive means (towels, rectal thermometer, etc.). Many epidemics have been noted in group settings with young girls with no evidence of sexual transmission. Therefore, we concluded that this patient's infection was likely an accidental transmission within her family. The acknowledgement of these transmission routes is very important in order to avoid misguided suspicion of sexual abuse and the possible traumatic family and psychosocial consequences.
Vulvovaginitis, prepubescent
2015, The 5-Minute Clinical Consult Standard 2016: Twenty Fourth Edition
The role of cystovaginoscopy and hygienic advice in girls referred for symptoms of vulvovaginitis
2012, Archives of Disease in Childhood

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