> Table of Contents > Vulvovaginitis, Prepubescent
Vulvovaginitis, Prepubescent
Sarah Parrott, DO
image BASICS
DESCRIPTION
  • Vulvitis is inflammation of the external genitals.
  • Vaginitis, often associated with vaginal discharge, is inflammation involving the vaginal mucosa.
  • In premenarchal girls, vulvitis is usually primary with secondary extension into the vagina.
  • System(s) affected: reproductive, skin/exocrine
  • Synonym(s): vaginitis; vulvitis
EPIDEMIOLOGY
Incidence
Unknown
Prevalence
Most common gynecologic problem in prepubertal girls
ETIOLOGY AND PATHOPHYSIOLOGY
  • In the prepubertal child, the levels of estrogen are low.
  • Due to the low levels of estrogen, the vaginal epithelium is thin, immature, and fragile.
  • Absence of pubic hair and a well-developed labia as well as close proximity of the anus and vagina, make contamination more likely.
  • The prepubertal child also has an absence of lactobacilli, creating a neutral to alkaline vaginal pH.
  • Neutral pH, atrophic mucosa, and moist environment of the vagina increase the risk of infection.
  • Most cases of pediatric vulvovaginitis are nonspecific inflammation.
  • Specific infections that occur are typically respiratory, enteric, or sexually transmitted.
  • Nonspecific vulvovaginitis
  • Poor perineal hygiene
  • Nonspecific chemical irritants (bubble baths, scented soaps, shampoos)
  • Tight-fitting clothing
  • Etiology
    • Bacterial: The most common bacteria are introduced from respiratory and GI tracts.
      • The most common respiratory pathogen is Streptococcus pyogenes (1)[B]. Vulvitis may occur in the absence of respiratory symptoms.
      • Urinary tract infections are common in children with vulvovaginitis (2)[B].
      • Escherichia coli is the most common fecal pathogen.
      • Shigella vaginitis is associated with mucopurulent bloody discharge and likewise, is not always accompanied by a history of diarrhea.
  • Enterobius vermicularis (pinworms)
    • Very common in young children and certain populations
    • Should be considered in children with vaginal itching and irritation
    • Most common symptom is nocturnal perineal itching.
    • Foreign body
      • Presents with foul-smelling, bloody, or brown discharge from the vagina
      • Should be considered with recurrent vulvovaginitis where other causes have been eliminated
    • Other
      • With chronic vulvovaginitis, anatomic abnormalities or systemic disease should be considered:
        • Anatomic abnormalities include double vagina with fistula, ectopic ureter, and urethral prolapse.
    • Systemic disease (inflammatory diseases)
    • Other conditions, such as lichen sclerosus, vitiligo, psoriasis, and atopic dermatitis, should be considered.
Genetics
Understudied
RISK FACTORS
  • Prepubertal girls are particularly susceptible due to behavioral and anatomic reasons:
    • Inadequate hand washing or perineal cleansing after urination and defecation
    • Tight-fitting clothing
    • Proximity of the vagina to the anus, lack of protective hair, and labial fat pads
    • Trauma
  • Obese girls are also susceptible to nonspecific vulvovaginitis (3)[A].
GENERAL PREVENTION
  • Good perineal hygiene (including wiping from front to back)
  • Urination with legs spread apart and labia separated
  • Avoidance of tight-fitting clothing and nonabsorbent underwear
  • Avoidance of irritants such as harsh/perfumed soaps and bubble baths
image DIAGNOSIS
PHYSICAL EXAM
  • Look for evidence of chronic illness or dermatologic disease.
  • Look for trauma or other signs that may correlate with abuse.
  • Inspect the genital area in the supine position:
    • Excoriation of the genital area
    • Inflammation (erythema, swelling) of the introitus
    • Inspect the vagina and cervix in the knee-chest position or frog leg position.
    • Perform rectal exam if vaginal bleeding or abdominal pain.
DIFFERENTIAL DIAGNOSIS
  • Contact dermatitis
  • Eczema
  • Psoriasis
  • Lichen sclerosus
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Culture for bacteria, fungi (yeast), or viruses (herpes)
  • Urinalysis, urine culture, and urine for STI (via nucleic acid amplification test)
  • Tape exam for pinworms
  • Potassium hydroxide and saline smears of vaginal discharge, if present
  • If an anatomic abnormality is suspected, imaging may be necessary to confirm.
  • Consider consultation with a pediatric or adult gynecologist to determine the most appropriate imaging study.
Follow-Up Tests & Special Considerations
Exploration of the vagina for a foreign body may be necessary in cases of persistent, recurrent vulvitis.
P.1139

Diagnostic Procedures/Other
If blood or foul-smelling discharge is present, visualization is mandatory:
  • Place the child in the knee-chest position for best results. Hold the buttocks apart and slightly upward.
  • Visualization of the vagina may be necessary by using a nasal speculum or infant laryngoscope.
  • If available, consider referral to a provider with specific training/experience in this specialized exam.
image TREATMENT
  • The definitive diagnosis of bacterial vulvitis requires a culture of vulva and vaginal secretions.
  • The typical colony count and bacterial mix are unknown in prepubescent girls. Antibiotic use should be directed against the species with the highest colony count.
  • General hygiene should always be recommended, particularly in cases of a retained foreign body (e.g., toilet paper).
  • When no cause is identified, treatment should focus on hygiene as well as minimizing soap exposure and tight-fitting clothes (1).
GENERAL MEASURES
  • Appropriate health care: outpatient (except where systemic illness requires hospital care)
  • Soak the vulva/perineum in a small amount of clear, warm water for 15 minutes BID.
  • If smegma is present in the labial folds, clean the area gently with a mild soap.
MEDICATION
First Line
  • To break the itching-scratching-infection cycle, use a low-dose topical hydrocortisone cream for a limited time.
  • Estrogen deficiency with labial adhesion/agglutination: estrogen cream 0.625 mg to fused area nightly for 2 weeks
  • Emollients or protective creams may offer symptomatic relief.
  • Antibiotic use should be restricted to cases of bacterial infection only (4)[A].
  • Specific organisms on culture
    • Group A Streptococcus, S. pneumoniae: penicillin V (Pen Vee K) 250 mg PO BID-TID for 10 days
    • Haemophilus influenzae: amoxicillin, 20 to 40 mg/kg/day PO divided TID for 7 days
    • Staphylococcus aureus: cephalexin, 25 to 50 mg/kg/day PO divided QID for 7 to 10 days or dicloxacillin, 25 mg/kg/day divided QID for 7 to 10 days or amoxicillin-clavulanate, 20 to 40 mg/kg/day PO divided BID for 7 to 10 days
    • S. pyogenes: amoxicillin, 50 mg/kg/day PO divided into 3 doses/day for 10 days
    • Candida sp.: topical nystatin (Mycostatin), miconazole, clotrimazole, or terconazole
    • Shigella: trimethoprim/sulfamethoxazole or ampicillin for 5 days
    • Pinworms: mebendazole, 100 mg PO, repeated in 2 weeks
    • Chlamydia trachomatis: ≤45 kg: erythromycin, 50 mg/kg/day QID for 14 days; ≥45 kg and <8 years old: azithromycin, 1 g PO single dose; ≥45 kg and ≥8 years old: azithromycin, 1 g PO single dose or doxycycline 100 mg BID for 7 days
    • Neisseria gonorrhoeae: ≤45 kg: ceftriaxone, 125 mg IM plus medication for chlamydia; >45 kg: ceftriaxone, 250 mg IM × 1 plus medication for chlamydia
    • Trichomonas: metronidazole, 15 mg/kg/day PO divided TID (max 250 mg TID) for 7 days
  • Contraindications: allergy to proposed treatment
  • Precautions: Avoid potential allergens and topical sensitizers if possible.
ISSUES FOR REFERRAL
  • Suspected sexual abuse
  • Suspected anatomic abnormality (except minor labial agglutination)
  • Persistent, severe, or recurrent infections
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Monitor for fever, pruritus, and vaginal discharge.
DIET
  • Healthy balanced diet, high in fiber to prevent constipation
  • Adequate fluid intake
PATIENT EDUCATION
Hygiene
  • Wipe front to back after elimination.
  • Avoid bubble baths and other irritating products.
  • Clean daily with mild soap and water and dry gently with soft towel or cool hair dryer.
  • Apply bland ointments for skin protection, if necessary.
PROGNOSIS
Excellent
REFERENCES
1. Gorbachinsky I, Sherertz R, Russell G, et al. Altered perineal microbiome is associated with vulvovaginitis and urinary tract infection in preadolescent girls. Ther Adv Urol. 2014;6(6):224-229.
2. Stricker T, Navratil F, Sennhauser FH. Vulvovaginitis in prepubertal girls. Arch Dis Child. 2003;88(4): 324-326.
3. Van Eyk N, Allen L, Giesbrecht E, et al. Pediatric vulvovaginal disorders: a diagnostic approach and review of the literature. J Obstet Gynaecol Can. 2009;31(9):850-862.
4. Dei M, Di Maggio F, Di Paolo G, et al. Vulvovaginitis in childhood. Best Pract Res Clin Obstet Gynaecol. 2010;24(2):129-137.
Additional Reading
&NA;
  • Delago C, Finkel MA, Deblinger E. Urogenital symptoms in premenarchal girls: parents' and girls' perceptions and associations with irritants. J Pediatr Adolesc Gynecol. 2012;25(1):67-73.
  • Joishy M, Ashtekar CS, Jain A, et al. Do we need to treat vulvovaginitis in prepubertal girls? BMJ. 2005;330(7484):186-188.
  • Velander MH, Mikkelsen DB, Bygum A. Labial agglutination in a prepubertal girl: effect of topical oestrogen. Acta Derm Venereol. 2009;89(2):198-199.
Codes
&NA;
ICD10
  • N76.0 Acute vaginitis
  • N77.1 Vaginitis, vulvitis and vulvovaginitis in dis classd elswhr
Clinical Pearls
&NA;
  • Vulvovaginitis is the most common gynecologic problem in prepubescent girls.
  • The hypoestrogenic state and prepubescent anatomy may increase susceptibility to vulvar and vaginal infection.
  • Treatment is typically supportive (avoid scratching, warm soaks) but may require antibiotics if a bacterial infection is suspected.
  • Isolating an infection with known sexual transmission should prompt further investigation.
  • Recurrent or persistent vulvitis, especially with foulsmelling discharge, should prompt a skilled exam of the vagina for a retained foreign body.
  • Good perineal hygiene will limit this condition.