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Vulvovaginitis, Prepubescent

- 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.

- 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 ƒ — 1 plus medication for chlamydia - Trichomonas: metronidazole, 15 mg/kg/day PO divided TID (max 250 mg TID) for 7 days

para>Cultures of sexually transmitted organisms in prepubertal children warrant investigations of sexual abuse. ‚

DIAGNOSIS

HISTORY

  • Irritation and erythema of vulva
  • Itching
  • Bleeding
  • Vaginal discharge
  • Unpleasant odor
  • Dysuria
  • Soreness

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 areaInflammation (erythema, swelling) of the introitusInspect 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. ‚

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.

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 cultureGroup A Streptococcus, S. pneumoniae: penicillin V (Pen Vee K) 250 mg PO BID " “TID for 10 daysHaemophilus influenzae: amoxicillin, 20 to 40 mg/kg/day PO divided TID for 7 daysStaphylococcus 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 daysS. pyogenes: amoxicillin, 50 mg/kg/day PO divided into 3 doses/day for 10 daysCandida sp.: topical nystatin (Mycostatin), miconazole, clotrimazole, or terconazoleShigella: trimethoprim/sulfamethoxazole or ampicillin for 5 daysPinworms: mebendazole, 100 mg PO, repeated in 2 weeksChlamydia 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 daysNeisseria gonorrhoeae: ≤45 kg: ceftriaxone, 125 mg IM plus medication for chlamydia; >45 kg: ceftriaxone, 250 mg IM ƒ — 1 plus medication for chlamydiaTrichomonas: 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

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 ‚

COMPLICATIONS

  • If an STI is identified and not treated effectively, the patient is at risk for pelvic inflammatory disease (PID).
  • Vaginismus

REFERENCES

11 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 " “249.22 Stricker ‚ T, Navratil ‚ F, Sennhauser ‚ FH. Vulvovaginitis in prepubertal girls. Arch Dis Child. 2003;88(4):324 " “326.33 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 " “862.44 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

  • 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

ICD10

  • N76.0 Acute vaginitis
  • N77.1 Vaginitis, vulvitis and vulvovaginitis in dis classd elswhr

ICD9

  • 616.10 Vaginitis and vulvovaginitis, unspecified
  • 616.11 Vaginitis and vulvovaginitis in diseases classified elsewhere

SNOMED

  • 53277000 Vulvovaginitis (disorder)
  • 237093007 Prepubertal vaginitis (disorder)
  • 237094001 Streptococcal vulvovaginitis (disorder)
  • 198212006 vaginitis and vulvovaginitis (disorder)
  • 419760006 Bacterial vaginosis (disorder)

CLINICAL PEARLS

  • 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 foul-smelling discharge, should prompt a skilled exam of the vagina for a retained foreign body.
  • Good perineal hygiene will limit this condition.