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 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. ‚
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 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
- 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.