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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 14-22

Prepubertal vulvovaginitis


Department of Obstetrics and Gynecology, King Khaled University Hospital, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication7-Jan-2019

Correspondence Address:
Salwa Mohammed Neyazi
Department of Obstetrics and Gynecology, King Khaled University Hospital, King Saud University, P.O. Box 7805, Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNSM.JNSM_33_18

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  Abstract 


Vulvovaginitis is one of the most common gynecologic complaints in prepubertal girls. It accounts for 40%–80% of visits to pediatric gynecology services. It arouses parental anxiety because of the perceived rarity of vulvovaginitis in children, the fear of sexual abuse or concerns over lack of appropriate supervision, and hygiene in daycare or school. The majority of cases are due to nonspecific vulvovaginitis in which vaginal cultures will grow organisms considered to be part of the normal flora. The condition is easily managed with good perineal hygiene. In reluctant cases, oral antibiotics or local estrogen cream may be helpful. A small percentage will have a specific etiology and vaginal cultures will identify the pathogen. Most of these pathogens will be intestinal organisms, respiratory organisms, or sexually transmitted diseases. The isolation of sexually transmitted organisms should alert the physician to investigate for child sexual abuse. Other causes of prepubertal vulvovaginitis include systemic illness and foreign bodies which will result in foul-smelling bloody discharge most commonly toilet paper which can be removed by in-office vaginal irrigation but requires a cooperative child otherwise we may have to do vaginoscopy under general anesthesia.

Keywords: Prepubertal, vaginitis, vulvitis


How to cite this article:
Neyazi SM. Prepubertal vulvovaginitis. J Nat Sci Med 2019;2:14-22

How to cite this URL:
Neyazi SM. Prepubertal vulvovaginitis. J Nat Sci Med [serial online] 2019 [cited 2019 Jan 19];2:14-22. Available from: http://www.jnsmonline.org/text.asp?2019/2/1/14/242162




  Introduction Top


Vulvovaginitis is defined as inflammation of the vulva or vagina due to variable infective and non infective causes. In prepubertal girls the most common cause of inflammation is nonspecific overgrowth of normal flora resulting from lack of the protective physiologic and anatomical factors present in adults. Usually it is easily treated by the elimination of risk factors and simple hygienic measures. Occasionally vulvo vaginitis may be due to a specific pathogen which results in significant erythema and vaginal discharge and the onset is more abrupt than is seen with non specific vulvovaginitis. Therefore it is essential that the health care givers involved in the management of these cases are aware of the differences between adults and prepubertal genitalia, the possible causes of vulvovaginitis, appropriate investigations and management in this age group.


  Pathophysiology Top


Prepubertal girls are susceptible to vulvovaginitis due to behavioral, anatomic, and physiologic predisposing factors. Behavioral factors include wearing tight nonabsorbent clothing and suboptimal hygienic practices (poor hygiene), particularly when young girls start to be responsible for their own hygiene. Girls may be wiping from back to front following voiding and defecation or maybe wiping inadequately, and residual urine in the vulvar area may cause local irritation. Frequently the use of hygienic products such as soap, shampoo, and bubble bath can cause chemical urethritis and dysuria. It can occur due to using scented soap, harsh antibacterial soap, perfumed creams, or bubble bath.

Anatomic factors include – short distance between vagina and anus, lack of vulvar fat pads and hair, thin delicate vulvar skin, small labia minora, and small hymnal opening obstructing outflow of secretions. Physiologic factors include unestrogenized atrophic vagina with limited antibodies in vaginal secretions and neutral PH due to lack of lactobacilli. The role of these lactobacilli (in adults) is to produce an acidic environment that prevents the presence of potentially pathogenic flora. Sex hormone secretion begins in the peripubertal period (starting around 7 years of age) it increases as puberty progresses and it will result in increasing the numbers of lactobacilli in the vagina. The vagina becomes acidic, and girl will start having physiologic vaginal discharge (leukorrhea).[1]

This physiologic vaginal discharge dries on the skin leading to local irritation inflammation and secondary infection. Autoinoculation may occur if a family member or child has upper respiratory tract infection or gastrointestinal tract illness.

The symptoms primarily include vulvar irritation or burning with or without discharge and occasionally bleeding. Girls may also complain of burning with urination making the distinction from urinary tract infection challenging.

Most often the etiology is nonspecific and easy to treat, but occasionally, a bacterial infection, sexually transmitted infection due to abuse or foreign body may be the offender.[2]


  Diagnosis Top


A detailed history should include – an accurate description of symptoms (duration, color of discharge, odor, quantity, bleeding, itching, burning, dysuria, swelling, redness, hygienic habits especially taking a bath and front to back wiping after using the toilet). Recurrent malodorous discharge with bleeding indicates the presence of foreign body. We should also ask about clothing: if it is tight, nonabsorbent or if the child is wearing colored nylon underwear. Other important points in the history include history of systemic infections, chronic illness such as (autoimmune diseases, atopic dermatitis, or eczema), and the use of personal care products such as using bubble bath or perfumed creams and soaps, new detergents, new household pet, favorite play sites such as (sandboxes) all of which may cause allergy, or transmit infections. Nocturnal pruritus may indicate pinworms and bed-wetting will cause vulvar irritation. We should also ask about the use of medications such as antibiotics and steroids and consider the possibility of sexual abuse.


  Clinical Features of Vulvovaginitis Top


On a literature review studying the presentation of girls with vulvovaginitis: the symptoms included vaginal discharge (62%–92%), redness (82%), soreness (74%), itching (45%–58%), dysuria (19%), and bleeding (5%–10%). Physical signs included inflammation (redness of the introitus in 87%), excoriation of the genital area, and vaginal discharge.[3]

Vaginal discharge is the most common gynecological symptom in prepubertal girls and can cause repeated clinical episodes. 110 cases were identified through a retrospective chart review study over 15 years period. The most common cause of discharge was vulvovaginitis (82%) which often responds to simple hygiene measures. Awareness of the less common causes of vaginal discharge is essential. It included suspected sexual abuse (5%), foreign body (3%), labial adhesions (3%), and vaginal agenesis (2%). Nearly 35% of patients were admitted for vaginoscopy.[4]

Eight hundred patients referred to the pediatric gynecology service in the UK district hospital were studied. The study included pediatric and adolescent patient up to age 16. Vulvovaginitis was the most common presentation (18%), followed by labial adhesions in (14%) of girls, abdominal pain in (7%) of girls, and precocious puberty in (6%). Vaginoscopy was the most common procedure out of a total of 15% of patients that were admitted, largely for elective procedures. Vaginal discharge the most frequent symptom experienced (44%). Vaginal soreness was found in (16%) of girls and malodor in (10%). A foreign body in the vagina was identified in five patients out of those presenting with recurrent vulvovaginitis or prepubertal vaginal bleeding.[5]

In a case series of 330 premenarchal girls, 62 (approximately 20%) complained of genital bleeding. The bleeding was due to a vaginal lesion in 46 of 62 patients (74%) Vulvovaginits was found to be the most common cause of genital bleeding (28 girls). Six girls had urethral prolapse, six girls had history of trauma, foreign bodies were found in three girls, and vaginal tumors in three. 16 patients (26%) had no demonstrable local lesions, and the bleeding was due to precocious puberty. Secondary precocious puberty due to a hormonally active ovarian tumor occurred in six patients. Idiopathic precocious puberty was found in three patients. In seven patients no cause for the bleeding could be identified.[6]

[Table 1] summarizes the clinical presentation of girls with vulvovaginitis. The most common presenting symptom is vaginal discharge accounting for 81% of cases followed by redness 43%, itching 34%, soreness 25%, dysuria 17%, bleeding 10.5%, burning 6.1%, and malodor 6%.
Table 1: Presentation of girls with vulvovaginitis percentage of symptoms

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Physical examination

It requires patience and gentleness. A complete physical examination should be performed looking for dermatological conditions such as eczema, allergic reaction, or other systemic illness. Tanner staging should be documented. You have to explain to the child what you are going to do and promise no harm. A child should never be forced for genital examination. The panties should be inspected for the presence of discharge or bleeding. Then, inspect the vulva and lower third of the vagina by placing the child in either frog legged position or knee-chest position which allows more of the vaginal canal to be visualized. If necessary, a nasal speculum may be used to visualize the vagina.

Per rectal examination may be done as required. Colposcopy is used if sexual abuse is suspected.

What should you look for?

The presence of discharge, signs of inflammation, smegma, stool contamination, labial adhesions, or whitish discoloration. Also look for vulvar swelling, vesicular lesions, ulcerations, or skin excoriation. Visualize lower part of the vagina, vulva, and anus for signs of trauma: scars, tears, loss of hymnal continuity that may indicate sexual abuse.

How to obtain a sample?

If there is discharge, a vaginal culture should be obtained. You should use a saline-moistened swab and try not to touch the hymen because it is very sensitive. The sample should be obtained from the lower vagina. If a foreign body is suspected, you can use a butterfly intravenous catheter within a rubber catheter for vaginal irrigation with warm saline or betadine and aspiration if the child is cooperative. This will often dislodge the foreign body. If sexual abuse is suspected cultures for Chlamydia trachomatis,  Neisseria More Details gonorrhoeae, and Trichomonas vaginalis should be obtained.

Examination under anesthesia and vaginoscopy is indicated when a foreign body is suspected if the infection is not responding to treatment, if there is associated vaginal bleeding or in cases with recurrent vulvovaginitis.


  Etiology Top


Nonspecific vulvovaginitis is found in 50%–80% of the patient while in the remaining group of patients a specific causative organism can be identified.

[Table 2] summarizes the etiology of prepubertal vulvovaginitis. The most common etiological factor is nonspecific vulvovaginitis accounting for 68% of cases followed by streptococci 17.2%, Staphylococcus aureus and enterofecalis each accounting for around 12%, Haemophilus influenzae 9.7%, Candida 9.2%, thread worms 7.3%, bacteria of fecal origin 5.4%, and N gonorrhea 4.7%.
Table 2: Etiology of prepubertal vulvovaginitis percentage of microorganism isolates

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Unfortunately, we do not have studies in Saudi Arabia about prepubertal vulvovaginitis and its etiological factors. However, from personal observation, it seems to be less common in this country probably due to our cultural variation and Islamic habits of washing the genitalia with water after urination or defecation unlike western country were they rely mainly on wiping with toilet paper which may cause irritation abrasions to the skin; in addition, it is the most common vaginal foreign body.

Nonspecific vulvovaginitis

There is striking overlap in bacterial flora between symptomatic and asymptomatic girls.[7] [Table 3] shows the normal vaginal flora in prepubertal girls. The history is typically of symptoms that have waxed and waned over several months.
Table 3: Normal flora

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Pathophysiology – in girls with nonspecific vulvovaginitis predisposing factors lead to overpopulation by any of the normal flora resulting in inflammation, vulvovaginal scratching and possibly secondary infection. Vaginal culture usually will reveal normal flora; therefore, it is unnecessary except in cases with recurrent vulvovaginitis or those with distinct discharge and odor.

In a study done in Finland on 68 pediatric and adolescent girls with vulvar symptoms, it was found that vulvovaginal symptoms during childhood are more common among younger children (<7 years). Forty-eight patients had abnormal clinical findings on examination and 16 (33%) of them had an infectious etiology. Streptococcus pyogenes infection was identified in 11 (16%) patients. Candida was identified in 6 (9%) patients. They concluded that no infectious etiology could be found in 67% of patients with vulvovaginal symptoms.[8]

Forty-two premenarchal girls with vaginal inflammation or discharge were surveyed over 5 years period by a general practice group in the UK. Nonspecific vulvovaginitis with mixed bacterial flora, associated with poor hygiene and atrophic vaginal mucosa, was the most common cause (69%); specific bacteria were found in 10 out of 42 cases, including S. pyogenes (17%), H. influenzae (5%), and S. aureus (2%). No Candida was isolated. Threadworms were isolated in one patient.

Treatment with topical estrogen cream was effective only with mixed infection; oral antibiotics were effective in both mixed and single organisms. No evidence of sexual abuse or foreign body was found.[9]

In a recent article from Serbia, they studied the vaginal introitus microbial flora in girls with and without symptoms of vulvovaginitis. Five hundred girls aged 2-12 years with vulvovaginitis symptoms and 30 age matched asymptomatic control group were enrolled in this study. Both groups had similar microbial flora; however, girls with vulvovaginitis had significantly more positive microbiological findings compared to controls (P < 0.001). The following bacteria were isolated in patients with vulvovaginitis: S. pyogenes (4.2%), H. influenzae (0.4%), and S. aureus (5.8%). Bacteria of fecal origin were found in 33.8% of cases, most commonly Proteus mirabilis (14.4%), Enterococcus faecalis (12.2%), and  Escherichia More Details coli (7.0%). Girls with vulvovaginitis had significantly more common fecal flora compared to controls (P < 0.05), 2.4% of girls with vulvovaginitis symptoms were found to have Candida species.[10]

Similarly another study from Lithuania done on 115 prepubertal girls with vulvovaginitis symptoms and 20 age-matched asymptomatic girls found that girls with vulvovaginitis had significantly more common positive microbiological findings compared to controls 100% versus 60% (P < 0.001). The main causative premenarchal vulvovaginitis agents are fecal in origin in 53% girls with vulvovaginitis and 25% of girls without vaginal inflammation (P < 0.05) The dominant bacteria in the target group, accounting for 66% of all isolated microbes, were Escherichia coli, E. faecalis, coagulase negative staphylococcus, alpha hemolytic streptocci andgroup A beta hemolytic streptococci. Instances of Candida species were rare (2.6%).[11]

Specific vulvovaginitis (20%–50%)

It is usually associated with significant erythema. The symptoms are recent less than a week with more abrupt onset than is seen with a nonspecific vulvovaginitis.

In a microbiological study of vulvovaginitis in premenarcheal girls vaginal swabs for 262 cases were collected. A pathogenic microorganism was found in 70 patients (28%). S. pyogenes isolated in 3%, Candida albicans in 1.5%, N. gonorrhoeae 1 case, H. influenzae in 7.6%, and Enterobius vermicularis in 12.6. They concluded that the role of H. influenzae and E. vermicularis should be considered due to the high prevalence of isolation in this group of patients.[12]

In another retrospective study on vulvovaginitis, they evaluated 80 prepubertal girls, aged 2–12 years. The clinical features, bacterial cultures, and microscopic examination of vaginal secretions were studied. In 36% of cases, pathogenic bacteria were isolated. Out of these, 59% the isolated pathogen was Group A β-hemolytic Streptococcus. H. influenzae was isolated in 24% of cases, S. aureus isolated in 24% of cases. Nearly, 3.4% of cases had Klebsiella pneumoniae, and 3.4% had Shigella flexneri. No patient had growth of Candida. Leukocytes in vaginal secretions were used as an indicator for growth of pathogenic bacteria. It had a sensitivity of 83% and a specificity of 59%. Therefore, antimicrobial treatment should be based on bacteriological cultures of vaginal secretions rather than the presence of leukocytes alone. The clinical presentation of these girls included vaginal discharge in 74 girls (92%), Itching in 36 girls (45%), redness in 24 girls (30%), dysuria in 15 girls (19%), pain in 6 girls (8%), and bleeding in 4 girls (5%).[13]

One hundred and fifteen girls aged 2–8 (mean 4.8) years, presenting with vulvovaginitis were evaluated in Zagreb Children's Hospital. Nearly 43 patients (37.4%) had upper respiratory tract infection and received antibiotic therapy more than 1 month before their visit to the clinic. Increased vaginal discharge was the most common presenting symptom found in 26 of 115 (22.6%) patients usually noticed on the pants or diaper, vulvar redness was found in 16 (13.9%) patients, seven (6.1%) patients had burning sensation, 7 (6.1%) patients had itching in the vulvovaginal area, 6 (5.2%) patients had soreness, 3 (2.6%) patients had odor, and 50 (43.5%) patients had combination of two or more of these symptoms.

Normal gynecologic clinical finding was found in 59 of 115 children. Erythema was the most common finding observed in 19 girls, vaginal discharge was found in ten girls, and 13 patients had a combination of discharge and erythema. Causative organisms were isolated in 38 (33%) of 115 study patients from vaginal culture. Group A β hemolytic Streptococcus was found in 21 patients, H. influenzae in five patients, Escherichia coli in three, Enterococcus spp. in two, and S. aureus, P. mirabilis, and Streptococcus pneumoniae one in each. Thirty-one patients received antibiotic therapy, and seven patients who had intestinal bacteria and S. aureus topical therapy and hygienic measures were applied alone.

In conclusion, upper respiratory tract pathogens were the most common cause of vulvovaginitis in girls. It is associated with the symptoms of redness and vaginal discharge and antibiotic treatment is indicated in these cases.

The most prepubertal girls with vulvovaginitis symptoms or signs will improve with simple hygienic measures and topical treatment.[14]

A study comparing clinical and microbiological features of vulvovaginitis in prepubertal and pubertal girls was conducted in Turkey in 2012. It has confirmed that the etiopathogenesis and culture results differ between prepubertal and adolescent girls with vulvovaginitis. The records of 112 patients were evaluated, 72 of which were prepubertal (64.2%), and 40 were pubertal (35.7%) at the time of diagnosis. Thirty-eight prepubertal patients (52.7%) had a positive result on vaginal culture, the most commonly encountered microorganism being Group A beta-hemolytic Streptococcus (15.2%). Culture positivity rate in the pubertal group was 47.5% (19 patients), with C. albicans being the most frequently isolated microorganism (27.5%).[15]

Respiratory pathogens

The history suggests upper respiratory tract infection. It spreads by oral-digital route to the genital area through autoinoculation.

A study on streptococcal vulvovaginitis in girls Group A β-hemolytic streptococci was isolated in (19%) of cases. It results in vaginal bleeding and distinctive fiery red vulvitis; other pathogens include H. influenzae (11%), S. pneumoniae, and pneumococci. This suggests that vulvovaginitis is more commonly associated with Group A β-hemolytic streptococci than reported previously.[16]

A total of 106 vaginal swabs were collected in another study on respiratory pathogens and vulvovaginitis in girls. In 43 cases (40.5%), organisms were recognized as causes of vulvovaginitis. Group A β-hemolytic Streptococcus was the most common found in 19 cases, H. influenzae was the second most common in 11 cases. Candida was isolated in 9 cases.[17]

In another study done on 32 girls with vulvovaginitis aged 18 months to 11 years, there were thirty-eight isolates of H. influenzae and one of the Haemophilus parainfluenzae. H. influenzae caused recurrent episodes in 6 girls and 14 children had recurrent vaginal symptoms. It was concluded that H. influenzae vulvovaginitis in children could result in recurrent symptoms.[18]

Vulvovaginitis is the most common gynecological problem in prepubertal girls and clear-cut data on the microbial etiology of moderate-to-severe infections are lacking. Many microorganisms have been reported in several studies, but frequently, the pediatrician does not know the pathogenic significance of an isolate reported in vaginal specimens of girls with vulvovaginitis.

A multicenter study on girls with vulvovaginitis included 74 girls aged 2–12 years old. All the specimens were Gram-stained and cultured and a questionnaire was completed to assess risk factor. There was a control group of 11 girls without vulvovaginitis attending a clinic. S. pyogenes were isolated in 47 patients and Haemophilus spp. were isolated in 12 cases. There were two significant risk factors Upper respiratory infection in the previous month (P < 0.001) and vulvovaginitis in the previous year (P < 0.05). The other studied risk factors including foreign bodies, sexual abuse, poor hygiene, and bad socioeconomic situation were not statistically significant for the infection. In conclusion, prepubertal vulvovaginitis is mainly caused by upper respiratory tract organisms and an upper respiratory tract infection in the previous month was the most common risk factor for this infection.[19]

A prospective laboratory-based survey was carried out over 19 month, to establish the common pathogens associated with infective vulvovaginitis in young girls. One hundred and six swabs were received during the study period of which 43 (40.5%) yielded organisms recognized as causes of vulvovaginitis. The most common pathogen was Group A β hemolytic Streptococcus 19 cases, with H. influenzae the second most common 11 cases, and Candida was isolated on nine occasions.[17]

Gastrointestinal tract pathogens

E. coli are part of the normal flora in 40% of girls. It should be treated if isolated without other bacteria in symptomatic patients. Shigella spread from the GIT to the genital region in 4%–24% of girls. Diarrhea is absent in most of the patients. Mucopurulent, malodorous, and bloody discharge occurs in 47% of cases.  Yersinia More Details enterocolitica vulvovaginitis is rare.

Vulvovaginitis caused by Shigella species (Shigella spp.) has rarely been reported. One report paper describes the two cases of ampicillin-resistant S. flexneri and trimethoprim-sulfamethoxazole-resistant Shigella sonnei in prepubertal girls presenting with a bloody and purulent vaginal discharge. They concluded that in developing countries where

Shigella spp. are endemic it could be a potential cause of vulvovaginitis in prepubertal girls.[20]

Candida

Candida species are not as rare as were thought to be in prepubertal girls accounting for 9.2% of vulvovaginitis cases. It causes vulvar erythema and edema with whitish plaques. Risk factors include diabetes mellitus, immunocompromised patients, antibiotic use, and if the patient is still in diapers. It can occur also as a secondary infection in patients with other type of vulvovaginitis. Newborns can get it from a colonized maternal vagina.

A retrospective case-note review was on children with genital candidiasis between May 2000 and July 2001. A total of 473 children were studied from which a total of 570 specimens were collected. There were 34 positive culture results taken from 32 patients. The age distributions of these patients were as follows: 0–3-year age group there were 19 patients, 3–9-year age group there were six patients and seven in the 9–12-year age group. Prematurity, immunosuppression, and prior antibiotic therapy were the major risk factors for infection. There was suspicion of sexual abuse in three children. In conclusion, it is uncommon to find Candida infection in toilet-trained prepubertal girls; therefore, it is not indicated to use empirical antifungal therapy in this age group unless there are well-recognized predisposing factors.[21]

Staphylococcus aureus

Is part of the normal flora (2%–7%). It should be treated when isolated in symptomatic patient without other bacteria.

Pinworms

Nearly 12% cause nocturnal pruritus when pinworms emerge to lay their eggs. Adult worm may migrate from rectum to vagina causing intense inflammation. The eggs are transmitted by the fecal-oral route and through hand contamination with shared clothing, bedding, or toys. The incubation period from the time of ingestion of the eggs is 1–2 months. Young children and their caregivers and institutionalized individuals have higher rates of infestation. To recover the pinworm eggs, a cellophane tape may be applied to the anus early in the morning; however, the yield is low. Pinworms and their eggs may be seen during physical examination; however, they are difficult to isolate. Therefore, treatment may be based on symptoms alone. Mebendazole, pyrantel pamoate, and albendazole are used for the treatment of pinworms.

It is given in two doses 2 weeks apart. The treatment should include all family members. Prophylactic measures to reduce transmission include keeping fingernails short and proper hand washing.[22]

Sexually transmitted infections

These infections should alert the physician to the possibility of sexual abuse. In prepubertal patient, cultures for gonorrhea and chlamydia are obtained from vagina rather than cervix.

Gonorrhea

Gonorrhea causes copious purulent greenish discharge. Sexual abuse must be assumed outside the neonatal period. Gonorrhea is found in 3%–20% of girls with a history of sexual abuse.

A prospective study was done on 93 prepubertal girls with symptoms of vulvovaginitis. Patients were excluded if there was a history of sexual abuse. 43 patients had a vaginal discharge and out of these cases 9% had Neisseria gonorrhea, 26% had group A, B, or F streptococci and one case had S. aureus.

Forty-four patients had no discharge and out of these 3 had Streptococcus infection and 2 had C. albicans. In conclusion, the prevalence of Neisseria gonorrhea was high and emphasizes the importance of culturing Tanner I girls for Neisseria gonorrhea when they have a vaginal discharge

Girls with a vaginal discharge on examination had microbial etiology significantly more than girls without discharge.[23]

Contradicting results were obtained in a study performed on 865 sexually abused prepubertal girls seen within 72 h following an assault. Positive cultures were found in 1.4% of girls and 5.6% of the adults' control group. The differences are statistically significant. They concluded that routine vaginal cultures in asymptomatic prepubertal girls may not be indicated as part of the initial evaluation of sexual abuse.[24]

In a retrospective review of 10 cases of genital gonorrhea in prepubertal children, 153 potential contacts of these prepubertal children were investigated. 9/10 cases had at least one positive potential “contact.” Although the sample size was limited, it was concluded that the mode of transmission of gonorrhea was sexual abuse in at least 40% of children and nonsexual transmission could not be determined in any case.[25]

Chlamydia

Nonsexual transmission of chlamydia can occur from mother to newborn and persists up to 1 year. It can cause conjunctival or genital infections. Sexual abuse should be considered in children >1 year of age. Chlamydia is found in 4%–17% of girls with a history of sexual abuse.

Human papillomavirus

Perinatal exposure to human papillomavirus (HPV) can occur in thefirst 1–2 years of life. It can be transmitted through close physical contact. Sexual abuse is found in (50%) of girls with HPV.

Herpes

Herpes transmission may be through the oro-genital route or sexual abuse.

Genital herpes in children under age 11 is extremely rare and usually caused by herpes simplex virus type 1. The incidence of confirmed and reported cases is 0.091 and 0.13 /100,000 children per year, respectively. The mode of transmission in children may not be exclusively sexual; however, sexual abuse should always be considered. Sexual abuse is rarely confirmed although too few cases are referred for investigation to exclude abuse. Increased virological investigation of herpetic lesions, screening for sexually transmitted infections, and more referrals for child protection investigations are warranted.[26]

Trichomonas

Trichomonas is rarely found in children outside the newborn period.

Gardnerella

Gardnerella has been recovered in 4.2% of girls with no suspicion of sexual abuse, but more frequent in sexually abused patients (14.6%).

A study was performed on the anogenital bacteriology in nonabused preschool children and the occurrence of Gardnerella vaginalis in both genders. They included 278 (99 boys and 179 girls) aged 5.13–6.73 years old. Nearly 59 (33.9%) girls had at least one bacterial species isolated from genital cultures. Most common isolates (39 out of 99) were staphylococci and coryneform organisms representing skin flora. The second most common group of isolates (31 out of 99) was viridans streptococci and related organisms. The single most frequent bacterial species identified (17 isolates) was S. anginosus. Two girls had S. pyogenes isolated from the genitals. One girl had S. pneumoniae and eight girls had H. influenzae. No girls had G. vaginalis isolated from the genitals; however, it was isolated from the anal canal of three children. In conclusion, different aerobic organisms were isolated from the genital area. However, G. vaginalis was not found in genital cultures and only isolated rarely from the anal canal.[27]

Syphilis

Perinatal transmission occurs in the neonatal period or it may be acquired through sexual abuse. However, it is the least common sexually transmitted disease among sexually abused children (2/6000).

Systemic illness

Upper respiratory tract infections, gastrointestinal infections, and systemic diseases with skin manifestations such as measles or chicken pox.

Skin diseases

Such as atopic dermatitis, seborrheic dermatitis, psoriasis, lichen sclerosis, and contact dermatitis.

Foreign body

May be found in 4% of girls with vulvovaginal symptoms. Nearly 50% of patients with vaginal foreign body will present with purulent, foul-smelling, and bloody discharge that does not respond to antibiotic treatment. It is commonly toilet paper in 79% of cases. It requires examination under anesthesia and vaginoscopy for removal.

A retrospective review of medical records of 35 girls aged 2.6–9.2 years old with a vaginal foreign body seen in an outpatient clinic for pediatric and adolescent gynecology between 1980 and 2000 was performed and showed the following results: Blood-stained vaginal discharge/vaginal bleeding was the most common symptom (49%). The symptoms varied in duration from 1 day to 2 years. A foreign object was inserted by the girl herself in 44% of the patients. Most patients (91%) either recalled insertion of the foreign body and/or had blood-stained or foul-smelling vaginal discharge or vaginal bleeding, and/or palpation or visualization of the foreign body in physical examination. The resolution of symptoms occurred after removal of the foreign body followed by a irrigation with povidone-Iodine. In conclusion, A carefully obtained history and physical examination suggest the diagnosis of a vaginal foreign object in the majority of patients. The most common symptoms are blood-stained or foul-smelling vaginal discharge or vaginal bleeding. The definitive treatment is removal of the foreign body followed by single irrigation with povidone-iodine, and no additional measures are required.[28]

Other causes

Of vulvovaginitis include ectopic ureter, Crohn's disease with fistula and constipation.


  Management Top


Management of nonspecific vulvovaginitis is focused mainly on improving perineal hygiene and relieving symptoms. The following measures have been shown to be helpful in these patients: frequent sitz baths using warm water only, to pat the vulva dry after washing, using unscented toilet paper, front to back wiping after bowel movement, avoidance of harsh soaps and washing underwear well with water to remove any remnant of detergents, wearing white cotton underwear and changing it frequently, avoidance of exposure to potential bacteria while playing in sandboxes or with house hold pets, avoidance of tight pants, or pantyhoses especially in summer. To relieve symptoms of acute inflammation colloidal oatmeal (aveeno) may be added to sitz bath, and then, simple emollients, for example, vaseline should be applied. Topical steroids (hydrocortisone 1%–2.5%) may be required in severe cases.

In a recent study published in 2015, 45 girls with vulvovaginitis were included in this study. Vulvovaginitis was found to be mostly related to poor personal hygiene factors, 89.3% of girls were cleaning by themselves after defecation, 42.9% were wiping back to front, 60.7% were using toilet paper, and 21.4% were using wet wipes, 14.3% had bath by standing, and 46.4% by sitting. 35.7% of children wear tight clothing.[29]

A study was conducted in Italy on 90 prepubertal girls with persistent vulvovaginitis The girls were randomly assigned to receive either local antibiotic treatment or a systemic antibiotic (45 girls in each group). Pathogenic bacteria were isolated in vaginal secretions of 84/90 (93%) girls. Six girls had persistent discharge and repetitive isolations of Escherichia coli despite receiving antibiotic treatment. Administration type was selected at random. Symptoms and signs were resolved in all girls; however, there was 1 recurrence (2.22%) in local antibiotic treatment group versus 6 recurrences (13.33%) in oral antibiotic treatment group (P = 0.049). In conclusion, topical medication based on netilmicin, associated with benzalkonium-chloride, showed a clinical and microbiological effectiveness asfirst-line treatment of bacterial vulvovaginitis, comparable to conventional drugs. Therefore, local treatment may be a good alternative to systemic treatment decreasing the use of oral antibiotics in young people and related risks of bacterial resistances.[30]

The management of specific vulvovaginitis depends on the pathogenic organism isolated on vaginal culture. Current evidence suggests that in prepubertal girls with clinical features of vulvovaginitis, antibiotics should be used only if a pure or predominant growth of a pathogen is identified.[3]

For pathogenic bacteria, antibiotics are used according to sensitivity; pinworms should be treated with mebendazole, candidiasis treated with antifungal cream, human papillomavirus treated with topical podophyllin, trichloroacetic acid, cryocautery or laser; herpes can be treated with antiviral drugs plus symptomatic treatment.

If the child has a systemic illness or skin disease appropriate treatment will be given accordingly.

The foreign body requires examination under anesthesia and vaginoscopy for removal. Sexual abuse requires special management and referral.

To evaluate the use of cystovaginoscopy for prepubertal vulvovaginitis, a study was done on 48 out of the 53 patients with symptoms of vulvovaginitis. The patient's ages ranged from 4 to 15 years. The duration of symptoms ranged from 8 to 33 months. At cystovaginoscopy, 15 patients had mild nonspecific cystitis, 3 patients had labial adhesions, and 1 child with a single right ureteric orifice. The rest were entirely normal.

All patients received strict hygienic advice after the procedure and were followed-up 3–6 months postoperatively. Thirty-nine patients reported marked improvement of symptoms or complete cure, which significantly improved their quality of life.

This study demonstrates that cystovaginoscopy does not alter the management of recurrent or chronic vulvovaginitis. With this in mind, we suggest that a child suffering from symptoms of vulvovaginitis need not be subjected to cystovaginoscopy and anesthesia if the kidney–ureter–bladder ultrasound scan is normal.

It was concluded from this study that hygienic advice that is rigorously followed significantly improves the symptoms of vulvovaginitis and therefore should be thefirst line of treatment.[31]


  Conclusions Top


  1. Prepubertal vulvovaginitis is a common and easily managed problem
  2. Prepubertal girls are susceptible to vulvovaginitis due to behavioral, anatomic, and physiologic predisposing factors
  3. History taking is an important aspect in the initial evaluation and that should include an accurate description of symptoms, behavioral factors, hygienic measures and history of systemic infections or diseases that predispose to the condition
  4. Physical examination important but should never be forced
  5. Vaginal discharge is the most common gynecological symptom in prepubertal girls with vulvovaginitis
  6. Other symptoms include redness, soreness, itching, dysuria, and bleeding
  7. A broad differential diagnoses must be considered, and the treating physician should be familiar with the potential causes and treatment to improve patient care
  8. Nonspecific vulvovaginitis is found in 50%–80% of the patient where there will mixed growth of organisms. There is striking overlap in bacterial flora between symptomatic and asymptomatic girls
  9. In the remaining group of patients, a specific causative organism can be identified with pure culture growth
  10. The main causative premenarchal vulvovaginitis agents are of respiratory origin (e.g., beta-hemolytic streptococci and H. influenzae) likely following respiratory infections; it spreads by oral-digital route to the genital area through autoinoculation
  11. The next most common pathogen isolated in these patients are S.aureus and enterofecalis each accounting for 12% due to contamination by the skin organisms, poor hygiene and proximity of the vagina to the anus
  12. Sexual abuse must be suspected if there are signs of trauma or sexually transmitted disease organisms isolated
  13. Candida species are not as rare as were thought to be in prepubertal girls accounting for 9.4%. Likely due to the fact some of these girls are still in diapers or may be exposed to antibiotics for the treatment of common upper respiratory tract infections
  14. Foreign body may be found in 4% of girls with vulvovaginal symptoms. 50% of patients with vaginal foreign body will present with purulent, foul-smelling, bloody discharge that does not respond to antibiotic treatment
  15. Management of nonspecific vulvovaginitis is focused mainly on improving perineal hygiene and relieving symptoms
  16. Management of specific vulvovaginitis depends on the pathogenic organism isolated from vaginal culture
  17. Cystovaginoscopy is not indicated for the management of prepubertal vulvovaginitis
  18. Studies on prepubertal vulvovaginitis in Saudi Arabia are required.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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