VULVOVAGINITIS IN THE PREPUBERTAL CHILD

Vulvovaginitis in the prepubertal child is the most common gynecological complaint seen in pediatric practice. Prepubertal children are particularly susceptible to non-specific vulvovaginal infections secondary to poor hygiene, but they can also have specific infections from sexually acquired organisms as a result of sexual abuse or from respiratory or enteric pathogens.

What are the most common causes of vulvovaginitis in the diapered infant?

Vulvovaginitis in the young infant and toddler is usually diagnosed as “diaper dermatitis”. Most commonly, these infants suffer from vulvitis due to local irritation from moisture, either urine or stool, which is part of a broader diaper dermatitis. Diapered infants may also have specific infections like candida dermatitis which is not common in the older prepubertal child who is no longer in diapers.

Why are prepubertal children susceptible to vulvovaginitis?

There are several predisposing factors for vulvovaginitis in the prepubertal child which include inadequate hygiene, lack of protective hair and labial fat pads and lack of estrogenization. As a result of all of these factors the skin is easily traumatized by clothing and friction. Improper wiping of the vaginal area after voiding, masturbation, and simply sitting in tights for a few hours may cause erythema, skin breakdown and discomfort in the vulval area. The vulval inflammation may progress and lead to a secondary vaginitis.

What is the most common cause of vulvovaginitis in the prepubertal child?

“Non-specific vulvovaginitis” is by far the most common cause of vulvovaginitis in prepubertal children. The factors that predispose to this condition include skin disorders such as eczema, atopy, the wearing of tight fitting nylon clothes, obesity, masturbation and poor hygiene.

What specific infections cause vulvovaginitis in the prepubertal child?

Group A Beta-hemolytic streptococcus (GABHS) is not an uncommon cause of vulvovaginitis. It is often accompanied by an anal streptoccoccal proctitis (which presents as a beefy, red, well demarcated ring the size of a quarter around the anal area). GABHS vulvovaginitis presents with a purulent vaginal discharge which may simply manifest itself as soiling on the child’s panties.. Candida vulvovaginitis is extremely uncommon in the prepubertal child who is no longer wearing diapers. It must be remembered however that some of these children do wear diapers at night only (nocturnal enuresis) until they are well beyond 5 years of age and they may be susceptible to a candida vulvovaginitis.

Can vulvovaginitis be a manifestation of sexual abuse? The sexually acquired infections seen in the prepubertal child include N. gonorrhea, Gardnerella vaginalis, Trichomonas, C. Trachomatis, Herpes Simplex and Condyloma accuminata.These are all extremely unusual organisms to find in the prepubertal child and must immediately raise the suspicion of possible sexual abuse.

What other causes of vulvovaginal complaints should the examining physician be aware of?

Vaginal foreign bodies must be considered in all cases of recurrent vulvovaginitis. The most common foreign bodies in the vagina are wads of toilet paper (which are not radio-opaque). Pinworm infestations are not infrequently associated with vulvovaginal irritation. Chicken pox seborrhea and eczema may all result in prepubertal vulvovaginitis. Lichen sclerosis is rare in the prepubertal child but has a characteristic white parchment-like epithelium that often appears in a figure of eight pattern around the vagina and anus.

How does the physician evaluate vulvovaginitis in a prepubertal child?

A thorough history is important and should include information on hygiene, the use of bubble baths, the presence of a discharge which is mucousy or purulent, and the history of caretakers and contacts of the child if sexual abuse is a possibility. A brief external examination is all that is required in the majority of children who have a scant or mucoid discharge associated with non-specific vulvovaginitis or pinworm infestation. It should be noted that children with a visible discharge are significantly more likely to have a specific diagnosis than children who do not have a discharge at the time of examination. The discharge should be cultured and sent to the laboratory for specific analysis. Children with vulva or anal pruritus should be screened for pinworms. In the case of recurrent vulvovaginitis, trauma, suspicion of sexual abuse or the presence of a foreign body, referral to a consultant is advised.

What is the treatment of vulvovaginitis?

The treatment of non-specific vulvovaginitis includes proper and regular hygiene, avoidance of tight clothing in susceptible children, the double rinsing of cotton underwear, the avoidance of bubble baths, and tepid sitz baths. Where a specific infection such as GABHS is cultured, appropriate oral antibiotics should be used. The rare occurrence of candida vaginitis in the older child still in diapers should be treated with topical medications such as Mycostatin or Clotrimazole. In cases where sexually acquired infections such as N.gonorrhoea are found, this should be reported to the local authorities that deal with childhood sexual abuse.