Vulvovaginitis, Prepubescent

DESCRIPTION

• Vulvitis is inflammation of the external genitalia.
• Vaginitis is inflammation involving the vaginal mucosa and can be characterized with or without odor or bleeding.
• In premenarchal girls, vulvitis is usually primary with secondary extension into the vagina.
• Vulvovaginitis can be classified as either nonspecific (not likely infectious but rather hygienic/behavioral cause) or specific (likely infectious cause).
• Systems affected: reproductive, integumentary
• Clinical features: vaginal/vulvar itching, soreness, dysuria, redness, discharge, bleeding, odor, and pain

EPIDEMIOLOGY

ETIOLOGY AND PATHOPHYSIOLOGY

• In the prepubertal child, levels of estrogen are low, leading to thin, immature, and fragile vaginal epithelium.
• Anatomically, underdeveloped labia minora, absence of pubic hair, minimal adiposity of the labia majora, and close proximity of the introitus to the anus make contamination more likely (1).
• The prepubertal child also has an alkaline vaginal pH due to a relative deficiency of lactobacilli (which is lactic acid forming) as compared to adolescent and adult females (1).
• Infectious organisms causing vulvovaginitis are typically respiratory, enteric, or rarely sexually transmitted.
• Most cases (~75%) of pediatric vulvovaginitis are classified as nonspecific vulvovaginitis and do not have an infectious etiology.
• Nonspecific vulvovaginitis causes include:
  • Poor perineal hygiene (wiping back to front) (2)
  • Chemical irritants (bubble baths, scented soaps, wipes, laundry detergents)
  • Tight-fitting clothing or underwear made of synthetic materials
• Specific vulvovaginitis causes include:
  • Bacterial:
    • The most common respiratory pathogen is Streptococcus pyogenes. Vulvitis may occur in the absence of respiratory symptoms.
    • Escherichia coli is the most common fecal pathogen.
    • Shigella vaginitis is associated with mucopurulent bloody discharge and is not always accompanied by a history of diarrhea.
      ALERT
      
      Presence of Neisseria gonorrhoeae or Chlamydia trachomatis strongly suggests sexual transmission and should prompt consideration of sexual abuse.
• Enterobius vermicularis (pinworms)
  • Most common symptom is nocturnal perineal itching.
  • Should be considered in children with vaginal itching and irritation
  • Very common in young children and certain populations
• Considerations for recurrent/chronic vulvovaginitis:
  • Anatomic abnormalities could include double vagina with fistula, ectopic ureter, and urethral prolapse.
  • Systemic inflammatory diseases
  • Other conditions, such as Crohn disease, lichen sclerosus, vitiligo, psoriasis, and atopic dermatitis are possible.
  • Foreign body
    • Presents with foul-smelling, bloody, or brown discharge from the vagina
    • Should be considered in patients with recurrent vulvovaginitis after other causes are ruled out
    • Most common objects: toilet paper, small toys, hair clips
    • If there is a gray watery discharge, consider possibility of battery as foreign body (1).

RISK FACTORS

• Inadequate hand washing or perineal cleansing after urination and defecation (2)
• Wearing of tight-fitting or wet clothing
• Obesity
• Immunosuppression
  • Diabetes
  • Recent antibiotic use
• Anatomic abnormalities

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

COMMONLY ASSOCIATED CONDITIONS

• Urinary tract infections are common in children with vulvovaginitis.
• Constipation predisposes to vulvovaginitis and vice versa.