Vulvovaginitis, Prepubescent

Vulvovaginitis, Prepubescent is a topic covered in the 5-Minute Clinical Consult.

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  • Vulvitis is inflammation of the external genitals.
  • Vaginitis, often associated with vaginal discharge, is inflammation involving the vaginal mucosa.
  • In premenarchal girls, vulvitis is usually primary with secondary extension into the vagina.
  • System(s) affected: reproductive, skin/exocrine
  • Synonym(s): vaginitis; vulvitis



Most common gynecologic problem in prepubertal girls

Etiology and Pathophysiology

  • In the prepubertal child, the levels of estrogen are low.
  • Due to the low levels of estrogen, the vaginal epithelium is thin, immature, and fragile.
  • Absence of pubic hair and a well-developed labia, as well as close proximity of the anus and vagina, makes contamination more likely.
  • The prepubertal child also has an absence of lactobacilli, creating a neutral to alkaline vaginal pH.
  • Neutral pH, atrophic mucosa, and moist environment of the vagina increase the risk of infection.
  • Most cases of pediatric vulvovaginitis are nonspecific inflammation.
  • Specific infections that occur are typically respiratory, enteric, or sexually transmitted.
  • Nonspecific vulvovaginitis
  • Poor perineal hygiene (wiping back to front) (1)
  • Nonspecific chemical irritants (bubble baths, scented soaps, shampoos)
  • Tight-fitting clothing
  • Etiology
    • Bacterial: The most common bacteria are introduced from respiratory and GI tracts.
      • The most common respiratory pathogen is Streptococcus pyogenes (2)[B]. Vulvitis may occur in the absence of respiratory symptoms.
      • Urinary tract infections are common in children with vulvovaginitis (3)[B].
      • Escherichia coli is the most common fecal pathogen.
      • Shigella vaginitis is associated with mucopurulent bloody discharge and likewise, is not always accompanied by a history of diarrhea.
  • Enterobius vermicularis (pinworms)
    • Very common in young children and certain populations
    • Should be considered in children with vaginal itching and irritation
    • Most common symptom is nocturnal perineal itching.
    • Foreign body
      • Presents with foul-smelling, bloody, or brown discharge from the vagina
      • Should be considered with recurrent vulvovaginitis where other causes have been eliminated
    • Other
      • With chronic vulvovaginitis, anatomic abnormalities or systemic disease should be considered:
        • Anatomic abnormalities include double vagina with fistula, ectopic ureter, and urethral prolapse.
    • Systemic disease (inflammatory diseases)
    • Other conditions, such as lichen sclerosus, vitiligo, psoriasis, and atopic dermatitis, should be considered.


Risk Factors

  • Prepubertal girls are particularly susceptible due to behavioral and anatomic reasons:
    • Inadequate hand washing or perineal cleansing after urination and defecation
    • Tight-fitting clothing
    • Proximity of the vagina to the anus, lack of protective hair, and labial fat pads
    • Trauma
  • Obese girls are also susceptible to nonspecific vulvovaginitis (4)[A].

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

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

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