Vulvovaginitis, Prepubescent

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

To view the entire topic, please or .

Medicine Central™ is a quick-consult mobile and web resource that includes diagnosis, treatment, medications, and follow-up information on over 700 diseases and disorders, providing fast answers—anytime, anywhere. Explore these free sample topics:

-- The first section of this topic is shown below --

Basics

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

Incidence
Unknown

Prevalence
Most common gynecologic problem in prepubertal girls

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 (3). 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 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 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 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.

-- To view the remaining sections of this topic, please or --

Basics

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

Incidence
Unknown

Prevalence
Most common gynecologic problem in prepubertal girls

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 (3). 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 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 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 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.

There's more to see -- the rest of this topic is available only to subscribers.