Description

• 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.
• Vulvovaginitis can be classified as either nonspecific or specific
• Systems affected: reproductive, integumentary

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, with an absence of lactobacilli (1).
• Infectious organisms causing vulvovaginitis are typically respiratory, enteric, or rarely sexually transmitted.
• Most cases 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)
  • Nonspecific chemical irritants (bubble baths, scented soaps, laundry detergents)
  • Tight-fitting clothing or underwear made of synthetic materials
• Specific vulvovaginitis causes include:
  • Bacterial: The most common bacteria are introduced from respiratory and GI tracts.
    • 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 gonorrhea or Chlamydia trachomatis strongly suggests sexual transmission and should prompt consideration of sexual abuse

  • 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
• 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.

Risk Factors

• Inadequate hand washing or perineal cleansing after urination and defecation increases risk (2).
• Wearing of tight-fitting clothing increases risk
• Obesity also predisposes to nonspecific vulvovaginitis (4).

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 (4).