Vulvovaginitis, Prepubescent



  • 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



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. 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.
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.

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