- 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:
- 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.
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).
- Inadequate hand washing or perineal cleansing after urination and defecation (2)
- Wearing of tight-fitting clothing
- Recent antibiotic use
- Anatomic abnormalities
- 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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Domino, Frank J., et al., editors. "Vulvovaginitis, Prepubescent." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2020. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116651/all/Vulvovaginitis__Prepubescent.
Vulvovaginitis, Prepubescent. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2020. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116651/all/Vulvovaginitis__Prepubescent. Accessed May 29, 2023.
Vulvovaginitis, Prepubescent. (2020). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (27th ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116651/all/Vulvovaginitis__Prepubescent
Vulvovaginitis, Prepubescent [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2020. [cited 2023 May 29]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116651/all/Vulvovaginitis__Prepubescent.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Vulvovaginitis, Prepubescent ID - 116651 ED - Domino,Frank J, ED - Baldor,Robert A, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116651/all/Vulvovaginitis__Prepubescent PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -