Vulvovaginitis, Prepubescent

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.
• System(s) affected: reproductive, skin/exocrine
• Synonym(s): vaginitis; vulvitis

Epidemiology

Incidence
Unknown

Prevalence
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, make 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.

Genetics
Understudied

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

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