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BASICS

  • Vulvitis typically precedes vaginitis in prepubertal girls due to low estrogen and immature anatomy.
  • Clinical features: vaginal/vulvar itching, soreness, dysuria, redness, discharge, bleeding, odor, pain.
  • System(s) affected: female genital tract.

EPIDEMIOLOGY

  • Most common gynecologic problem in prepubertal girls.
  • Incidence unknown.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Low estrogen → thin, fragile vaginal epithelium.
  • Anatomical factors: underdeveloped labia minora, absence of pubic hair, minimal labial adiposity.
  • Proximity of anus to introitus → increased contamination risk.
  • Alkaline vaginal pH (vs acidic in adults) → predisposes to infection.
  • Infectious agents mostly respiratory or enteric flora; rarely sexually transmitted.
  • ~75% cases have infectious etiology.
  • Nonspecific causes: poor hygiene (wiping back to front), chemical irritants (bubble baths, soaps), tight clothing.
  • Specific bacterial causes:
  • Streptococcus pyogenes (respiratory)
  • Escherichia coli (fecal)
  • Shigella (bloody mucopurulent discharge)
  • Alert: Neisseria gonorrhoeae or Chlamydia trachomatis suggests sexual transmission → consider abuse.
  • Parasitic: Enterobius vermicularis (pinworms) cause nocturnal itching.
  • Recurrent/chronic cases may have anatomical abnormalities or systemic diseases (Crohn’s, lichen sclerosus).
  • Foreign bodies (toilet paper, toys) cause foul-smelling, bloody/brown discharge.

RISK FACTORS

  • Poor hygiene (improper wiping technique).
  • Tight clothing.
  • Obesity.
  • Immunosuppression.
  • Diabetes.
  • Recent antibiotics.
  • Anatomical abnormalities.

GENERAL PREVENTION

  • Good perineal hygiene; wipe front to back.
  • Urinate with legs apart and labia separated.
  • Avoid irritants (harsh soaps, bubble baths).
  • Avoid tight clothing.

COMMONLY ASSOCIATED CONDITIONS

  • Urinary tract infections.
  • Constipation.

DIAGNOSIS

History

  • Establish rapport with child and family.
  • Symptoms: vaginal discharge, itching, burning, soreness, dysuria, bleeding.
  • Ask about recent infections in patient or contacts.
  • Identify exposure to irritants.
  • Assess toileting habits: wiping technique, voiding posture, bathroom habits.

Physical Exam

  • Inform patient and caregivers about exam process.
  • Positions for exam:
  • Supine frog-leg (external genitalia)
  • Prone knee-chest (internal vagina and cervix)
  • Look for erythema, excoriation, swelling, discharge, foreign body, lichenification.
  • Rectovaginal exam if bleeding, pain, or suspected tumor/foreign body.
  • Obtain cultures if infection suspected.

DIFFERENTIAL DIAGNOSIS

  • Lichen sclerosus
  • Contact dermatitis
  • Eczema
  • Psoriasis

DIAGNOSTIC TESTS & INTERPRETATION

  • Usually clinical diagnosis.
  • Consider testing for infectious causes if indicated.
  • Swab lesions for bacterial/fungal culture.
  • PCR for STIs or herpes if suspected.
  • KOH and saline smears for fungal/bacterial diagnosis (limited sensitivity).
  • Urinalysis and culture to evaluate urinary infection.
  • Tape test for pinworms.
  • Imaging or specialist referral if anatomical abnormality suspected.
  • Vaginal exploration for foreign body if recurrent/persistent symptoms.

TREATMENT

General Measures

  • Avoid irritants (scented soaps, bubble baths).
  • Warm water soaks 15 minutes, 1-4 times daily.
  • Avoid underwear to bed or wear loose cotton clothing.
  • Educate on hygiene and toileting posture.

Medications

Nonantibiotic

  • Clobetasol propionate 0.05% ointment initially for itching-scratch cycle; follow with hydrocortisone 1% for maintenance.
  • Unscented emollients or barrier creams for skin protection.

Antibiotic

  • Use only if bacterial infection confirmed or strongly suspected.
  • Common pathogens: S. pyogenes, S. pneumoniae, H. influenzae, S. aureus, Shigella, E. coli.
  • Duration: 5 to 10 days.

Specific Infections

  • Chlamydia trachomatis:
  • ≤45 kg: erythromycin 50 mg/kg/day QID for 14 days
  • ≥45 kg & <8 years: azithromycin 1 g single dose
  • ≥45 kg & ≥8 years: azithromycin 1 g single dose or doxycycline 100 mg BID for 7 days
  • Neisseria gonorrhoeae:
  • ≤45 kg: ceftriaxone 25-50 mg/kg (max 250 mg) IM/IV once

  • 45 kg: ceftriaxone 500 mg IM/IV once

  • Trichomonas vaginalis: metronidazole 500 mg PO TID for 7 days
  • Candida spp.: topical nystatin, miconazole, clotrimazole, terconazole
  • Pinworms: mebendazole 100 mg PO once, repeat in 2 weeks

ISSUES FOR REFERRAL

  • Suspected sexual abuse
  • Anatomical abnormalities (except minor labial agglutination)
  • Persistent, severe, or recurrent infections
  • Unable to tolerate physical exam and serious cause suspected

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Psychological support for child and parent, especially mother, to manage hygiene-related stress and stigma.
  • Normalize condition and reduce feelings of guilt.

ONGOING CARE

Follow-Up

  • Monitor for fever, pruritus, and discharge.

Diet

  • Healthy, balanced diet with adequate hydration.

PATIENT EDUCATION

  • Perineal hygiene: wipe front to back, avoid reuse of toilet paper.
  • Urinate with legs apart, sitting forward or facing backward on toilet to reduce urine pooling.
  • Avoid bubble baths, scented products, tight/synthetic clothing, wet swimwear.
  • Clean vulva daily with mild soap and water; dry gently.
  • Delay hair shampooing to end of bath, wash hair standing if possible.
  • Use unscented barrier creams for skin protection.

PROGNOSIS

  • Good with appropriate treatment and hygiene.
  • Recurrent/persistent cases may indicate foreign body or anatomic abnormality.

COMPLICATIONS

  • Pelvic inflammatory disease if STI untreated.
  • Labial adhesions from chronic inflammation.
  • Vaginismus secondary to traumatic exams or prolonged symptoms.

REFERENCES

  1. Romano ME. Prepubertal vulvovaginitis. Clin Obstet Gynecol. 2020;63(3):479-485.
  2. Cemek F, Odabaş D, Şenel Ü, et al. Personal hygiene and vulvovaginitis in prepubertal children. J Pediatr Adolesc Gynecol. 2016;29(3):223-227.

ICD10

  • N76.0 Acute vaginitis
  • N77.1 Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere

Clinical Pearls

  • Vulvovaginitis is the most common gynecologic problem in prepubertal girls.
  • Hypoestrogenic state and anatomy increase susceptibility.
  • Treatment mostly supportive; antibiotics only if bacterial infection confirmed.
  • Isolating sexually transmitted infection should prompt abuse evaluation.
  • Recurrent vulvovaginitis with foul discharge warrants exam for retained foreign body.
  • Good hygiene limits recurrence.