VULVOVAGINITIS, PREPUBESCENT

VULVOVAGINITIS, PREPUBESCENT - Theresa N. Grabo, PhD, APRN, BC, FNP
BASICS
DESCRIPTION
• Irritation and/or inflammation of the vulva and/or vagina, associated with vaginal discharge
• In children, the vulva usually becomes inflamed first, with the vagina either not involved, or affected secondarily.
• System(s) Affected: Reproductive; Skin/exocrine
• Synonym(s): Vaginitis; Vulvitis
ALERT
Pediatric Considerations
• Usual adult vulvitis/vaginitis organisms are rare in the prepubertal child.
• Lack of estrogen causes thin vaginal mucosa, which is more susceptible to trauma and infection.
GENERAL PREVENTION
• Perineal hygiene
• Avoidance of irritants and tight or occlusive, nonbreathable clothing
• White, unscented toilet paper
EPIDEMIOLOGY
• Predominant age: Toddlers to menarche
• Predominant sex: Female only
Incidence
Unknown
Prevalence
Common in the US
RISK FACTORS
• Coexisting pharyngitis or other systemic conditions
• Faulty hygiene
• Trauma
Genetics
Not well studied
ETIOLOGY
• Most often due to
- Poor hygiene, may lead to labial agglutination
- Primary infection elsewhere (e.g., otitis media, pharyngitis)
• Most common specific organisms
- Group A -hemolytic streptococci; Streptococcus pyogenes, S. pneumoniae
- Escherichia coli
- Staphylococcus aureus
- Haemophilus influenzae
• Less common specific organisms
- Pinworms
- Sarcoptes scabiei (scabies)
- Candida spp: most common with immunocompromised, antibiotic therapy, or diapers
- Shigella flexneri
• Systemic illnesses
- Measles
- Chickenpox
- Stevens-Johnson syndrome
- Inflammatory conditions (e.g., Reiter syndrome)
• Localized vulvar disease
- Seborrheic dermatitis
- Psoriasis
- Atopic dermatitis
- Contact dermatitis
- Lichen sclerosus et atrophicus
• Other
- Urethral prolapse
- Ectopic ureter
- Sexual abuse (gonorrhea, chlamydia, trichomoniasis, herpes). In 1 study, 4% of girls not suspected to have sexual abuse had positive cultures for gonorrhea.
- Other trauma
- Foreign body
- Tumors or polyps
- Masturbation
- Genital tract malformations
- Polyps or tumors


DIAGNOSIS
SIGNS AND SYMPTOMS
• Irritation and erythema of vulva
• Vaginal discharge
• Unpleasant odor
• Itching
• Excoriation of the genital area
• Bleeding
• Dysuria
• Inflammation of the introitus
• Soreness
Physical Exam
• See "Diagnostic Procedures."
• Look for evidence of chronic illness or dermatologic disease
• Inspection of the genital area in the supine position
• Inspection of the vagina and cervix in the knee-chest position
• Rectal examination if vaginal bleeding or abdominal pain
TESTS
Lab
• Culture for bacteria, fungi, or viruses
• Gram stain
• Tape examination for pinworms
• Potassium hydroxide and saline smears
• Special tests: Exploration of vagina for foreign body may be necessary in long-standing foul vaginal discharge.
Diagnostic Procedures/Surgery
Visualization of the vagina may be necessary using a nasal speculum or infant laryngoscope. If blood or foul-smelling discharge is present, visualization is mandatory. Place child in knee-chest position for best result. Hold buttocks apart and slightly upward.
DIFFERENTIAL DIAGNOSIS
• Contact dermatitis
• Eczema
• Psoriasis
• Shigella vulvovaginitis
TREATMENT
GENERAL MEASURES
• Appropriate health care: Outpatient (except where systemic illness requires hospital care)
• Hygiene
- Wipe front-to-back after elimination.
- Avoid bubble baths and other irritating products.
- Clean daily with mild soap and water and dry gently with soft towel or cool hair dryer.
- Apply bland ointments for protection of the skin, if necessary.
Diet
Healthy balanced diet, high in fiber to prevent constipation; adequate fluid intake.
Activity
Normal with regular exercise
MEDICATION (DRUGS)
First Line
• For empiric treatment, amoxicillin 20 mg/kg/d for 7 days; in areas of high prevalence of resistant H. influenzae, amoxicillin-clavulanate (Augmentin) 20 mg/kg/d
• Estrogen deficiency with labial adhesion/agglutination: Estrogen, conjugated cream to fused area nightly for 2 weeks
• Specific organisms on culture
- Group A -streptococcus, Streptococcus pneumoniae: Penicillin V (Pen Vee K)25-50 mg/kg/d, maximum of 3 g/d, divided q.i.d., for 10 days
- H. influenzae:Amoxicillin 20-40 mg/kg/d for 7 days; amoxicillin-clavulanate 20 mg/kg/d
- Staphylococcus aureus:Cephalexin 25-50 mg/kg/d, divided q.i.d., for 7-10 days; or dicloxacillin 12.5-25 mg/kg/d for 7-10 days
- Candida spp: Topical nystatin (Mycostatin), miconazole, clotrimazole, or terconazole
• Contraindications: Allergy to proposed treatment
• Precautions: Avoid potential allergens and topical sensitizers if possible.
• Significant possible interactions: See the manufacturer's profile for each drug.
Second Line
Topical corticosteroids for pruritus; avoid long-term use
FOLLOW-UP
Recurring vulvovaginitis that does not respond to treatment should be referred to a specialist for further evaluation
PROGNOSIS
Usually clears with appropriate treatment with no permanent sequelae (if not due to underlying disease such as psoriasis, etc.)
COMPLICATIONS
Labial agglutination or adhesions
PATIENT MONITORING
Only if symptoms do not respond to treatment
REFERENCES
1. Jones R. Childhood vulvovaginitis and vaginal discharge in general practice. Fam Pract. 1996;13(4):369-372.
2. Paek SC, Merritt D, Mallory SB. Pruritus vulvae in prepubertal children. J Am Acad Dermatol. 2001;44:795-802.
3. Pierce AM, Hart CA. Vulvovaginitis: Causes and management. Arch Dis Child. 1992;67:509-512.
4. Shapiro RA, Schubert CJ, Siegel RM. Neisseria gonorrhea infections in girls younger than 12 years of age evaluated for vaginitis. Pediatrics. 1999;104(6):e72.
5. Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent. Pediatr Rev. 1993;14:141-147.
6. Jasper JM, Ward MA. Shigella vulvovaginitis in a prepubertal child. Pediatr Emerg Care. 2006;22(8):585-6. (3) [C].
7. Emans SJ, Goldstein DP. Pediatrics. The gynecologic examination of the prepubertal child with vulvovaginitis: Use of the knee-chest position. Pediatrics. 1980;65(4):758-760.
8. Joishy M, Ashtekar CS, Jain A, Gonsalves R. Do we need to treat vulvovaginitis in prepubertal girls? Br Med J. 2005;22:330(7484):186-188.
9. Stricker T, Navratil F, Sennhauser FH. BMJ. 2002. Archives of Disease in Childhood. 2003;88:324-326. (2) [B].
ADDITIONAL READING
• Sultan C, ed. Pediatric and adolescent gynecology. evidence-based clinical practice. Endocr Dev. 2004;7:1-8.
• Farrington PF. Pediatric Vulvo-Vaginitis. Clinical Obstetrics  Gynecology. Thyroid Diseases in Pregnancy. 1997;40(1):135-140.
• Merkley K. Vulvovaginitis and vaginal discharge in the pediatric patient. J Emerg Nurs. 2005;31(4):400-402.