Common Pediatric Vulvar Disorders: Vulvovaginitis, Lichen Sclerosus, and Labial Agglutination

Pediatric Vulvovaginitis

Introduction

Vulvovaginitis is considered to be one of the most common gynecologic problems in premenarchal girls,^[3] accounting for approximately 80% to 90% of outpatient visits by children to gynecology offices.^[4] The severity varies from child to child and may result from multiple causes, including infection, irritation, foreign body, allergy, systemic diseases, or sexual abuse.^[5] In prepubertal girls, the majority of vulvovaginitis infections involve primary irritation of the vulva with secondary involvement of the lower one third of vagina.^[4,5] Although vaginal discharge is one of the most common presenting symptoms,^[6] it is prudent to remember that an increase in physiologic vaginal discharge is common in the months before menarche in response to increasing estrogen levels.^[7]

Etiology

In premenarchal girls, nonspecific vulvovaginitis accounts for 50% to 75% of vulvovaginitis cases.^[4,8] There are anatomic, physiologic, and behavioral reasons that predispose premenarchal girls to vulvovaginitis.^[3] Anatomically, prepubertal girls are susceptible to nonspecific vulvovaginitis because of their small labia minora^[9] and the absence of labial fat pads and pubic hair. These anatomic characteristics diminish protection of the introitus by the labia majora, leaving the vagina open and unprotected when the child squats.^[3] Physiologically, prepubertal girls are hypoestrogenic and therefore have thin vaginal epithelium which is susceptible to irritation and inflammation. In addition, the vagina lacks lactobacilli, which may increase susceptibility to bacterial growth.^[3,7] Behavioral factors including poor perineal hygiene (further exacerbated by the proximity of the anus to the vagina), use of tight-fitting, nonabsorbent clothing, and exposure to chemicals such as bubble bath, shampoos, and deodorant soaps make young girls prone to vulvovaginitis.^[3,4] Sexual abuse and frequent masturbation leading to vulvar irritation are other causes of nonspecific vulvovaginitis.^[10]

Specific infections (infectious vulvovaginitis) in prepubertal girls are often secondary to respiratory, enteric, and, less frequently, sexually transmitted organisms.^[11] The respiratory pathogens passed from nose and mouth to the vulva secondary to poor hygiene include group A streptococcus, Staphylococcus aureus, Haemophilus influenza, Streptococcus pneumoniae, and Neiserria meningitidis; enteric pathogens include Shigella and Yersinia.^[10] Recurrent vulvar/perianal pruritis, especially at night, is suspicious for a parasitic infection such as pinworms (Enterobius vermicularis).^[10] Additional rare pathogens include Candida species, Gardnerella vaginalis, and sexually transmitted diseases such as Neiserria gonorrhea, Chlamydia trachomatis, and human papillomavirus, frequently a result of sexual abuse.^[12]

Other rare noninfectious factors may be responsible for acute or chronic vulvovaginitis. These include foreign bodies, vaginal polyps or tumors, systemic illnesses, ectopic ureters, and urethral prolapse.^[10]

Diagnosis

Evaluation for vulvovaginitis includes obtaining a careful history, and information should be elicited regarding bathroom habits, recent upper respiratory infection, and the use of irritants such as soaps and bubble baths. Common symptoms include diffuse vulvovaginal pain, burning, pruritus, dysuria, and possible seropurulent discharge.^[13] Examination entails careful vulvar and hymenal inspection. The vulvovaginal region may have a markedly mottled erythematous appearance.^[4] In cases with an infectious cause, the vaginal discharge may be more purulent and malodorous.^[7,10]

Most authors conclude that a microbiologic investigation is indicated if visible vaginal discharge with moderate-to-severe inflammation is present upon examination.^[6,7,11] Diagnostic tests include a wet prep, smear for Gram stain, and aerobic culture.^[7] Other exclusion methods may be used, such as a pinworm test or chlamydia/gonorrhea cultures if sexual abuse is suspected.^[5]

The challenge in diagnosing vulvovaginitis in this age group is differentiating between infectious and noninfectious causes. Discerning the correct diagnosis may be difficult because of the overlap between normal flora and potential pathogens in the pediatric population.^[14] The presence of an organism is not necessarily deemed to be the etiologic cause. A diagnosis of nonspecific vulvovaginitis should be made if vaginal cultures grow normal flora and no other etiology is known for the vulvovaginitis.^[4,5]

Treatment

In most pediatric cases, vulvovaginitis does not have a specific cause. In those cases, treatment should focus on improving hygiene and providing appropriate vulvar care. Figure 1 is a parent/patient education handout for vulvovaginitis. Bland soap may be used sparingly; however, the vulva should not be scrubbed.^[5] Afterwards, the patient should gently pat dry the vulvar region or allow it to air dry.^[4,9] Clothes should be washed in a mild detergent with no rinse or dryer additives. Small amounts of a bland nonmedicated ointment may be used to protect the vulvar skin.^[4,9] If a child is suspected to be in an itch-scratch cycle from pruritus secondary to chronic discharge and inflammation, sitz baths should be recommended. Sitz baths consist of having the child sit in lukewarm water to soothe the inflamed vulva.^[9] It is best to minimize the use of soap on the vulva and wash with a white washcloth or fingers. Occasionally, a low-dose topical steroid (hydrocortisone 1% or 2.5%) may help relieve itching and inflammation if unresponsive to conservative measures.^[4,9]

If symptoms do not resolve with hygiene methods, broad-spectrum antibiotics should be initiated.^[4,7,9] An adequate clinical response can be achieved with a course of oral penicillin, cephalosporin, or erythromycin. Amoxicillin 40 mg/kg/day, or penicillin VK 125 to 250 mg orally 4 times a day, or erythromycin 30-50 mg/kg/day for 10 days usually offers adequate therapeutic coverage for the common pathogens that cause vulvovaginitis.^[7,9]

If a specific overgrowth of bacteria is noted, antibiotic therapy should be directed toward the particular pathogen. If a diagnosis of pinworm is made, therapy should be instituted using mebendazole 100 mg orally in a single dose and repeated in 1 week. In these cases, it is advised to treat the entire family to prevent reinfection.^[9]

If symptoms fail to resolve after 2 courses of broad-spectrum antibiotic therapy, then an examination under anesthesia to rule out a foreign body^[15] or referral to a specialist should be considered.

Clinical Pearls

1. Most cases of vulvovaginitis are nonspecific, with cultures demonstrating normal urogenital flora and no other identifiable etiology.
   
   
2. Vulvovaginal candidiasis is very rare in children unless the child is immunocompromised or on antibiotics.
   
   
3. Foreign bodies are rare and are often associated with foul-smelling bloody discharge.
   
   
4. Hygiene is critical in the management of vulvovaginitis (see patient handout, Figure 1).
   
   
5. Chronic vulvovaginitis unresponsive to therapy warrants a referral to a specialist.

Figure 1. Parent/patient education handout for vulvovaginitis.
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