Vulvovaginitis is the most common gynecological disorder in childhood; its causes include physical and chemical irritants and a variety of infectious agents.
Group A β-hemolytic Streptococcus and Haemophilus influenzae can be self-inoculated from nose and mouth to the vulvar region.
Good hygiene is fundamental to the resolution of many pediatric vulvar conditions.
Candidal vaginitis is rare in prepubertal children and should raise suspicion of diabetes mellitus or depressed immune function.
Enterobius vermicularis (pinworms) can be a source of irritant vaginitis.
Vulvovaginitis, or inflammation of the vulva and vagina, is the most common gynecological problem in prepubertal girls and can cause anxiety in both the child and the parent.1,2,3 Symptoms may include vaginal discharge, redness, soreness, itching, dysuria, bleeding, or pain.2,3 Vulvovaginal symptoms may be caused by nonspecific irritants, specific infections, trauma, or dermatologic conditions (Table 103-1).4 Contributing factors for prepubertal girls are poor hygiene, lack of estrogenization, proximity of vagina to anus, and lack of labial fat pads or pubic hair.1,2
Nonspecific vulvovaginitis Specific vulvovaginitis Respiratory pathogens Streptococcus pyogens, Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae Enteric pathogens Shigella, Yersenia Candidal infection Sexually transmitted infections Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, condyloma acuminata Pinworms Foreign body Vulvar dermatologic conditions Others: trauma, polyps, tumors, systemic illness, psychosomatic vaginal complaints |
Evaluation should include a full history, including symptoms (soreness, itching, burning, dysuria, odor, discharge), location, duration, prior treatments, hygiene habits, voiding habits, physical activities, and the potential for sexual abuse (sexual abuse is covered in Chapter 144 and a comprehensive discussion of sexually transmitted infections is covered in Chapter 89).1 Evaluation should also include an external genital examination. Aspects of a complete external genitalia exam are noted in Table 103-2. A vaginal culture should be obtained if significant vaginal discharge is present.5 Positive cultures are more likely in the clinical setting of visible vaginal discharge with moderate to severe inflammation extending beyond the introitus.6
Explain to child, parent/care giver that the examination is not painful, provide opportunity to ask questions Educate child in appropriate language that only parents/caregivers/health care providers can touch or examine genital/private area Do not rush examination |
Vitals signs and systemic physical examination first followed by genital inspection Examination should include inspection of external genitalia, visualization of the vagina, and rarely a recto-abdominal examination if mass is suspected |
Most common position for genital examination is frog-leg position on exam table Alternatives include: Frog-leg position on parent/caregiver’s lap Lithotomy position with use of stirrups Knee-chest position Supine with knees flexed on abdomen |
Lateral spread technique/gentle traction of the labia majora should be utilized to expose the structures of the genitalia Valsalva or cough can aid in visualization of the distal portion of the vagina |
Physical examination documentation should include the following: Tanner staging Description of perineal hygiene Presence or absence of discharge Description of hymen including any anomalies Condition of skin and mucosa including any lesions Secondary excoriations Foreign body Trauma signs Consider offering a mirror if the child is interested |
Child must feel in total control over examination If child is very hesitant, consider deferring examination until the next visit or if problem is urgent, performing under anesthesia |
NONSPECIFIC VULVOVAGINITIS
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