Chapter 102: Vaginitis

• 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.

• 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.^1,2 Symptoms may include vaginal discharge, redness, soreness, itching, or dysuria.² Vulvovaginal symptoms may be caused by nonspecific irritants, specific infections, trauma, or dermatologic conditions (Table 102-1).³ 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

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 143 and a comprehensive discussion of sexually transmitted infections is covered in Chapter 88).¹ Evaluation should also include an external genital examination, and a vaginal culture should be obtained if significant vaginal discharge is present.⁴

Nonspecific vulvovaginitis accounts for 25% to 75% of the cases of vulvovaginitis in prepubertal girls.^5,6 The pathogenesis may be associated with an alteration of vaginal flora with an overgrowth of fecal aerobic bacteria or an overpopulation of anaerobic bacteria found in vaginal flora.⁴ Vaginal culture from girls with vulvovaginitis typically grows organisms considered to be normal flora such as diphtheroids, enterococci, and lactobacilli.⁴ The presence of Escherichia coli is also often found on vaginal culture, which suggests contamination with bowel flora.¹

Management of nonspecific vulvovaginitis includes proper hygiene and avoidance of vulvar irritants (Table 102-2).³ If symptoms persist for longer than 2 to 3 weeks despite these measures, a trial of oral antibiotics, such as amoxicillin, or amoxicillin/clavulanic acid may be given for 10 days.^1,5

Respiratory Pathogens

Vulvovaginitis may be caused by bacterial pathogens, with respiratory pathogens being the most common. Streptococcus pyogenes (group A β-hemolytic streptococci) is the most common respiratory pathogen isolated in girls with vulvovaginitis.⁷ Another common pathogen is H. influenzae.⁷ The mode of transmission is likely self-inoculation by hand from the nose and mouth to the vulvar region. Recurrent vulvovaginitis with S. pyogenes may be associated with persistent asymptomatic bacterial carriage in the nasopharynx.¹

In addition to vaginal discharge, an erythematous dermatitis involving the vulva and perianal tissues is often noted.¹ Treatment is directed toward the specific bacteria isolated. Empiric therapy with oral penicillin or amoxicillin for 10 days may be started if symptoms and discharge are profuse once cultures are taken.^1,5 If treatment with amoxicilin fails for H. Influenzae cases, treatment with amoxicillin/clavulanate is recommended.¹

Enteric Pathogens

Enteric pathogens including Shigella and Yersinia may be a cause of vaginitis in the prepubertal child.⁵ Shigella flexneri can cause a mucopurulent, bloody discharge sometimes seen after an episode of diarrhea.⁵ Diagnosis is made by culture of the vaginal discharge.⁸ Treatment should be directed toward antibiotic sensitivities, and options include trimethoprim/sulfamethoxazole, ampicillin, ceftriaxone, and azithromycin.^1,8

Vulvovaginal Candidiasis

Candidal vaginitis occurs more frequently in adolescents than younger girls because Candida albicans colonizes the vagina after the onset of puberty, when estrogen is present to promote fungal growth.¹ Candidal infections are, therefore, uncommon in the prepubertal girl, except in the presence of diabetes mellitus, immunodeficiency, antibiotic use or diaper use.²

The symptoms of candidal vaginitis include inflammation of the vulva and perianal region, and a thick, whitish discharge.⁵ Satellite lesions and white plaques may sometimes be identified.⁹ A wet mount with a potassium hydroxide preparation is used to make the diagnosis.⁵ If the diagnosis is still in question, specific cultures for yeast may be sent.⁹

Treatment includes topical antifungals (nystatin, miconazole, clotrimazole, or terconazole) for external genitalia.⁵ If topical antifungals are unsuccessful, oral fluconazole should be considered.¹

Pinworms

Pinworms, or E. vermicularis, can cause vulvar symptoms.¹ These 1-cm long, thin white worms can crawl from the anus to the vulvar introitus and cause anal or vulvar pruritus.^1,5 Diagnosis is made by either anal pinworm preparation or an application of transparent adhesive tape to the anal region in the morning to identify eggs.⁵ Treatment is mebendazole orally once and repeated in 2 weeks.⁵

Foreign Body

Vulvovaginal symptoms can be caused by the presence of a foreign body in the vagina. Symptoms include vaginal discharge, intermittent spotting, or foul smelling odor.¹ Toilet paper is the most common foreign body found.⁵ Irrigation with warmed fluid can be used to remove the foreign body, but more complex cases might require examination under sedation or anesthesia.¹

Vulvar Dermatologic Conditions

Symptoms of vulvovaginitis and vulvar dermatologic conditions overlap and it is important to make the distinction for proper management. Typical symptoms include irritation, pruritus, and pain.¹ The most common dermatologic conditions causing vulvar complaints include atopic dermatitis, lichen sclerosus, psoriasis, and contact dermatitis.^1,5 Diagnosis is made by detailed history and physical examination, including evaluation of extragenital skin, which might assist in diagnosis of atopic dermatitis, psoriasis, or other conditions.