Vaginitis in Children

A physiologic vaginal discharge can occur in children during developmental phases in which serum estrogen levels are elevated. During pregnancy, the fetus is exposed to high levels of estrogen from the mother or produced by the mother or placenta. At birth, this exposure ceases, and in the first week of life, infants may have a vaginal discharge. As serum estrogen levels decrease, some female infants have withdrawal vaginal bleeding (estrogen can stimulate the fetal vaginal epithelium or endometrium). In pre-adolescents, as estrogen production increases during the few months before menarche, physiologic vaginal discharge (usually clear, white, or sometimes pale yellow) may begin, which will continue throughout the reproductive years.

In children, vaginitis and/or vulvitis is usually caused by local irritation or allergy, infection with pinworms (Enterobius vermicularis), or infection with or gastrointestinal or respiratory tract flora.

Local irritation or allergy may be due to chemicals in bubble baths, soaps, diapers, toilet paper, laundry detergent, or any other products that come into contact with the vulva.

Foreign bodies are also a common cause of vulvovaginal inflammation. Occasionally, children have residual toilet paper adherent to the vulva or that becomes intravaginal or they may place small objects (eg, toys) into body cavities, including the vagina.

Pinworm infection is common in young children and can cause intense perianal or vulvar pruritus, causing an inflammatory vulvitis. Scratching exacerbates the inflammation, and excoriations can cause injury or secondary bacterial infection.

Infection with gastrointestinal tract flora or respiratory tract flora from the nose or oral pharynx may occur. Common contributing factors in young girls are: exposure of the genital tract to bacteria by contact with toilet paper or their hands (eg, wiping from back to front after bowel movements; not washing hands after bowel movements; frequent touching of the perineum or vagina; or touching the vagina after wiping a nose or coughing into a hand).

Vulvovaginal candidiasis is uncommon in children (except following recent antibiotic therapy or in immunocompromised patients), and tends to be overdiagnosed and treated (1).

Less commonly, vaginal discharge in children is indicative of sexually transmitted infections resulting from sexual abuse. In addition, cervical discharge due to cervicitis caused by gonorrhea or chlamydia passes through the vagina and can be thought to be vaginal discharge. If abuse is suspected, measures to ensure the child’s safety must be taken, and a report must be made to the appropriate authorities.

Vaginitis in children typically presents with a vaginal discharge, which may be accompanied by odor, pruritus, vaginal discomfort, or dysuria, and sometimes bleeding or fever. The patient and parent (or guardian) should be asked about frequency (eg, daily or several times per week), volume, color, and consistency (eg, thin, thick).

Vulvitis presents with vulvar erythema or edema, and sometimes vulvar pruritus or pain or dysuria. It may be accompanied by a rash on the surrounding skin (groin, mons, perineum, perianal area). Sometimes excoriations (due to scratching) or lesions are present.

Associated symptoms, such as anal pruritus, particularly at night, or fever should be noted.

On external genital examinations, labial adhesions in young children may be caused by infection or inflammation in the setting of low estrogen levels prior to menarche. Other vulvar or vaginal lesions (eg, vulvar whitening, vaginal mass) should prompt further evaluation by a clinician experienced in pediatric gynecology.

Sexual abuse or other trauma is suspected if vulvovaginal bruising, injury, or bleeding is present. Infection with Trichomonas vaginalis typically has a profuse, thin, yellow-green, malodorous discharge with vulvitis and often dysuria. Infection with Neisseria gonorrhoeae or Chlamydia trachomatis can be asymptomatic or present with a yellow-green vaginal discharge, sometimes with dysuria or fever. Vulvar ulcers may be due to genital herpes or syphilis, or can be caused by noninfectious diseases (eg, Crohn disease, Behcet disease, or acute genital ulceration (also called aphthous ulcers). Vulvar condylomata acuminata (genital warts) are usually caused by maternal-to-child transmission during vaginal delivery, but may be caused by sexual abuse.

• External genital examination

• Infrequently, internal pelvic examination (typically performed under anesthesia)

• Sometimes microscopy of vaginal fluid

• Sometimes vaginal culture

• If sexual abuse is suspected, testing for sexually transmitted infections

Initial evaluation of vulvovaginitis in a child is with history and physical examination. The medical history is obtained from the parent (or guardian) and the child, if age appropriate. If a pelvic examination in a child is required, it should be performed by an experienced clinician. The parent and child should be educated regarding the examination so they know what to expect and to build trust between the child and clinician. In children, if internal pelvic examination is required, it is typically performed under anesthesia. The evaluation of vulvovaginal pruritus or vaginal discharge in a child is discussed in detail separately.

Typical symptoms and signs of common causes of vaginitis and/or vulvitis in children include:

• Nonspecific vaginitis: Yellow or green vaginal discharge, but not purulent. Vulvitis is usually also present and is mild or moderate. If the cause is exposure to a chemical irritant or allergen, a rash may be present on the labia major and may extend to the surrounding skin of the groin, mons, perineum, and perianal area. If there is a foreign body in the vagina, discharge may be blood-tinged.

• Pinworm infection: Intense vulvar and perianal pruritus, particularly at night. Vulvitis, often with excoriations, is usually present due to scratching. There is usually no vaginal discharge.

• Infection with enteric or respiratory bacteria (eg, group A Streptococcus, Shigella): Purulent vaginal discharge.

If nonspecific vaginitis is suspected, no further testing is required.

If contact irritant or allergic vulvitis is suspected, the patient should systematically eliminate potential irritants or allergens to identify the cause. Severe dermatitis or allergic reactions require evaluation by an allergist or dermatologist.

Pinworm infection may be visualized on external examination, or cellophane tape can be used to collect a sample from the perianal area or vulva and placed on a slide to examine microscopically.

If vaginitis persists after initial treatment or there is a purulent discharge, a vaginal bacterial culture should be performed. Results may be difficult to interpret, since they may detect norma vaginal flora. Bacterial culture results in a child that warrant antibiotic treatment include heavy growth of certain skin flora (Staphylococcus epidermidis, Streptococcus pyogenes, Streptococcus viridans, Staphylococcus aureus); respiratory flora (eg, Group A Streptococcus); or common gastrointestinal tract bacteria (eg, Escherichia coli, Enterococcus faecalis, Proteus vulgaris).

A wet mount with 10% potassium hydroxide or fungal culture can be performed if candidiasis is suspected.

If an intravaginal foreign body is suspected, internal pelvic examination, sometimes with vaginoscopy, is performed under anesthesia.

For suspected sexual abuse, testing should be performed for sexually transmitted infections. Most testing for genital tract infection can be performed with a vulvar swab (herpes simplex virus, sample from syphilis chancre), urine sample (gonorrhea, chlamydia), or blood test.

• Treatment of etiology

• Symptom management

Treatment is directed at the cause.

Prepubertal girls with nonspecific vulvovaginitis should be taught vulvar hygiene (eg, wiping front to back after bowel movements and voiding, washing hands, avoiding frequent touching of the vulvovaginal area).

An intravaginal foreign body is removed via examination under anesthesia.

Pinworm infection, bacterial infection, or viral infection is treated as appropriate for the specific infection.

• In children, vaginal discharge or vulvar symptoms (discomfort, swelling, lesions, or pruritus) are usually caused by inflammation or infection and require evaluation.

• Common causes of vaginitis and/or vulvitis in children include local irritation or allergy, foreign body, pinworm infection, and exposure to gastrointestinal or respiratory tract bacteria.

• Evaluate children with vulvovaginal symptoms with history and external genital examination.

• If vaginitis persists after initial treatment or there is a purulent discharge, test with a vaginal bacterial and sometimes wet mount or fungal culture, and sometimes with internal pelvic examination under anesthesia.

• If sexual abuse is suspected, test for sexual transmitted infections.

• Manage nonspecific vulvovaginitis with patient eduction about vulvar hygiene or removal of irritants or allergens or a foreign body. Treat infections with targeted antimicrobials.