Paediatric Acute care Guidelines PMH Emergency Department

Vulvovaginitis is the general term which refers to many types of vaginal/vulva inflammation or infection. 

Background

In prepubertal girls non specific vulvovaginitis is responsible for 25-75% of vulvovaginitis

Causal Factors of non specific vulvovaginitis in prepubertal child 

  • Unoestrogenised thin vaginal mucosa with lack of labial development
  • More alkaline pH (pH 7) than post-menarchal girls
  • Moisture to area (aggravated by synthetic fibre underwear, tight clothing, wet bathers, obesity, poor hygiene)
  • Irritants (e.g. bubble baths, shampoos, soaps, antiseptics)

Assessment

Signs Symptoms
  • Redness
  • Swelling to area
  • Bleeding
  • Vaginal discharge
  • Pruritis
  • Dysuria

Examination 

  • Examine the perineum of prepubertal child in “frog leg” position (girl supine with heels together) and always wear gloves
  • A nurse chaperone must be in attendance throughout the examination
  • Do not perform an internal vaginal examination or take vaginal swabs

Investigations

  • Mild Vulvovaginitis
    • No investigations (e.g. swabs) are necessary
  • Profuse/offensive discharge take an introital swab

Differential Diagnosis

If persistent, offensive or bloody discharge, consider the following: 

  • Threadworm if pruritus (vulval and/or perianal) is prominent especially at night
  • Foreign body if chronic vaginal discharge, intermittent bleeding, offensive odour. Toilet paper commonest foreign body. Refer to paediatric gynaecologist as required. 
  • Specific Organisms if discharge is profuse/offensive take an introital swab
Group A Streptococcus
  • Treat with penicillin 
S. aureus, H. influenzae, Shingella
  • May resolve with hygienic measures but culture- negative persistent vaginitis may resolve with 10 days of Amoxycillin/Clavulanic Acid 
Candida 
  • Unusual (3%) in > 2 year old prepubertal girls
  • Usually if recent antibiotic therapy, immunocompromised or wearing nappies
Sexually Transmitted Infections 
  • Typically the result of sexual abuse with some exceptions
  • All cases of Neisseria gonorrhoea, Chlamydia trachomatis, HPV, Herpes simplex must be referred to Child Protection Unit for further assessment
Systemic Illness 
  • Measles, Chickenpox, Kawasaki disease, Steven-Johnson syndrome, and Chrohn’s disease may be associated with vulvovaginal symptoms
Lichen Sclerosus 
  • Dermatological abnormality – unclear aetiology
  • Presents with pruritus, discharge and/or bleeding. It usually consists of pale atrophic patches on the labia and perineum. The patches can be confluence and extensive.
    • If asymptomatic – no treatment required
    • If symptomatic (itchy, uncomfortable and bleeding) – avoid irritants/use barrier cream +/- 1% hydrocortisone (BD for 2 weeks) then review by paediatric gynaecologist/dermatologist 

 

Management

The resolution of non-specific mucoid discharge and/or odour within 2-3 weeks should result from the following:

  • Explanation
  • Avoid excess moisture and irritants
  • Daily warm baths (not hot) 
    • Add 1/2 cup of white vinegar to a shallow bath and soak for 10-15 minutes
    • Pat dry
  • Review hygiene with child
    • Emphasize wiping from front to back after bowel motions
    • May use wet wipes instead of toilet paper if sensitive
  • Cool compresses may relieve discomfort
  • Soft paraffin or Nappy-Mate® paste (zinc oxide paste) may help with pain and protect the skin

Nursing

  • Routine nursing care

References

  • Laufer MR and Emans SJ (2014) Vulvovaginal complaints in the prepubertal child. UpToDate. Accessed at www.uptodate.com
  • Joishy M et al. Do we need to treat vulvovaginitis in prepubertal girls? BMJ 2005;330:186.
  • Stricker,T,et al. Vulvovaginitis in prepubertal girls. Arch Dis Child 2003;88:324.

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