Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment

INTRODUCTION — This topic will discuss vulvovaginitis in the prepubertal female. The evaluation and management of sexual abuse in the prepubertal child are discussed separately. (See "Evaluation of sexual abuse in children and adolescents" and "Management and sequelae of sexual abuse in children and adolescents".)

NONSPECIFIC VULVOVAGINITIS

Etiology — Nonspecific vulvovaginitis is responsible for a large proportion of vulvovaginitis in prepubertal females [1]. Even in situations in which a bacterial isolate from the vagina or introitus is identified, the etiology of the discharge may not be related to the organism (eg, respiratory flora or enteric bacteria) but rather still considered "nonspecific." Factors that increase the risk of vulvovaginitis in prepubertal children include:

●Lack of labial development

●Thin mucosa due to lack of estrogen

●More alkaline pH (pH 7) than postmenarchal females

●Poor hygiene

●Bubble baths, shampoos, deodorant soaps, or other irritants

●Obesity

●Choice of clothing (leotards, tights, and blue jeans)

●Chronic masturbation activity

●Foreign bodies, primarily toilet paper

●Sexual abuse (see "Evaluation of sexual abuse in children and adolescents", section on 'Nonspecific findings')

Clinical manifestations and diagnosis — Nonspecific vulvovaginitis typically presents with complaints of nonspecific mucoid discharge, itching, erythema, rash, and/or odor. A prior history of nonspecific vulvovaginitis in association with upper respiratory infections has been described in some patients. The abrupt onset of a green or purulent vaginal discharge suggests a foreign body or a specific bacterial infection.

On physical examination, the vulva may be erythematous from occlusive diapers or other irritants, skin dermatosis such as atopic dermatitis or psoriasis, or streptococcal perianal infection.

The child with a nonspecific etiology for vaginal complaints typically has either no vaginal discharge or scant, white or clear, mucoid discharge. Vulvar irritation and, occasionally, thickening of the clitoral hood secondary to chronic itching/scratching or masturbation may also be present. Signs of poor genital hygiene such as bits of toilet paper and fecal matter around the anus, introitus, and/or vagina may be noted. Diagnosis is made based upon these clinical findings.

Management

Initial treatment — Hygiene measures (table 1) are the primary treatment for nonspecific vulvovaginitis. Symptoms resolve in most children within two to three weeks. In addition, for children with recurrent episodes of vulvar and/or perianal itching (especially at night), examine for pinworms and treat empirically, as needed. Treatment of pinworm is discussed separately. (See "Enterobiasis (pinworm) and trichuriasis (whipworm)".)

Recurrent or persistent symptoms — If, despite appropriate adherence to hygiene measures, the child develops a purulent discharge or bleeding, or symptoms of discharge persist, the possibility of a vaginal foreign body or specific infection should be assessed. Next steps include:

●Re-examination of the genitalia in the knee-chest position (figure 1) to see if a vaginal foreign body is present. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vaginal foreign body'.)

●If no foreign body is seen, then appropriate testing for bacterial pathogens should be obtained, which includes a vaginal culture for enteric and respiratory organisms and, in prepubertal females with appropriate indications, testing for sexually transmitted infections (STIs). (See "Gynecologic examination of the newborn and child", section on 'How to obtain cultures and other specimens from children' and "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims'.)

Vaginal pH and microscopy are not useful for evaluating vaginitis in prepubertal females. (See "Gynecologic examination of the newborn and child", section on 'Other tests'.)

Further treatment is determined by test results:

•Positive results – The approach to treatment of infectious vulvovaginitis by potential pathogen is provided below. (See 'Infectious causes' below.)

•Negative results or mixed flora on vaginal culture – Although not indicated for most cases of nonspecific vaginal discharge, which resolves with the measures above, antibiotic therapy may hasten the resolution of a purulent vaginal discharge (despite a negative culture for specific infections, such as group A streptococcus) that does not respond to hygiene measures and for which other diagnoses have been excluded. Empiric regimens include a 10-day course of oral amoxicillin or amoxicillin-clavulanate, topical metronidazole, or topical clindamycin.

Chronic discharge — Prepubertal females with chronic discharge and no clear etiology despite appropriate testing and empiric treatment warrant referral to a pediatric gynecologist or other pediatric specialist with similar expertise for further evaluation. Chronic discharge with or without bleeding may be caused by a vaginal foreign body not visible on physical examination as well as benign or malignant vaginal tumors. (See "Overview of vulvovaginal conditions in the prepubertal child".)

INFECTIOUS CAUSES

Etiology — Children may pass respiratory flora from the nose and oral pharynx to the vulvar area. Similarly, enteric flora from the anal area can be identified in vaginal cultures from females with vaginitis as well as in asymptomatic controls. Thus, the challenge for clinicians is to determine whether the bacteria found on cultures represent pathogens causing infection or are part of the vaginal flora in a young female presenting with symptoms.

Respiratory and enteric bacteria cultured in prepubertal females with vulvovaginitis include [2-5]:

●Respiratory bacteria

•Streptococcus pyogenes (group A streptococcus)

•Staphylococcus aureus

•Haemophilus influenzae

•Streptococcus pneumoniae

•Neisseria meningitidis

•Moraxella catarrhalis

●Enteric bacteria

•Escherichia coli

•Enterococcus faecalis

•Klebsiella pneumoniae

•Proteus mirabilis

•Pseudomonas species

•Shigella species

•Yersinia species

Less commonly, vulvovaginitis results from sexual contact. Positive testing for sexually transmitted infections (STIs) raises concern for sexual abuse, and additional evaluation is necessary. (See "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims' and "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

Although sometimes isolated, Candida species and Gardnerella vaginalis are not usually associated with vulvovaginitis in prepubertal females. (See 'Candida' below and 'Gardnerella vaginalis' below.)

Clinical manifestations and diagnosis — Infectious bacterial vulvovaginitis causes vulvar irritation, erythema, pain, and (in some patients) purulent yellow or green vaginal discharge that may be foul smelling. The diagnosis of infectious vulvovaginitis is made by a combination of physical findings and microbiologic testing. Vaginal cultures for respiratory and enteric flora should be obtained at the initial visit if S. pyogenes infection is suspected (see clinical features described below) or if purulent vaginal discharge is present. Cultures are also necessary in prepubertal females with persistent vulvovaginitis despite the institution of hygiene measures. (See 'Recurrent or persistent symptoms' above.)

Specific findings associated with group A streptoccocal, Shigella species, and Enterobiasis (pinworm) infections include:

●Group A streptococcal vaginitis – Prepubertal females with S. pyogenes vulvovaginitis is characterized by purulent vaginal discharge that is blood-tinged in about half of the cases [6]. Additional symptoms include pruritus, dysuria, or pain. A clinical hallmark of group A streptococcal perineal infection is a fiery or beefy red appearance of the perineal skin, often with a sharp margin (picture 1) [7]. Most patients with perineal streptococcal infection do not have symptomatic pharyngitis, but throat cultures are positive in about 75 percent of cases [6].

S. pyogenes is the most common bacterial pathogen in prepubertal females with infectious vulvovaginitis [2,5]. The generally accepted cause of streptococcal vulvovaginitis is autoinoculation from a streptococcal infection at another site, usually the throat [8-10]. Depending upon the definition of vulvovaginitis (vulvitis versus vaginitis only), the prior use of antibiotics, the type of culture obtained (vaginal versus introital), and the clinical setting, approximately 20 percent of females with vulvovaginitis have S. pyogenes [11-15]. Vulvovaginitis may also complicate scarlet fever. (See "Complications of streptococcal tonsillopharyngitis", section on 'Scarlet fever'.)

●Shigella vaginitis – Shigella infection produces mucopurulent and sometimes bloody vaginal discharge and often produces concomitant vulvitis [16,17]. Only about one-fourth of patients have a history of recent or concurrent diarrhea [17]. Nearly all reported cases of this uncommon infection have been caused by Shigella flexneri. Culture of vaginal secretions is necessary to establish the diagnosis; if performed, molecular testing should be confirmed by culture. Stool cultures are generally negative [16,18]. (See "Shigella infection: Epidemiology, clinical manifestations, and diagnosis", section on 'Other manifestations'.)

●Enterobiasis (pinworms) – Vulvovaginitis caused by pinworm infection presents with a history of vulvovaginal and anal itching that is worse at night and may be recurrent. Diagnosis can be established by visual inspection of the anal verge or undergarments for mobile worms or microscopic examination of specimens obtained by the paddle test (described separately) or from under the fingernails. (See "Enterobiasis (pinworm) and trichuriasis (whipworm)", section on 'Diagnosis'.)

Management

Pinworms — Pinworms can cause vulvar symptoms such as itching. Children with recurrent episodes of vulvar and/or perianal itching, especially at night, should be examined for pinworms and treated empirically, if indicated. (See "Enterobiasis (pinworm) and trichuriasis (whipworm)".)

Respiratory and enteric flora

Group A streptococcal infection — Treatment is warranted for all children with vulvovaginitis who have S. pyogenes isolated in culture (either alone or with other organisms). The initial regimen is the same as for streptococcal pharyngitis (ie, oral penicillin or amoxicillin for 10 days; alternative agents for patients with penicillin as shown in the table (table 2)). A longer course (14 to 21 days) is appropriate for patients with persistent or recurrent infection [19,20]. Treatment of streptococcal pharyngitis is discussed in greater detail separately. (See "Treatment and prevention of streptococcal pharyngitis in adults and children".)

Other respiratory flora — S. aureus, H. influenzae, and other respiratory flora often resolve with hygiene measures alone as described above but should be treated if vulvovaginitis is persistent or purulent:

•S. aureus – Oral antibiotic therapy is prescribed for persistent vaginal discharge using methicillin sensitivity as a guide (eg, cephalexin for methicillin-sensitive S. aureus; oral trimethoprim-sulfamethoxazole for methicillin-resistant S. aureus). If the child also has scattered impetiginous lesions on the vulva and buttocks without vaginitis, topical mupirocin is effective. (See "Skin and soft tissue infections in children >28 days: Evaluation and management", section on 'Impetigo or folliculitis'.)

•H. influenzae – Oral beta lactam therapy such as amoxicillin-clavulanate. Alternatives include an oral second- or third-generation cephalosporins and, for patients with penicillin and cephalosporin allergy, macrolides or doxycycline. (See "Epidemiology, clinical manifestations, diagnosis, and treatment of Haemophilus influenzae", section on 'Treatment'.)

While S. pyogenes should be treated with oral antibiotics, nonspecific vaginitis associated with other respiratory organisms often responds to improved hygiene. Similarly, group B streptococcus may be found as a single organism from the vaginal culture, and symptoms may resolve with hygiene and/or antibiotics.

Enteric bacteria — Treatment of vulvovaginitis associated with vaginal cultures positive for enteric bacteria depends upon the isolate:

●Shigella species – Positive vaginal cultures for Shigella warrant treatment guided by bacterial sensitivities as discussed separately. (See "Shigella infection: Treatment and prevention in children", section on 'Oral therapy'.)

●Yersinia species – Although antimicrobial therapy is not necessary for most patients with enterocolitis caused by Yersinia species, our experience suggests that patients with vulvovaginitis and Yersinia infection will typically not respond to hygiene measures alone and require treatment with oral antibiotics as described separately. (See "Yersiniosis: Infection due to Yersinia enterocolitica and Yersinia pseudotuberculosis".)

●Other isolates – Children with vulvovaginitis and enteric bacteria such as E. coli, E. faecalis, K. pneumoniae, Pseudomonas, and P. mirabilis on vaginal culture will usually improve with hygiene measures alone [2-4].

Mixed flora — A vaginal culture demonstrating mixed flora and no S. pyogenes does not warrant antibiotic therapy. Vulvovaginal hygiene measures are typically sufficient unless vulvovaginitis is persistent or recurrent (table 1). (See 'Recurrent or persistent symptoms' above.)

Sexually transmitted infections — STIs in children may result from sexual abuse. Pathogens include Neisseria gonorrhoeae, Chlamydia trachomatis, human papillomavirus (HPV), Treponema pallidum, and herpes simplex virus (HSV). The implications of identification of a sexually transmissible pathogen in a prepubertal child are discussed separately. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing'.)

Neisseria gonorrhoeae — N. gonorrhoeae usually presents with a green or mucoid vaginal discharge; the infection is rarely asymptomatic [21] but occasionally may be found without symptoms in females being evaluated for sexual abuse.

The diagnosis is made by culture and/or nonculture methods such as nucleic acid amplification testing (NAAT) in patients with an evident vaginal discharge. In settings where NAAT is accepted as forensic evidence, it may be the preferred testing method. NAAT of urine makes collection of specimens easier as well. (See "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims' and "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

Chlamydia trachomatis — C. trachomatis is primarily transmitted to newborns via exposure to an infected mother's genital flora during vaginal birth and may persist for months to several years unless treated with antibiotics (often for another reason). Newborns are less likely to acquire chlamydia at birth than in the past because of the increased screening and treatment of pregnant patients. C. trachomatis is also associated with vaginitis and sexual abuse, although patients may be asymptomatic. (See "Chlamydia trachomatis infections in the newborn", section on 'Epidemiology and transmission' and "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

Trichomonas vaginalis — Trichomonas vaginalis can occur in newborns from maternal transmission but is suspicious for sexual abuse in the prepubertal child. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections' and "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)

Condylomata acuminata — Condylomata acuminata are skin-colored or pink lesions that may be warty or smooth, flattened papules (picture 2 and picture 3). They are caused by HPV. In children younger than two to three years of age, these lesions are likely the result of maternal-child transmission during vaginal birth but may be acquired by sexual or nonsexual transmission. It is not necessary for the mother to be symptomatic or to have a history of HPV for this transmission to occur. HPV testing of mothers does not exclude sexual abuse and therefore is not generally performed. If sexual abuse is of concern, evaluation is needed. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

In older children, sexual transmission and evaluation for potential sexual abuse should be considered, and if there is a concern, children should be interviewed and evaluated by appropriately experienced professionals. Auto- and hetero-inoculation and indirect transmission via fomites are other possibilities. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

The diagnosis is usually made clinically and treated without a biopsy. A biopsy can, however, confirm the presence of HPV and leads to a conclusive diagnosis. HPV DNA typing may help the health care provider formulate a follow-up surveillance plan. There are over 100 distinct HPV subtypes; approximately 40 types are specific for the anogenital epithelium and have varying potentials to cause malignant change, such as cervical or anal cancer. (See "Virology of human papillomavirus infections and the link to cancer".)

Spontaneous resolution occurs within five years in more than 50 percent of patients [22]. Expectant management is a potential initial approach to asymptomatic pediatric condylomata; however, many families choose to have them treated. Treatment options have not been well studied and include (see "Condylomata acuminata (anogenital warts) in children"):

●Laser therapy (requires anesthesia)

●Trichloroacetic acetic (not well tolerated in this age group)

●Topical imiquimod cream (needs careful monitoring to assure vulvar reactions are not severe)

Candida — Colonization with Candida occurs in 3 to 4 percent of prepubertal females [3]. Candida infection is uncommon in healthy, toilet-trained prepubertal females, in whom it is frequently over-diagnosed and wrongly assumed to be the etiology of pruritus and the patient's symptoms. Clinicians should avoid antifungal treatment in these patients.

On the other hand, Candida infection in children who have had recent antibiotic therapy, are immunosuppressed, or who wear diapers does warrant treatment as described separately. In these special circumstances, empiric therapy is appropriate. (See "Candida vulvovaginitis: Clinical manifestations and diagnosis" and "Diaper dermatitis", section on 'Secondary infection' and "Diaper dermatitis".)

Gardnerella vaginalis — G. vaginalis is generally not associated with a vaginal discharge in prepubertal females. A possible relationship with sexual abuse has been disputed. In one study, Gardnerella was identified in 14.6 percent of sexually abused females compared with only 4.2 percent of control females [23]. In another report, however, the incidence of Gardnerella was equivalent in sexually abused females and the female children of friends of the author (controls) [24]. If Gardnerella is identified, then a careful history of sexual abuse should be obtained as with any child complaining of vulvovaginal issues. Symptoms may include discharge, odor, itching, and/or rash. Culture is helpful to make a definitive diagnosis, and treatment should then be initiated based on the culture and sensitivity results.

Systemic infections — The following systemic infections may have prominent vulvovaginal manifestations:

●Measles – The measles exanthem may involve the vulva and cause local pain and inflammation. (See "Measles: Clinical manifestations, diagnosis, treatment, and prevention".)

●Varicella (chickenpox) – Vulvar vesicular lesions directly cause itching and discomfort and can be a locus for secondarily infection, including group A streptococcal toxic shock syndrome. (See "Clinical features of varicella-zoster virus infection: Chickenpox".)

●Epstein-Barr virus (infectious mononucleosis) – Epstein-Barr virus infection has been associated with acute genital ulceration (Lipschütz ulcer) (picture 4 and picture 5). (See "Acute genital ulceration (Lipschütz ulcer)".)

●Mycoplasma pneumoniae-induced rash and mucositis (MIRM) – Painful lesions, primarily vesiculobullous, commonly affect the vulva and vagina in females with MIRM and may interfere with normal voiding. (See "Reactive infectious mucocutaneous eruption (RIME)", section on 'Clinical manifestations' and "Reactive infectious mucocutaneous eruption (RIME)", section on 'Urogenital lesions'.)

SUMMARY AND RECOMMENDATIONS

●Nonspecific vulvovaginitis – Prepubertal females with nonspecific vulvovaginitis typically present with itching, local irritation, and/or odor. Physical examination reveals vulvar irritation with no vaginal discharge, or scant, white or clear, mucoid discharge. Diagnosis is made based on these clinical findings. (See 'Clinical manifestations and diagnosis' above.)

The approach to treatment is as follows:

•Initial treatment – Start hygiene measures (table 1); symptoms typically resolve within two to three weeks. (See 'Initial treatment' above.)

In addition, for children with recurrent episodes of vulvar and/or perianal itching, especially at night, examine for pinworms and treat empirically, as needed. Treatment of pinworm is discussed separately. (See "Enterobiasis (pinworm) and trichuriasis (whipworm)".)

•Persistent or worsening signs or symptoms – Patients with persistent or worsening signs or symptoms (eg progression to purulent discharge and/or bleeding) require repeat visual inspection of the genitalia in the knee-chest position (figure 1) to assess for a vaginal foreign body (see "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vaginal foreign body'). If no foreign body is seen, then vaginal culture and testing for sexually transmitted infections (STIs) is indicated. Further treatment is determined by test results:

-Positive culture or testing – Treatment should be provided based upon the specific pathogen as described below.

-Negative culture and testing – For patients with a purulent vaginal discharge, negative vaginal culture (or mixed flora without S. pyogenes), and negative STI testing, we suggest empiric antimicrobial treatment (oral amoxicillin or amoxicillin-clavulanate for 10 days or topical metronidazole or clindamycin) (Grade 2C). (See 'Recurrent or persistent symptoms' above.)

•Chronic discharge – Prepubertal females with chronic discharge and no clear etiology despite appropriate testing and empiric treatment warrant referral to a pediatric gynecologist or other pediatric specialist with similar expertise to assess for a retained vaginal foreign body and vaginal tumors. (See "Overview of vulvovaginal conditions in the prepubertal child".)

●Infectious vulvovaginitis – Infectious bacterial vulvovaginitis often causes purulent yellow or green vaginal discharge that may be foul smelling. Prepubertal females with S. pyogenes vulvovaginitis often have a reddened and painful vulva that may be accompanied by serosanguinous vaginal discharge. (See 'Clinical manifestations and diagnosis' above.)

All patients with infectious vulvovaginitis should start hygiene measures (table 1). Results of vaginal culture for respiratory and enteric organisms and STI testing guide decisions about antimicrobial therapy:

•S. pyogenes (including when isolated with other organisms) – Treatment is warranted as for streptococcal pharyngitis and consists of oral penicillin or amoxicillin (alternative agents if penicillin allergy (table 2)). Patients with persistent or recurrent infection warrant repeat treatment for 14 to 21 days. (See 'Group A streptococcal infection' above.)

•Other respiratory flora – For patients with vulvovaginitis that is associated with purulent discharge or is persistent despite ensured hygiene, we suggest antibiotic therapy (Grade 2C). The choice of agent is based upon the susceptibility pattern of the isolated organism.

•Enteric bacteria – For females with symptomatic vulvovaginitis, purulent discharge, and Shigella or Yersinia species isolated from culture, we suggest antibiotic treatment (Grade 2C). The choice of agent is based upon the susceptibility pattern of the isolated organism. For other enteric bacteria, hygiene measures alone are usually sufficient. (See 'Enteric bacteria' above.)

•Mixed flora and no S. pyogenes – Antimicrobial therapy is not indicated if vaginal foreign body has been definitively ruled out and findings resolve with hygiene measures. Persistent or worsening vulvovaginitis warrants antimicrobial treatment as previously described.

•STIs – If an STI is identified, appropriate treatment should be provided, and further evaluation and management in consultation with a child abuse specialist and multidisciplinary child protection team is required. Suspected sexual abuse should be reported to Child Protective Services (CPS). (See "Evaluation of sexual abuse in children and adolescents" and "Management and sequelae of sexual abuse in children and adolescents".)

•Candida – Candida infection is an uncommon cause of vaginal discharge or vulvar pruritus in healthy, toilet-trained, prepubertal females. Antifungal treatment should be avoided unless the patient has had recent antibiotic therapy, is immunosuppressed, or wears diapers. Treatment of Candida vulvovaginitis is described separately. (See "Candida vulvovaginitis in adults: Treatment of acute infection" and "Diaper dermatitis".)

•Systemic infections – Vulvovaginal inflammation and mucosal lesions may occur in prepubertal females with systemic infections such as measles, varicella, Epstein-Barr virus, and M. pneumoniae. (See 'Systemic infections' above.)