Overview of vulvovaginal conditions in the prepubertal child

INTRODUCTION — Vulvovaginal complaints in prepubertal children may be the result of infection, congenital abnormalities, trauma, or dermatologic conditions. This topic will discuss common vulvovaginal disorders in this population. The gynecological history and physical examination and techniques for obtaining cultures in these children are reviewed separately. (See "Gynecologic examination of the newborn and child".)

VULVOVAGINITIS — Vulvovaginitis is the most common gynecological problem in prepubertal females [1]. Symptoms include vaginal discharge, erythema, soreness, pruritus, dysuria, and bleeding. Occasionally, urinary tract or bowel symptoms may be interpreted by a child or parent as vulvar or vaginal complaints. The diagnosis and treatment of vulvovaginitis in the prepubertal female is discussed in greater detail separately. (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment".)

VAGINAL FOREIGN BODY — Foreign bodies in children can cause acute and chronic recurrent vulvovaginitis and may be associated with bleeding. Toilet paper is the most common foreign body found in the vaginas of children; small toys, hair bands, and paper clips are also frequently found.

●Clinical manifestations – Medical history of foreign body placement is usually lacking. Chronic vaginal discharge, intermittent bleeding or spotting, and/or a foul-smelling odor are the usual clinical manifestations. If the patient has pain and a gray, watery discharge, an intravaginal battery should be suspected [2-4].

●Diagnosis – Visualization of the foreign body during examination (child in the knee-chest position (figure 1)) confirms the diagnosis. A vaginoscopy can be performed in the office if tolerated; otherwise, an examination under anesthesia may be necessary. On plain radiographs, vaginal button batteries appear as a radio-opaque, circular object located in the pelvis [5].

●Management – Management depends upon the type and size of the vaginal foreign body:

•Button batteries – Although rare, button batteries in the vagina can be associated with serious complications including deep vaginal burns or vaginal perforation [2-5]. Thus, emergency removal under general anesthesia is warranted. After removal, the vaginal mucosa should be carefully inspected by vaginoscopy to determine the depth of the burn. Depending upon the depth of the burn, assessment of the bladder or rectal mucosa may also be indicated.

•Toilet paper and small foreign bodies – Treatment of the introitus with a small amount of 2% xylocaine jelly often permits cooperation and removal of toilet paper and other small foreign bodies using a calcium alginate swab. Alternatively, once the clinician is sure that a button battery is not present, the patient may undergo vaginal irrigation with warmed fluid.

•Large foreign bodies – Large, lodged foreign bodies and those that cannot be removed using a swab or irrigation require removal under deep sedation or general anesthesia.

VULVAR TRAUMA — Vulvar trauma can cause significant bleeding because the area is highly vascular and children do not have mature labia with fat pads, which protect the vulvar area of adults. Females who sustain straddle or inline skating injuries may require surgical intervention [6]. (See "Straddle injuries in children: Evaluation and management".)

A careful history should be obtained and physical examination performed. The history must correlate with the physical findings to confirm nonsexual trauma. If a child has a straddle injury, she will most likely have an injury to the anterior area of the vulva, including the mons, clitoral hood, and anterior aspect of the labia (picture 1A-E).

An injury to the posterior fourchette and hymenal area suggest possible sexual abuse. As an example, a laceration to the lower half of the hymenal area (using a clock, the location would be three o'clock to nine o'clock) is consistent with a penetrating injury, and the etiology must be further explored (picture 2A-B) [7]. Normal hymenal variants must be understood to be able to identify abnormal hymenal findings due to trauma [8-10]. (See "Gynecologic examination of the newborn and child", section on 'Evaluation of the hymen'.)

Assessment of ability to urinate is essential as a large, obstructive hematoma can result from blunt trauma to the vulva. Ice to the area, bladder drainage, and pain medications are appropriate support measures for a female with a large hematoma. Most vulvar hematomas will resolve spontaneously. Surgical drainage is not usually needed because the hematoma is usually the result of a compromise to small vessels that are difficult to identify if the hematoma is opened. In addition, surgical disruption of the skin facilitates introduction of bacteria, and an abscess can result. (See "Evaluation and management of female lower genital tract trauma".)

VULVAR ULCERS — Important causes of vulvar ulcers include:

●Herpes simplex virus (HSV) – Genital herpes virus infections appear as grouped, umbilicated 2- to 4-mm vesicles with underlying erythema that can progress to vesicopustules, erosions, and ulcerations. The diagnosis is made by culture or polymerase chain reaction (PCR) assay of suspicious lesions; all specimens should be typed (HSV1 versus HSV2). Although HSV 1 can be spread by self-inoculation, a diagnosis of HSV warrants further evaluation for sexual abuse. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infections'.)

●Acute genital ulceration (Lipschütz ulcer) – Non-sexually transmitted vulvar ulcers (sometimes called Lipschütz ulcers, "virginal ulcers," or "aphthous ulcers") typically occur in non-sexually active adolescent or young adult females who report the sudden onset of one or multiple intensely painful vulvar ulcerations. Ulcers are usually large (>1 cm) and deep, with a red-violaceous border and a necrotic base covered with a grayish exudate or an adherent gray-black eschar (picture 3). A partially symmetrical appearance ("kissing lesions") is characteristic (picture 4). Most patients also report prodromal influenza-like or mononucleosis-like symptoms, including fever, malaise, and/or sore throat. Some patients also have a history of oral aphthosis and/or have concomitant oral lesions at the time of presentation. (See "Acute genital ulceration (Lipschütz ulcer)", section on 'Clinical manifestations'.)

Acute genital ulceration is a clinical diagnosis that requires exclusion of other causes of genital ulceration. The diagnosis and treatment of Lipschütz ulcers are discussed in detail separately. (See "Acute genital ulceration (Lipschütz ulcer)", section on 'Diagnosis' and "Acute genital ulceration (Lipschütz ulcer)", section on 'Treatment'.)

●Syphilis – A genital chancre is the initial clinical manifestation of primary syphilis. The lesion begins as a papule, which is typically (but not always) painless, appearing at the site of inoculation. This soon ulcerates to produce the classic chancre of primary syphilis, a 1- to 2-centimeter ulcer with a raised, indurated margin (picture 5). The ulcer generally has a nonexudative base and is associated with mild to moderate regional lymphadenopathy that is often bilateral. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV".)

●Crohn disease – Although initial manifestations typically consist of abdominal pain, weight loss, and diarrhea with or without blood, persistent vulvar ulcers can occur in females with Crohn disease and occasionally may be a presenting feature. (See "Clinical manifestations and complications of inflammatory bowel disease in children and adolescents".)

●Behçet syndrome – Recurrent vulvar ulcers, especially if associated with evidence of systemic involvement and vasculitis (oral lesions, uveitis, arthritis) should suggest the possibility of Behçet syndrome. (See "Clinical manifestations and diagnosis of Behçet syndrome", section on 'Clinical manifestations'.)

VULVAR SKIN CONDITIONS

Condylomata acuminata — Condylomata acuminata are skin-colored or pink lesions that may be warty or smooth, flattened papules (picture 6 and picture 7). 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 [11]. 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)

Lichen sclerosus — Lichen sclerosus is a dermatologic abnormality of unclear etiology. Clinical manifestations in females include itching, discomfort in the vulvar area, bowel or bladder symptoms, discharge, or bleeding. The vulvar tissue displays a white, onion skin-like lesion, typically in an hourglass configuration with the whitened skin circumscribing the vulvar and perianal areas (picture 8 and picture 9). There may also be punctate hemorrhages, which can occur anywhere on the affected skin. (See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis".)

The diagnosis in children is made by visual inspection; a biopsy is rarely required, in contrast to the adult population. Lichen sclerosus can be associated with underlying malignancies in adults, but this does not appear to be true for children. (See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

The treatment of vulvar lichen sclerosis in children is discussed separately. (See "Vulvar lichen sclerosus: Management", section on 'Pharmacologic therapy for children'.)

Patient information is provided. (See 'Information for patients' below.)

Hemangiomas — Hemangiomas occur on the vulva, as on other body surfaces. Most hemangiomas will involute between two and five years of age and require no further intervention. Once involuted, the remaining skin and fatty tissue can be evaluated to determine whether the lesion is of significant size to necessitate a surgical resection.

Hemangiomas of the vulvar and clitoral region rarely bleed. A complete evaluation, including vascular magnetic resonance imaging (MRI), can be helpful for determining the extent of internal involvement of a larger hemangioma. Co-management with a vascular surgeon is recommended for hemangiomas that require surgical intervention.

The clinical features, evaluation, and management of hemangiomas are discussed in detail separately. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications" and "Infantile hemangiomas: Evaluation and diagnosis" and "Infantile hemangiomas: Management".)

Other — Prepubertal hypoestrogenic tissues are atrophic and more susceptible to infection and irritation. Thus, the majority of vulvar symptoms in children are due to local irritants, foreign bodies, or infection [12]. Common causes of vulvovaginitis in the prepubertal female are discussed in greater detail separately (see "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment"). In addition, a number of dermatologic conditions also have vulvar rashes and irritation including:

●Seborrhea (see "Cradle cap and seborrheic dermatitis in infants")

●Psoriasis (see "Psoriasis: Epidemiology, clinical manifestations, and diagnosis")

●Atopic dermatitis (see "Overview of dermatitis (eczematous dermatoses)")

●Bullous diseases (see "Vesicular, pustular, and bullous lesions in the newborn and infant", section on 'Congenital/inherited disorders')

●Zinc deficiency (picture 10) (see "Zinc deficiency and supplementation in children")

●Nickel allergy (see "Common allergens in allergic contact dermatitis", section on 'Metals')

SYSTEMIC ILLNESS — Systemic illnesses with the potential for serious complications involving the vagina include:

●Stevens-Johnson syndrome – Severe cases of Stevens-Johnson syndrome may result in vaginal stenosis or obstruction. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae", section on 'Long-term sequelae' and "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Mucosal involvement'.)

●Crohn disease – Highly destructive perianal disease in prepubertal females with Crohn disease can produce fistulas with fecal vaginal discharge. (See "Clinical manifestations and complications of inflammatory bowel disease in children and adolescents".)

VAGINAL AND VULVAR TUMORS — Persistent complaints of vaginal discharge and/or bleeding in prepubertal females that are otherwise unexplained by genital examination and noninvasive imaging (such as a pelvic ultrasound) may be a manifestation of a genitourinary tumor (eg, rhabdomyosarcoma, endodermal sinus tumor, or benign vaginal papilloma) [13]. Referral to a pediatric gynecologist or urologist for further evaluation is warranted for such patients.

Vaginal and vulvar tumors in prepubertal children are rare and include [14]:

●Vaginal polyp – Benign polyps may involve the vagina and hymenal area. Vaginal polyps are rare. They appear as a fleshy mass on a slender stalk. Hymenal "skin tags" can be confused with a polyp and are also benign.

A skin tag of the hymen can usually remain in place. However, removal may be warranted if it is changing in size or causing an issue (pain from pulling of the skin tag with wiping or later insertion of a tampon). Otherwise, treatment is surgical; the specific procedure depends upon the pathology of the tissue that is removed:

•A simple polyp can be removed with surgical excision.

•A vaginal sarcoma requires biopsy for diagnosis and then chemotherapy and conservative surgery with the aim to treat the tumor while maintaining future sexual and reproductive function. (See "Vaginal cancer", section on 'Treatment'.)

●Sarcoma botryoides – Sarcoma botryoides is a type of rhabdomyosarcoma that can involve the hymen, lower urethra, or anterior vaginal wall (picture 11). The peak incidence is at age two to five years. These tumors are more likely to arise higher up along the anterior vaginal wall towards the cervix in older preadolescent females. (See "Rhabdomyosarcoma in childhood and adolescence: Epidemiology, pathology, and molecular pathogenesis" and "Vaginal cancer", section on 'Sarcoma'.)

●Neurofibromas – Neurofibromas usually begin to appear just before or during adolescence, although small lesions can be seen in younger children, especially if the skin is viewed with side lighting. They tend to increase in size and number with age and vary in number from just a few to thousands, with the highest density occurring over the trunk. Cutaneous neurofibromas are benign and do not carry a risk of malignant transformation. (See "Neurofibromatosis type 1 (NF1): Pathogenesis, clinical features, and diagnosis", section on 'Cutaneous neurofibromas'.)

●Leiomyomas or leiomyosarcomas – Rarely, these smooth muscle tumors may present as a vulvar mass. Diagnosis requires noninvasive imaging and tissue biopsy. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Most common subtypes'.)

●Granular cell tumors – Granular cell tumors in prepubertal females appear as firm, usually painless, enlarging masses involving the labia [15]. Because these can be malignant, they require referral for surgical excision and pathologic evaluation. However, even benign tumors may recur. Thus, all patients warrant follow-up, regardless of tumor pathology.

●Nodular fasciitis – Nodular fasciitis is a benign tumor that can present as a labial mass in prepubertal females and adults [16]. Surgical resection and pathologic evaluation are necessary to differentiate these tumors from malignant tumors of the vulva. Recurrence is unlikely but has been described.

URINARY TRACT ABNORMALITY

Ectopic ureter — An ectopic ureter can cause chronic vulvar irritation and wetness. The ectopic ureter arises from the upper pole of a duplex collecting system, or from a dysplastic kidney. The diagnosis is made by imaging studies that identify the ectopic ureter. Management consists of surgical reconstruction. (See "Ectopic ureter".)

Urethral prolapse — Urethral prolapse most commonly occurs in prepubertal females 2 to 10 years of age and presents with a dusky red or purplish annular mass at the urethral location on physical examination [17-19]. The distal end of the urethra can prolapse either partially (anterior or posterior) or in a complete circumferential ("donut-like") (picture 12) fashion. The tissue may be friable and become infected but rarely becomes necrotic. Children with urethral prolapse present with bleeding, dysuria, and/or difficulty with urination.

It is important to make sure of the diagnosis because a sarcoma botryoides (picture 11) originating in the distal urethra or a prolapsed ureterocele can both be easily mistaken for urethral prolapse. A pediatric urology consultation may be needed for confirmation of the diagnosis.

Prepubertal females with symptomatic urethral prolapse can be treated with topical estrogen therapy (eg, Premarin cream or Estrace cream 0.01%). Sitz baths twice daily may also be helpful. Topical estrogen cream is applied twice daily after the sitz bath for two weeks, then the urethra is reassessed and treatment is continued if the prolapse has not resolved and is still present. The prolapse will usually resolve within a few weeks of topical estrogen treatment but can sometimes take longer.

Urethral prolapse with the following features warrants referral to a pediatric urologist [20,21]:

●A necrotic distal urethra, which may require excision under general anesthesia.

●Persistence of the prolapse, which may require assessment for a urethral polyp and reduction under general anesthesia.

LABIAL ADHESIONS — Labial adhesions (also called labial agglutination and synechia vulvae) are most frequently seen in infants and young children with a peak incidence of up to 3 percent of females in the second year of life [22]. Inflammation of the labia minora combined with low estrogen in prepubertal females provides one possible explanation for adhesions, especially in the setting of poor perineal hygiene, trauma (eg, straddle injury, female genital mutilation, or sexual abuse), vaginal infection (eg, Candida, group A Streptococcus, Neisseria gonorrhoeae, Mycoplasma pneumoniae mucositis, or herpes simplex virus [HSV]), or lichen sclerosis.

Clinical manifestations — Labial adhesions are diagnosed on a routine genital examination [22]. They can be partial, involving only the upper or lower labia, or complete (picture 13). In patients with complete adhesions, a small pinhole orifice is present that functions as a means for urine to exit from behind the fused labia. Labial adhesions may be asymptomatic or cause a pulling sensation, difficulty with urination, urinary dribbling, vaginal pain or discharge, recurrent urinary tract infections, or recurrent vaginal infections.

Management — The management of labial adhesions is determined by the presence and degree of symptoms (algorithm 1) [22]:

Asymptomatic — No treatment is necessary if the adhesions are asymptomatic, involve only a small portion of the labia, and are not affecting the urine stream. The adhesions typically resolve when estrogen production increases at puberty.

Symptomatic — Labial adhesions warrant treatment in patients with any one of the following [22]:

●Extensive labial fusion

●Diversion of the urinary stream

●Collection of "clean void" urine culture is not possible in patients with recurrent febrile illnesses without an obvious source

●Recurrent urinary or vaginal infections

●Vaginal pain or discharge

An approach to treatment is provided in the algorithm (algorithm 1):

●Topical therapy – Initial treatment of symptomatic labial adhesions consists of application of topical medications (eg, estrogen, estradiol cream, or betamethasone cream), not manual separation. The choice of topical therapy requires shared decision-making with caregivers regarding potential side effects related to systemic absorption. These include local irritation, vulvar hyperpigmentation, breast bud formation, and minimal vaginal bleeding with hormonal creams and, if applied excessively or for longer than three months, skin atrophy and systemic corticosteroid absorption with betamethasone cream.

•Topical estrogen or estradiol – The most common treatment consists of topical estrogen or estradiol cream 0.01% applied twice daily using a fingertip or, rarely, a cotton swab at the point of midline fusion where there is a thin, white line [23]. With the application of the estrogen cream, great care should be taken so as not to traumatically tear the adhesion.

Therapy is continued with re-evaluation to assess response until the labial adhesions resolve. The most common reason for medical failure is placement of the cream in the wrong location or placement of too small an amount of cream.

Local hormonal effects may be managed by ensuring proper application and limiting the duration of estrogen or estradiol treatment [22]. Application of the estrogen cream to the vulva should be discontinued once the labial adhesion has completely resolved to avoid further systemic absorption. Breast bud formation and vaginal bleeding resolve after the cessation of the topical estrogen cream. This complication is less likely if the cream is applied sparingly and limited to the adhesion alone.

The response of labial adhesions to topical estrogen therapy was illustrated in a retrospective review of 109 young females (three months to 10 years of age) [24]. Topical estrogen therapy was successful in 79 percent of patients after a mean duration of four months. Minimal breast development occurred in six females (5 percent), and scant vaginal bleeding in one (<1 percent). In our experience, labial adhesions resolve in nearly all females treated with correct technique for two to six weeks. Successful separation should be followed by attention to vaginal hygiene, daily baths, and the application of a bland ointment, such as white petroleum jelly, for 6 to 12 months.

In a blinded, randomized trial of 38 females with labial adhesions, topical hormones were more effective in reducing severity of adhesions compared with topical emollients, although estrogen had lower efficacy for resolution than previously reported [25].

•Topical betamethasone – Topical betamethasone 0.05% is another effective topical therapy for labial adhesions [22]. Several studies have reported efficacy of 68 to 89 percent with the use of betamethasone 0.05% cream twice daily for four to six weeks [26-28]. In one series, in which most patients had failed topical hormonal therapy, 13 of 19 had complete resolution of adhesions after one course of treatment [26]. In another study, in which 19 females received treatment with betamethasone, 15 (79 percent) had resolution, which was reported to occur more rapidly than with estrogen cream (1.3 versus 2.2 months) [29].

Although we continue to primarily use estrogen creams in our practice, betamethasone topical therapy appears to have similar efficacy and is an option as primary, secondary, or adjunctive therapy. If betamethasone is used, care must be taken to avoid prolonged use (greater than three months) that can cause skin atrophy and systemic corticosteroid effects. Topical betamethasone is a reasonable choice for patients who fail initial estrogen treatment.

If adhesions are not improved after four to eight weeks of properly administered initial topical therapy, then the alternative cream should be applied for an additional two to four weeks. If there is still no improvement, then the patient should be referred to a specialist with pediatric gynecologic expertise.

●Physical separation – Bedside or surgical separation of adhesions is rarely indicated and reserved for patients who have severe obstruction to urinary flow with retention or recurrent infections or failure of topical therapy. Failure of topical therapy tends to occur with thick adhesions (3 to 4 mm in width) with no thin, translucent raphe [22,30,31].

•Nonsurgical separation – Nonsurgical separation should only be performed by physicians experienced with the technique. Local analgesia and, depending upon the degree of adhesion and level of patient concern, sedation should accompany the procedure. (See "Procedural sedation in children: Selection of medications", section on 'Minimally painful procedures'.)

Nonsurgical separation may be performed in the office with cooperative patients. Application of topical anesthetic (eg, topical lidocaine) and mild sedation, as needed, is followed by insertion of a lubricated cotton swab behind the labia minora [22]. The cotton swab is then gently pulled forward along the midline raphe formed by the fused labia minora.

•Surgical separation – Surgical intervention for labial adhesions is reserved for rare patients with complete obstruction of urine flow. When necessary, surgical separation is performed with deep sedation or general anesthesia. After surgery, the patient should receive topical estrogen cream for one to two weeks followed by application of a bland emollient (eg, white petroleum jelly) for 6 to 12 months with proper hygiene measures (table 1) to prevent recurrence.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Lichen sclerosus (The Basics)")

●Beyond the basics topic (See "Patient education: Vulvar lichen sclerosus (Beyond the Basics)".)

SUMMARY AND RECOMMENDATIONS

●Overview – Common vulvovaginal conditions in prepubertal children include nonspecific and infectious vulvovaginitis, vaginal foreign body, labial adhesions, and vulvar trauma. Vulvovaginitis in prepubertal females is discussed separately. (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment".)

●Vaginal foreign body – Foreign bodies in prepuberal females can cause acute or chronic recurrent vulvovaginitis, which may have associated bleeding. Pain and a gray, watery discharge suggests an intravaginal button battery. Visualization of the foreign body during examination (child in the knee-chest position (figure 1)) confirms the diagnosis. Plain radiographs of the pelvis can detect button batteries. Management depends upon the type and size of the vaginal foreign body (see 'Vaginal foreign body' above):

•Button batteries – Button batteries require emergency removal under general anesthesia by a pediatric gynecologist or other surgeon with similar expertise.

•Other foreign bodies – After application of a small amount of topical anesthetic to the introitus, bedside removal is often possible for patients with intravaginal toilet paper or other small foreign bodies. Large, lodged foreign bodies and those that fail bedside removal require removal under sedation or general anesthesia.

●Labial adhesions – Labial adhesions are diagnosed on a routine genital examination (picture 13). The management of labial adhesions is determined by the presence and degree of symptoms (algorithm 1). (See 'Labial adhesions' above.)

For females with symptomatic labial adhesions (ie, associated with vaginal pain or discharge, extensive labial fusion, diversion of the urinary stream, or recurrent urinary or vaginal infections), we suggest treatment with either topical estrogen (eg, estrogen or estradiol 0.01% cream) or topical corticosteroids (eg, betamethasone 0.05% cream) (Grade 2C). Prolonged use (>3 months) of betamethasone cream should be avoided to prevent skin atrophy and systemic corticosteroid absorption.

If adhesions are not improved after four to eight weeks of properly administered topical therapy, the alternative cream should be applied for an additional two to four weeks. If there is still no improvement, the patient should be referred to a specialist with pediatric gynecologic expertise.

●Vulvar trauma – Unintentional vulvar trauma typically follows a straddle injury and presents with anterior bruising or lacerations involving the mons pubis, clitoral hood, and/or anterior aspect of the labia (picture 1A-E). An injury to the posterior fourchette and hymenal area suggest possible sexual abuse (picture 2A-B). Evaluation and management of straddle injuries are discussed in detail separately. (See "Straddle injuries in children: Evaluation and management".)

●Other conditions – Other important conditions:

•Vulvar ulcers – Important causes include herpes simplex virus (HSV), acute genital ulceration (Lipschütz ulcer), Crohn disease, and Behçet syndrome. (See 'Vulvar ulcers' above.)

•Vulvar skin conditions – Commonly, vulvar itching and rashes are caused by seborrhea and atopic dermatitis. Systemic infection (eg, measles, varicella, or Mycoplasma pneumoniae-induced rash and mucositis), Stevens-Johnson syndrome, lichen sclerosis, zinc deficiency, and nickel allergy are other important etiologies. (See 'Vulvar skin conditions' above and 'Systemic illness' above.)

•Vaginal and vulvar tumors – Vulvar tumors are rare and include (see 'Vaginal and vulvar tumors' above):

-Benign tumors such as a benign vaginal papilloma/polyps, cutaneous neurofibroma, or nodular fasciitis

-Malignant tumors such as sarcoma botryoides (picture 11), endodermal sinus tumor, granular cell tumors, or leiomyosarcoma

●Urinary tract abnormality – Genitourinary abnormalities that can cause vulvovaginal complaints include:

•Ectopic ureter – Ectopic ureter presents with chronic vulvar irritation and wetness. (See 'Ectopic ureter' above.)

•Urethral prolapse – Urethral prolapse presents with a dusky red or purplish annular mass at the urethral location on physical examination (picture 12). Topical hormonal therapy is curative in most patients. Persistent prolapse or prolapse associated with a necrotic distal urethra requires referral to a pediatric urologist. (See 'Urethral prolapse' above.)