Vulvovaginitis is the most common gynecologic problem among prepubertal children. There are several factors that predispose young girls to vulvovaginal irritation. Anatomically, the genitalia of preadolescent girls are relatively unprotected due to the lack of labial fat pads and pubic hair. In addition, the labia minora are smaller and tend to open when the child squats, uncovering the more sensitive tissues within the hymenal ring. Finally, the close anatomic proximity of the rectum promotes fecal bacterial contamination.
The relatively poor hygiene practices of young children tend to exacerbate the problem of the vulnerable genital area. Children are notoriously careless about handwashing and are likely to spend much of their leisure time sitting on the floor, in the yard, and in the sandbox. Furthermore, young girls may inadvertently contaminate the vaginal area by wiping feces from back to front following a bowel movement. Masturbation among young children may also lead to vulvovaginal irritation.
The hormonal milieu in the preadolescent child is a major factor contributing to susceptibility to vulvovaginitis. The squamous epithelium of the vaginal mucosa is exquisitely sensitive to steroid hormones. In the absence of estrogen, the squamous epithelium is undifferentiated, a state found in both the prepubertal child and the postmenopausal woman. This thin atrophic epithelium is more susceptible to invasion by pathogens. Estrogen promotes the differentiation of squamous epithelium into the well-recognized basal, intermediate, and superficial cell layers characteristic of the vaginal mucosa of the reproductive years. ' The abundance of superficial cells is directly proportional to the estrogen influence and, indeed, the percentage of superficial cells present on a vaginal smear is an approximate indication of the amount of estrogenic activity. The superficial cells of the vaginal epithelium contain abundant glycogen, which serves as a substrate for the enzymatic processes of normal bacterial flora. This results in the production of lactic and acetic acid, maintaining an acid environment with a pH of 4.0 to 5.0. The lack of estrogenic activity and the consequent lack of the protective superficial layer of vaginal epithelium in the prepubertal child promote an environment of neutral pH with an easily penetrable mucosa.
AEROBIC AND FACULTATIVELY ANAEROBIC BACTERIA ISOLATED FROM VAGINAL CULTURES OF 59 GIRLS AGES 2 MONTHS TO 15 YEARS
PHYSIOLOGIC VAGINAL DISCHARGE
With regard to vulvovaginal irritation in children, one must first have a grasp of what is physiologically and microbiologi cal Iy normal. It is important to remember that most female babies will experience a physiologic vaginal discharge during the newborn period. This leukorrhea is the result of maternal estrogen stimulation of the vaginal mucosa and cervical epithelium of the fetus. This thick mucoid material contains few or no white blood cells or pathogens. There may be a high percentage of superficial squamous epithelial cells noted in the discharge. This results in a relatively glycogen rich atmosphere, resulting in lactobacillus colonization. The fermentative activity of the lactobacillae results in the formation of lactic and acetic acid and a resultant drop in pH to the 4.0 to 5.0 range. Within a few days of birth, it may also contain microscopic red blood cells and occasionally the discharge may become grossly blood-tinged. This phenomenon is the result of withdrawal bleeding from the in utero estrogen stimulation of the endometrium. The physiologic leukorrhea of the newborn tends to disappear within 7 to 10 days, and after 2 to 3 weeks the vaginal mucosa becomes anestrogenic.
A second instance of physiologic vaginal discharge occurs in the months just prior to menarche. At this time, the child and her mother may be greatly concerned by a sudden increase in discharge and staining on the child's underclothing. The vaginal discharge in this instance is a copious, gray-white, non-foul-smelling and non- irritating fluid which, when examined under the microscope, is without white blood cells or pathogens. There also may be desquamated vaginal epithelial cells. The discharge is made up predominantly of vaginal transudate and endocervical mucus. In general, the leukorrhea of the perimenarchal child is the result of the increasing ovarian estrogenic activity. In both of these instances, reassurance and local hygienic measures are all the treatment necessary. However, it must be remembered that adenosis associated with diethylstilbestrol exposure in utero can be responsible for abundant mucus.
NORMAL VAGINAL FLORA
Several microorganisms once thought to be pathogens may normally reside within the vagina. Hammerschlag et al2 examined vaginal cultures from 100 healthy girls of ages 2 months to 1 5 years. They found diphtheroids and Staphylococcus epidermidis to be the most prevalent organisms. These were followed by the streptococci, the lactobacillae, and coliforms (Table 1). In addition, approximately 28% of the children had yeast isolated from their vaginal cultures. Colonization with yeast was more prevalent in the infants and teenagers than in the children in the 3- to 10-year-old age group. Also, GardnereUa vaginalis was isolated from approximately 13.5% of the children studied. This organism was also more prevalent in the younger and older children. In contrast, 6% of the girls studied were found to be colonized with Mycophsma hominis and 27% with Ureaplasma urealyticum, but the prevalence of these organisms did not differ by age.
It is useful to divide the broad category of vulvovaginitis into those cases with specific causes, including both the sexually transmitted and non-sex - ually transmitted diseases, and those with nonspecific causes (Table 2).
SPECIFIC BACTERIAL INFECTIONS
Specific bacterial infections that are not sexually transmitted usually feature a predominant organism that develops from an infection elsewhere. In particular, the gastrointestinal tract is often the culprit. Shigella can cause a chronic, persistent vaginitis with a foul-smelling purulent and often bloody discharge. Amebiasis and typhoid may cause an ulcerative vaginitis.
Enterobius vermicuhris, commonly known as "pinworms," is commonly a cause of perineal pruritis and discharge in school-age girls. This diagnosis can be made by the examination of a "scotch tape" swab obtained by early morning swabbing of the perianal area with cellophane tape and pressing the tape onto a glass slide. The slide is examined microscopically for ova that have a characteristic oval, mottled appearance. In addition, the parent can be instructed to examine the perianal area at night in search of the small, white, pin-sized worms. This infestation results in marked perianal itching. Scratching may result in persistent autoinfection. Occasionally, a worm can actually be recovered from the vaginal vault. Treatment of pinworms should include all household members and close contacts. A single dose of mebendazole (Vermox), 100 mg, may be given orally. Pyrantel pamoate oral suspension in a single dose of 11 mg/kg, up to a maximum dose of 1 g, or pyrovinium pamoate tablets, 5 mg/kg up to a maximum dose of 350 mg, may also be given. These medications are not used in pregnancy nor have they been studied in children under the age of 2 years.
Specific bacterial infections with a predominant organism can develop following an infection in the upper respiratory tract, oropharynx, or ears by autoinoculation. Simultaneous cultures from the oropharynx and vagina may yield similar organisms, such as Hemophilus influenzae type B, pneumococcus, Group A β-hemolytic Streptococcus, and meningococcus. This is much more common in younger children. Should one of these organisms be isolated, the patient should be treated specifically with oral antibiotics.
Skin infections in young children may also be a source of a bacterial inoculum resulting in vaginitis. The organisms most responsible in these cases are Staphylococcus aureus, hemolytic streptococci, or Proteus.
While it is unquestionably more common for a primary vulvovaginitis to result in a secondary urinary tract infection, a few cases have been reported in which a nonspecific vulvovaginitis has developed following a urinary tract infection. This is due to the anatomic proximity of the urethral meatus to the vagina and relatively poor hygiene among children.
Acute inflammation, edema, and irritation of the vulva and vaginal mucosa are not uncommon complications of the viral xanthems. Herpes zoster lesions frequently occur in the vulva and vagina and there have been cases probably due to autoinoculation from a recent vaccination.
Candida albicans is the organism responsible for many vulvovaginal infections in children. It is less common in younger children than in adolescents and adults because Candida tends to flourish in the estrogenic vagina. In most cases, the cardinal symptom is pruritus with a small amount of whitish discharge. The child may also complain ot external dysuria, resulting from contact with the raw excoriated vulvar areas. On examination, the vulva may be erythematous and edematous. There may be white plaques on the affected surfaces or adherent to the vaginal mucosa. The typical discharge is curd- like in appearance and non-foul smelling. The diagnosis is made by examination of a potassium hydroxide (KOH) preparation. This is done by mixing the vaginal secretions with a drop of 10% KOH solution on a glass slide. A coverelip is then applied and the slide examined under the microscope on high power for the characteristic hyphae or budding forms. A culture also can be sent in Biggy culture medium. A KOH preparation is preferable to a saline wet mount as the other cellular elements such as epithelial cells and leukocytes will be lysed, making it easier to demonstrate the fine filaments and spores of the yeast organisms. Treatment requires the use of one of the antifungal agents such as miconazole, clotrimazole, or butoconazole creams, which may be applied directly to the vulva and vagina twice daily fox 7 days. When intravaginal application is necessary, a small plastic hemorrhoid cream applicator tip may be used with hymenal openings as small as 5 mm. When perineal candidiasis repetitively occurs, it may be necessary to eliminate the gastrointestinal reservoir of yeast by treatment with an oral antifungal agent such as oral nystatin or ketoconazole. This would also be indicated in cases of concurrent oral candidiasis or thrush.
VULVOVAGINITIS IN PREPUBERTAL GIRLS
It is not infrequent that the source of the monilial infection in the infant or child is a similar infection in the mother. One should also consider diagnoses such as diabetes mellitus or immunodeficiency states in children presenting with severe infections of this sort. The most frequently reported history among children presenting with candidal infections, however, is that of an antecedent course of antibiotics.
Gordnerella vaginalis is an infrequent cause of vaginitis in children because, like candida, these organisms tend to prefer an estrogenic vagina. It is more likely to cause infection in the adolescent, who may present with a profuse pruritic and often foul-smelling vaginal discharge. Since this organism is more often found in older girls who are sexually active and is known to be transmitted between sexual partners, the appearance of GordnereUa vaginalis in a vaginal culture of a young child should at least raise the suspicion of sexual contact. The recommended treatment for this organism is metronidazole at a dose of 15 mg/kg per day in three divided doses for 7 days with a maximum dose of 250 mg. The older adolescent may be treated with 500 mg twice a day for 7 days. It is essential to treat the sexual partners.
SEXUALLY TRANSMITTED DISEASES
Sexually transmitted diseases account for an unfortunately high percentage of vaginal discharges in the pediatric population.
Neisseria gonorrhoeae vulvovaginitis in the prepubertal child is usually manifested as a purulent vaginal discharge with secondary vulvitis. In this instance, the vulva may become erythematous, edematous, and excoriated. There may be evidence of a thick, creamy, yellow discharge. Alternatively, the patient may present with a thin, mucoid discharge or may be asymptomatic. Thus, a Gram's stain and culture are important in the evaluation of the vaginal discharge in a premenarchal child. The incidence of gonorrhea in premenarchal vulvovaginitis varies greatly depending upon the series studied, with up to 37% of cases presenting to pediatric gynecology clinics being the result of this organism.
N. gonorrhoeae is an extremely fastidious organism that is poorly resistant to environmental factors and, thus, infection requires person-to-person contact. Although it is possible to acquire the organism through nonsexual personal contact, the presence of gonorrhea in a premenarchal child should alert the clinician to the strong possibility that sexual contact has occurred.
The diagnosis can be suspected from a Gram's stain of the vaginal discharge, which would show gramnegative intracellular diplococci. The definitive diagnosis of N. gonorrhoeae requires culturing on ThayerMartin media. Occasionally, other forms of Neisseria are present and N. gonorrhoeae must be identified in differential cultures. Since sexual abuse may involve urogenital and anogenital contact rather than or in addition to vaginal penetration, it is essential to culture the oropharynx and the rectum as well as the vaginal discharge. In addition, a serologic test for syphilis should be obtained as sexually transmitted diseases tend to coexist in infected patients. It has recently been noted that in approximately 45% of cases of adult gonorrhea, there is a coexistent infection with Chlamydia trachomatis; thus this organism should be tested for as well.3
The treatment of N. gonorrhoeae for older adolescents and children weighing over 45 kg is the same as the adult regimen for treating this organism. The Centers for Disease Control recommended regimens include amoxicillin 3.0 g or ampicillin 3.5 g orally or aqueous procaine penicillin-G (APPG) 4-8 million units intramuscularly (IM) in a single dose. This should be given with probenecid 1 g orally. For children under 45 kg, the preferred treatment is either APPG 100,000 units/kg IM or amoxicillin 50 mg/kg orally as a single dose, given with probenecid 25 mg/kg to a maximum dose of 1 g given orally. Probenecid should be given only to children over the age of 2 years. For penicillin-allergic children, spectinomycin 40 mg/kg IM may be given as a single dose. It should be remembered that spectinomycin is not recommended for the treatment of pharyngeal gonococcal infection. As an alternative regimen, tetracycline 40 mg/kg per day in four divided doses for 7 days or erythromycin 40 mg/kg per day in four divided doses for 7 days may be given. Tetracycline should not be used in children under 8 years of age because of the possibility of dental staining. Due to the high co-infection rate with Chlamydia trachomatis, the current Centers for Disease Control recommendations for the treatment of gonococcal infections are for a dual drug regimen with a single dose of penicillin in addition to a 7-day course of tetracycline or erythromycin as described in the treatment of chlamydia.
Because of the high likelihood of sexual abuse among children presenting with N. gonorrhoeae, immediate involvement of social services and state child and family service agencies is indicated. Patience is essential as repeated interviews, as well as therapy, may be necessary for the child to disclose the history. In many cases of sexual abuse, the abuser is a family member, caretaker, or friend.
Follow-up cultures of the oropharynx, vagina and rectum should be obtained 7 to 14 days following treatment. In addition, a follow-up serologic test for syphilis should be obtained as seroconversion may take 4 to 6 weeks to occur.
Chlamydia trachomatis is the most prevalent sexually transmitted bacterial pathogen in the adult population today. Its importance is now being recognized as a pathogen in both sexually active adolescents and in the sexually abused child with a vaginal discharge. The child will classically present with a mucopurulent cervicitis or dysuria and pyuria along with a vaginitis. Chlamydia is an obligate intracellular organism and must be grown in tissue culture, which takes up to 10 days. A relatively new and promising technique for the diagnosis of Chlamydia trachomatis is an immunofluorescent slide test that takes less than 24 hours. Because the organism lives in the columnar epithelial cells of the endocervix, it is essential to swab the endocervical canal; merely swabbing a pool of vaginal discharge will not always provide the epithelial cells necessary for staining the organisms.
The treatment of Chlamydia trachomatis infection in children over 45 kg should follow the recommended regimen of the Centers for Disease Control. This is tetracycline hydrochloride 500 mg by mouth, four times a day for 7 days or doxycycline 100 mg twice a day by mouth for 7 days. For children under 45 kg, the dose of tetracycline would be 50 mg/kg per day in four divided doses to a maximum dose of 500 mg for 7 days. For children under 8 years of age, in whom tetracycline would be contraindicated, erythromycin ethylsuccinate (ESS) is given in a dose of 50 mg/kg per day in four divided doses for 7 days.
Trichomonas vaginalis is a parasitic infection that is rarely encountered in prepubertal children as this organism also prefers an estrogenic environment. Trichomonads may be recovered in the vaginal secretions of a newborn infant as a result of colonization occurring when the child passes through the birth canal. The estrogenic newborn vaginal mucosa is more receptive to colonization with this organism and the rate may be as high as 5%. Vaginal trichomoniasis is much more common in the older prepubertal child. It is important to remember that while it may be acquired from voluntary sexual activity and close nonsexual physical contact, the suspicion of sexual abuse must be raised, as this organism is transmitted venereally as well.
The symptoms of Trichomonas in childhood are similar to those in the adult. The discharge is often copious, frothy, and yellow-gray in appearance, with a foul odor. The vaginal secretions will have a neutral or alkaline pH. Trichomonas vaginalis is associated with hyperemia and edema of the vulva with vulvar itching, burning, and frequently dysuria accompanying the vulvovaginitis.
The diagnosis of Trichomonas vaginalis is made by finding the live trichomonads in fresh saline wet mounts made from the vaginal discharge and viewed under a light microscope. The parasites are mobile, football shaped, flagellated organisms that are easily visible at high power.
The most efficacious therapy is metronidazole, which has been used in children at a dose of 15 mg/kg per day in three divided doses for 7 days to a maximum dose of 250 mg. Where voluntary sexual activity is involved, it is important to remember to treat the sexual partner as well.
Most cases of vulvovaginitis in children who are not sexually active nor abused are the nonspecific mixed bacterial infections with no obvious etiology. It is important to remember that this category is a diagnosis of exclusion and that every attempt must be made to rule out other etiologies. As might be expected, the signs and symptoms in these cases are extremely variable, but most frequently nonspecific vulvovaginitis presents when the mother notices an increase in the vaginal secretions staining the child's underwear. This is usually accompanied by a vulvitis consisting of erythema, edema, and secondary excoriations as a result of pruritus. The distal vagina may be secondarily involved; however, the nonspecific vulvovaginitis is usually a primary vulvitis. Approximately 70% of cases of nonspecific vulvovaginitis result from poor perineal hygiene, which is typical of children, with fecal contamination being the most frequent cause of infection.4 In these instances, vaginal cultures may demonstrate coliforms or other gastrointestinal bacteria, which strengthens this impression.
Another common cause of nonspecific vulvovaginitis in children is irritation by clothing, chemicals, or cosmetics. In taking the history from the child and her parent, it is important to ascertain the type of soap products used for both bathing and laundry and whether or not there has been a recent change in products that may be temporarily related to the vaginitis. They should be questioned about bubble baths, perfumes, and for the older adolescent, douches and "feminine hygiene deodorants." Attention should be paid to the type of underwear worn by the child. Noncotton underwear tends to be occlusive, creating a warm, moist environment that promotes masceration of tissue and bacterial growth. Tight fitting clothing, such as jeans, pantyhose, tights and ballet leotards, may have a similar effect, as will rubber pants or plastic covered paper diapers. Again, attention should be paid to toilet training and toilet hygiene, reinforcing for the parent and child the necessity to wipe from front to back to avoid fecal contamination of the vulva and vagina.
Even in cases of nonspecific vulvovaginitis where no single organism is recovered, it is important to consider the possibility of sexual molestation with chemical irritants. We recently have seen a patient with acute vulvitis and vulvar burns secondary to an alkaline soldering flux as well as a chronic erythematous vulvitis in a 4-year-old child who was being molested with hot peppers.
Foreign bodies as a cause of vaginal discharge in a child must be ruled out, particularly with a persistent bloody foul-smelling discharge. Bacterial cultures in this instance will be nonspecific. Vaginoscopy is essential when a foreign body is suspected, as the most common foreign body is rolled up wads of toilet tissue, which can neither be seen with ultrasound, palpated on rectoabdominal examination, nor visualized on xray.
In cases of chronic vulvitis, agglutination of the labia minora can occur. This may lead to persistent vulvitis on a hygienic basis by allowing collection of secretions, fecal matter, and/or pooled urine. Rarely, other genital tract anomalies may be responsible for a vulvovaginitis; most notably fistulas and ectopic ureters.
The mainstay of treatment for nonspecific vulvovaginitis is education and fastidious attention to good perineal hygiene. The child should be given Sitz baths twice daily with a bland, mild, nonperfumed soap. The vulva should then be carefully dried, avoiding rubbing. It is preferable to allow the area to air dry and may even be helpful to use a blow drier on a cool setting. Only undyed white cotton underpants should be used and changed frequently. The child should avoid tight fitting clothing, pantyhose, or jeans. For the occasional severe acute vulvitis, an estrogen-containing cream, such as premarin or thenestrol, can be applied nightly to the vulva for 2 to 3 weeks. This results in the development of a thicker, more differentiated protective vaginal and vulvar epithelium.
Vaginal discharges in prepubertal girls can be categorized under two broad headings - those with specific microbiological causes and, in the absence of such, those that are nonspecific in origin.
For specific vulvovaginitis, treatment should be tailored to the findings on cultures, wet mounts, KOH, or other slide preparations.
For the sexually transmissible organisms resulting in a vaginal discharge, thorough social service investigation should be undertaken in addition to appropriate antibiotic therapy.
When a microbiological cause cannot be found and a foreign body has been ruled out, one is left with a diagnosis of nonspecific vulvovaginitis; treatment goals should be aimed at reassuring and re-educating the patient and parents in good hygienic practices as well as the elimination of potential "irritants.
1. Friedrich EC: Vukar Disease. (2nd ed) Philadelphia. WB Saunders Company, 1983. pp 10-13.
2. Hammerschlag MR, Alperi S1 Rooter 1, et ai: Microbiology of the vagina in children: Normal and potentially pathogenic organism, ftdiamcs 1978: 62-57.
3. 1985 S I U Treatment Guidelines, US Department of Health and Human Services. Public Health Service. Centers ftir Disease Control, Atlanta. Georgia.
4. Huffman JW, DewhurstCJ, Capraro VJ: The gynecology of childhood and adolescence. (Znd ed) Philadelphia, WB Saunders Company. 1981. pp 124.
Akchelc A: Pediatric vulvovaginitis. Symposium on pediatric and adolescent gynecology. PediarrCin North Am 1972; 19:559.
Emans SJH, Goldstein DP: Pediatric and Adolescent Gynecology 2nd edition. Boston, Little Brown and Company, 1982.
Lavery JP, Sanfilippo JS: Pediatric and Adolescent Obstetrics and Gynecology. New York, Springer-Verlag. 1985.
Meteer RM, Marx P-. Aduk vulvovaginitis, Current problems in obstetrics, Gynecology and Fertility 1985; 8(10).
AEROBIC AND FACULTATIVELY ANAEROBIC BACTERIA ISOLATED FROM VAGINAL CULTURES OF 59 GIRLS AGES 2 MONTHS TO 15 YEARS
VULVOVAGINITIS IN PREPUBERTAL GIRLS