Prepubertal vulvovaginitis

Emily P.A. Brander; Sarah K. McQuillan

doi:10.1503/cmaj.180004

Inflammation and irritation of the lower genital tract, or vulvovaginitis, is common in prepubertal girls

Vulvovaginitis constitutes about 62% of pediatric gynecologic problems seen in primary care.1 Predisposing factors in prepubertal girls (usually defined as age 1–10 yr) include the proximity of the vagina and anus, the absence of protective pubic hair and a lack of labial fat pads.

Common presenting symptoms include pruritus, discharge, discomfort and dysuria

Most cases (70%–80%) have nonspecific causes1^–3 and require only reassurance and improved vulvar hygiene (Box 1). It is important to ask about prior episodes, treatments and hygiene habits (toileting, hand washing, tight-fitting clothing and bathing).

Box 1:

Tips for vulvar hygiene1^,3

Removal of irritants: no baby wipes; nylons or tight-fitting clothing; wet bathing suits; bathtubs filled with soap, shampoo or bubble bath; scented detergents; washing powders; or dryer sheets. Sleep in nightgowns or long T-shirts without underwear. All underwear should be dye free.
Cleaning: Soak the area in warm water for 10–15 minutes per day. Never scrub. Gently wipe front to back with a hypoallergenic soap. Stand up in bath to be soaped, shampooed and rinsed. Let air-dry or gently pat dry.
Toileting: Lean forward when voiding to prevent pooling of urine in the lower vagina and always wipe front to back.

About 25% of vulvovaginitis cases in children are caused by infections

Bacteria from the gastrointestinal (Escherichia coli) and respiratory tracts (β-hemolytic streptococci, Haemophilus influenzae) are the most common culprits.1^–4 These infections present with pain, erythema and, occasionally, discharge. Vaginitis caused by H. influenzae is decreasing with immunization.1 Vaginal yeast infections are rare in healthy girls out of diapers. Recent antibiotic use can be a predisposing factor, as can diabetes or immunodeficiency, rarely. Therefore, persistent cases warrant investigation.

Recurrent symptoms, associated with a foul smell, may be due to a foreign body in the vagina

Toilet paper is the most common foreign body found and can be flushed from the vagina with sterile saline.1 Otherwise, referral to a gynecologist for vaginoscopy is necessary.

Psoriasis, atopic dermatitis and lichen sclerosus may cause chronic vulvar dermatosis

Psoriasis presents as red, nonscaly, pruritic plaques, sometimes isolated to the vulva. It is more common in children than adults.1 About 15% of chronic vulvovaginitis in children is due to lichen sclerosis — a paper-white rash, in a figure-of-eight pattern around the vulva and anus. Both are treated initially with a midpotency topical steroid (e.g., clobetasol propionate 0.05%) and a low-potency steroid for maintenance (e.g., hydrocortisone 1%).1^,5

Footnotes

Competing interests: None declared.
This article has been peer reviewed.

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