Vulvovaginitis in Children

Vulvovaginitis in children is inflammation of the vulva and vagina in prepubertal girls, most often nonspecific and caused by poor hygiene, irritants and the unoestrogenised, thin vaginal epithelium.

• The prepubertal vagina has a thin mucosa, neutral pH and no lactobacilli, and the labia are small, so the area is vulnerable.
• Irritants: bubble baths, soaps, tight or synthetic clothing, wet swimwear, wiping back to front, and prolonged sitting in nappies.
• Specific infections: Group A Streptococcus, Haemophilus influenzae, Shigella (bloody discharge), Staphylococcus aureus, pinworms (Enterobius), Candida (after antibiotics, in diabetes, or in nappy-wearing girls), and rarely sexually transmitted infections.
• Foreign body (toilet paper) causes persistent, offensive, bloody discharge.
• Sexual abuse must be considered with specific infections or unusual features.

Symptoms are local.

• Vulval redness, soreness and itching, dysuria, and discharge (often yellow or green).
• Vulval erythema, excoriation and mild vaginal discharge on inspection.
• Nocturnal anal and perineal itching suggests threadworms.
• Foul-smelling bloody discharge suggests foreign body or Shigella.
• Thick white discharge with satellite lesions suggests candidiasis.
• Differential diagnosis: labial adhesions, lichen sclerosus (white, atrophic, haemorrhagic skin), urethral prolapse, ectopic ureter, vaginal foreign body, sexual abuse, urinary tract infection, vaginal tumour (sarcoma botryoides), eczema and psoriasis.
• Complications: labial adhesions, recurrent episodes, secondary bacterial infection and distress.

Diagnosis is clinical, with investigation if severe or atypical.

• History: hygiene practice, irritants, itching, bowel habit, antibiotic use, family illnesses and safeguarding concerns.
• Examination in frog-leg or knee-chest position; gentle labial traction to inspect the vestibule and hymen.
• Swab (vulval or lower vaginal) for culture if discharge is persistent or purulent.
• Urinalysis and culture for dysuria.
• Perianal tape test or swab for pinworm eggs.
• Vaginoscopy under anaesthesia if bloody discharge or suspected foreign body persists.
• Refer for safeguarding assessment if sexually transmitted infection or sexual abuse is suspected.

Hygiene and removal of irritants cure most cases.

• Supportive: daily warm sitz baths in plain water for 10 to 15 minutes (add bicarbonate 1 tablespoon if itchy), pat dry, wear loose cotton underwear, avoid soaps, bubble baths and wet swimwear, wipe front to back, change nappies frequently, and apply barrier ointment (zinc oxide or petroleum jelly).
• Treat constipation and threadworm if present: mebendazole 100 mg single dose, repeat in 2 weeks (over 2 years), or albendazole 400 mg single dose; treat the whole household.
• Pharmacological: for bacterial infection, amoxicillin 25 mg/kg twice daily or amoxicillin-clavulanate for 7 days (Group A Streptococcus: phenoxymethylpenicillin 125 to 250 mg twice daily for 10 days). For Candida, topical clotrimazole 1 percent cream twice daily for 7 to 14 days. Short course of hydrocortisone 1 percent cream may soothe inflammation.
• Topical oestrogen cream (oestradiol 0.01 percent, thin layer for 2 to 4 weeks) is reserved for refractory cases or labial adhesions, under specialist advice.
• Procedures: vaginal irrigation or removal of a foreign body, with sedation or general anaesthesia if needed.
• Special groups: suspected abuse requires multidisciplinary safeguarding evaluation.
• Red flags: bloody or foul discharge, recurrent episodes, genital ulcers, bruising or injury, suspected abuse, sexually transmitted infection and a vaginal mass.
• Follow-up: review in 2 to 4 weeks. Refer if persistent beyond 3 months.