Summary
There are a number of gynaecological conditions which commonly present in childhood. The commonest of these such as vulvovaginitis are self-limiting though they can be quite difficult to treat. They can often be diagnosed through thorough history taking even before an external physical examination and although most symptoms will have benign causes, it is important to be aware that there are rare conditions which need to be considered particularly if symptoms do not fit into the more frequent presentations.
4.1 Introduction
There are a number of gynaecological conditions which commonly present in childhood. The commonest of these such as vulvovaginitis are self-limiting though they can be quite difficult to treat. They can often be diagnosed through thorough history taking even before an external physical examination and although most symptoms will have benign causes, it is important to be aware that there are rare conditions which need to be considered particularly if symptoms do not fit into the more frequent presentations.
When assessing a child, it is important to be aware of the differences between a prepubertal vulva as compared to an adult. The labia majora and the mons pubis are devoid of not only hair but also any subcutaneous fat. The labia minora lack pigmentation and have an atrophic appearance. This means that the vaginal vestibule is more exposed to bacteria particularly when girls are squatting. These factors account for a lot of the pathology found in prepubertal girls.
4.2 Vulvovaginitis
This is by far one of the commonest presentations in young prepubertal girls between the ages of 2 and 7. The anatomy of the vulva in a prepubertal girl has fundamental differences which predispose her to developing nonspecific infections and irritation. As discussed above, the labia minora are underdeveloped whilst the labia majora have minimal adipose tissue, resulting in a flattened appearance. This leads to the introitus being open and so with the close proximity of the anus there are minimal physical barriers to infection. This, accompanied by the absence of pubic hair and lack of vaginal oestrogen (resulting in absence of lactobacilli and a more alkaline pH), results in a far less protective atmosphere.
Girls in this age group are often just starting to be responsible for their own perineal hygiene, and so poor practices as well as potentially more frequent exposures to irritants and pathogens in the form of sitting on the ground, playing in sand pits and so on result in higher risk of infection.
The key symptoms in the history may include vulval pruritus, pain, dysuria, vaginal discharge and possibly abnormal odour. It is important to determine the presence of irritants such as use of bath products, scented creams and laundry detergents as well as pre-existing skin conditions such as eczema in other parts of the body. Recent respiratory and gastrointestinal infections are also relevant as this is likely to increase transmission of pathogens to the vulva. Frequent episodes of pain especially during the night may signify the presence of threadworms, which are easily treatable.
On physical examination, the commonest findings are erythema of the vulva and perianal region with possible signs of excoriation and occasional discharge. It is possible to take a swab for culture but this is frequently negative. More than 75% of cases of vulvovaginitis are non-infectious, also known as ‘non-specific’. Persistent episodes, particularly if they are associated with profuse discharge or abnormal odour, are potentially more likely to be infective. The commonest causes are respiratory agents such as group A streptococci, Neisseria meningitidis, Haemophilus influenza and enteric pathogens such as Shigella spp., Yersinia enterolitica and Escherichia coli. Contrary to popular belief, candidiasis is very uncommon in prepubertal girls so empirical treatment with antifungals should be avoided unless there is proven infection.
It is important to consider sexual abuse in both the history and examination, and if any infection with sexually transmitted organisms is identified then safeguarding pathways need to be activated.
4.2.1 Management
The management of vulvovaginitis revolves around identifying and avoiding irritants and also education about appropriate hygiene as outlined in Table 4.1. It is not necessary to obtain cultures in the first instance unless there are frequently recurring episodes despite hygiene measures.
These hygiene practices can be time-consuming and improvement is very gradual with relapses if the measures are not maintained. It is important to provide reassurance to parents that symptoms will improve as the girl gets older, both because of development in her own ability to maintain her own hygiene but also because with the onset of puberty will come mucosal changes including a decrease in pH, tissue oestrogenisation and changes in anatomical appearance.
Table 4.1 Treatment of vulvovaginitis
Besides infection, persistently recurrent symptoms may suggest alternative causes such as presence of a foreign body (especially if associated with vaginal discharge or bleeding), which may even just be a small piece of toilet tissue or an anatomical variant such as an ectopic ureter. Any suspicion of the former merits examination under anaesthesia or a renal ultrasound for the latter.
Besides the measures in Table 4.1, it is especially important to spend time reinforcing to parents that this is a self-limiting condition which in most cases will resolve spontaneously. The British Society for Paediatric and Adolescent Gynaecology (BritSPAG) has excellent patient information leaflets which further support parents with information when at home.
4.3 Labial Adhesions
Labial adhesions are an acquired condition which occurs most commonly in girls aged 3 months to 3 years old. They are not present at birth. They are characterised by variable fusion of the labia minora ranging from complete fusion from the level of the posterior fourchette to the clitoris or partial fusion starting posteriorly and moving upwards. The prevalence has been reported as being between 1.8% and 3.3%, but it is likely a large number of asymptomatic adhesions remain unreported. This is supported by a study where girls had colposcopic examination, which reported an incidence of nearly 39%.
It is thought that they occur because of an inflammatory reaction resulting from a local irritant. In the absence of oestrogen during the healing process, the medial aspects of the labia minora are apposed and fuse partially or completely.
Symptoms reported in the history may be vulvovaginitis, pain on wiping and post-void dribbling or urinary tract infection. It is rare for labial fusion to cause urinary retention and often worried parents will present with a history of an ‘absent vagina’ noted during nappy change or bathing.
During physical examination, on separating the labia, a thin line is visible where the labia are fused in the midline giving the appearance of a flat perineum concealing the urethral meatus and hymen. In addition, there may be concurrent symptoms of vulvovaginitis in the form of erythema or excoriation.
4.3.1 Management
Up to 80% of labial adhesions will resolve spontaneously within a year of diagnosis and nearly all will disappear with the onset of puberty so management is largely conservative unless there are significant symptoms.
Treatment of adhesions is controversial due to the high risk of recurrence regardless of treatment regimen chosen. As such, management of asymptomatic adhesions is mainly focussed on perineal hygiene, frequent use of emollients and extensive parental reassurance that all internal anatomy is normal. If girls have significant symptoms in the form of either urinary tract infection or post-void dribbling, it is reasonable to consider treatment with topical oestrogen ointment. There is a large variety of treatment regimens reported but the adhesions will generally separate in 4–6 weeks with a reported success rate of between 15% and 100%, depending on the thickness of the fusion. Once they have separated, it is worth continued use of emollients to attempt to maintain the separation although it is reported that up to 34%, if not more, will recur.
Although the oestrogen use is topical, there is some systemic absorption which could result in side effects including breast budding, vulval pigmentation and vaginal bleeding. These side effects are uncommon and regress as soon as therapy is stopped but it is important to make parents aware of them.
An alternative to oestrogen therapy is topical use of steroids such as betamethasone with reportedly similar success rates but topical oestrogen is the preferred first-line course of therapy.
Surgical separation of adhesions under anaesthesia is reserved for severe symptomatic adhesions such as urinary obstruction or in the rare case that they persist following puberty. Unfortunately, recurrence is common even after surgical separation. It is worth noting that it is never appropriate to attempt separation of adhesions in a clinic setting whilst a girl is awake as this would not only be very painful, it would be traumatic for both the girl and her parents.
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