Prepubertal

Infections and inflammation of the vulva and vagina account for 85% to 90% of all genital problems in prepubertal girls. These conditions are encountered most commonly in children 2 to 7 years old. Infections of the vulva and vagina usually occur together and generally are considered one entity—vulvovaginitis. The various types of vulvovaginitis are differentiated by determining the presence or absence of specific microbial or other agents associated with the inflammation in a particular case. Vulvovaginitis accounts for greater than 80% of cases of recurrent vaginal discharge in prepubertal girls.

Genital discharge does not always indicate infection or inflammation. Most female infants have a grayish white, mucoid discharge from the vagina during the newborn period. This discharge consists of desquamated vaginal mucosa and cervical epithelium that has undergone hypertrophy because of prenatal stimulation by placental and maternal hormones. Microscopic examination of the material reveals masses of large, superficial vaginal epithelial cells ( Fig. 42.2 ). The condition may last for several weeks, is not pathogenic, and does not require treatment.

Cytosmear from the vaginal discharge of a newborn.

Similarly, a pubertal girl nearing menarche may develop a copious viscous, transparent secretion that exudes from the vagina. This normal state sometimes raises concern about possible vaginal infection. The vulvar and vaginal tissues appear thick and moist, a sign of increased estrogen stimulation, without erythema. Microscopic examination of the vaginal fluid reveals masses of estrogenized superficial vaginal epithelial cells and few leukocytes ( Fig. 42.3 ).

Cytosmear from the vaginal secretion of a pubertal girl. Masses of epithelial cells and few bacteria or leukocytes attest.

Genital discharge and perineal or vulvar discomfort are the most common symptoms of vulvovaginitis. The discomfort may range from minor pain or soreness to intense perineal burning or pruritus. Genital erythema is the most common sign in girls, and vulvovaginitis can be found in more than 80% of cases. Visible discharge is present in one third of cases. Infections of the vulva and vagina are more likely to be accompanied by moderate or severe inflammation and prominent discharge than is nonspecific vulvovaginitis. Infection can be present at times, however, with neither discomfort nor discharge.

The characteristics of the discharge frequently do not help identify a specific cause. At the onset of an infection, the discharge is often thick, purulent, and profuse. It may become scanty and seropurulent in later stages of infection. Discharges that are odorless and bloody or serosanguineous may result from noninfectious conditions, such as vulvar irritation, trauma, precocious puberty, urethral prolapse, and tumor. Vulvovaginitis caused by Shigella or group A streptococci also can cause bleeding, as can an eroding foreign body. Foul-smelling discharge suggests a foreign body but also may result from a necrotic tumor. Urinary leakage from an ectopic ureter opening into the genital tract may mimic a vaginal discharge. Specific diagnoses are made more often when symptoms have been present for less than 1 month.

In several series of 80 to 500 prepubertal and pubertal girls up to age 12 with vulvovaginitis and no suspicion of sexual abuse, the most common bacterial isolates were groups A and B streptococci, Staphylococcus aureus, and nontypable Haemophilus influenzae , Escherichia coli, P. mirabilis, and enterococci. Anaerobes were found in more than half of patients in one series. These bacteria, especially group A streptococci, causing vulvovaginitis may lead to more severe symptoms that result in care being sought soon after onset, whereas pathogenic bacteria generally are less likely to be found when girls initially are examined after several weeks of symptoms.

Postpubertal

Infections of the pubertal and postpubertal vulva and vagina produce a variety of overlapping symptoms, including vulvar pruritus, dysuria, and increased or altered vaginal discharge and spotting. As a result, distinguishing among various lower genital tract infections based solely on symptoms is difficult. The history, physical examination, and laboratory tests play an important role in assisting the clinician in differentiating urethritis, vaginitis, and cervicitis.

Nonspecific Vulvovaginitis

Nonspecific vulvovaginitis is a frequently encountered condition in prepubertal girls and is addressed in this section. Nonspecific vaginitis in postpubertal females is called bacterial vaginosis and is addressed in its respective section in this chapter.

Vulvovaginitis secondary to intestinal parasites.

Pinworms (Enterobius vermicularis) are the causative factor in many cases of recurrent or intractable nonspecific vulvovaginitis in children. Infection occurs when the worms in the lower bowel crawl out of the anus onto the perineum and migrate into the vagina, where they deposit ova. The pinworms may carry E. coli and other coliform bacteria into the vagina, which may lead to vulvovaginitis.

Pinworm ova may be deposited in playground soil, on toys or books, and on the hands of infected individuals. Infection frequently is asymptomatic. A child with a pinworm infection and vulvovaginitis usually has a history of a chronic vaginal discharge that has recurred despite repeated attempts to eradicate it. Parents may note worms on the perineum of the child and that she awakens at night because of perineal itching.

Examination reveals a low-grade inflammation of the vulva and vagina. Excoriations from scratching may be seen on the perineum. Vaginoscopy (if indicated) shows an inflammatory reaction extending to, but not including, the cervix. Vaginal cultures produce a mixed growth of nonpathogenic bacteria, with E. coli and other coliform bacteria generally predominating.

The diagnosis depends on finding pinworm ova on smears from the perineum or in the vaginal discharge or a report from parents that worms are visible on the child’s perianal skin. A perineal smear is most likely to show the presence of pinworms, but pinworm ova of E. vermicularis may be detected in a wet smear of vaginal secretions (pinworms, Fig. 42.4 ).

Pinworm ova discovered in a vaginal smear from a child with intractable vulvovaginitis.

The adhesive tape test can be performed in the office or the parent asked to collect three specimens at night. The parent is given a wooden tongue blade or paddle with adhesive tape and a glass microscopic slide ( Fig. 42.5 ). The adhesive side is applied firmly to several areas around the anus. It is removed and applied, adhesive side down, to the glass slide, which is sent to the laboratory for examination.

Technique for obtaining a perianal smear for detection of pinworm ova, using adhesive tape and a tongue depressor.

Treatment consists of eradicating the pinworms. All members of the family are presumed to be infected and should be treated. Recommended treatment regimens are mebendazole 100 mg orally; albendazole 400 mg orally; or pyrantel pamoate 11 mg/kg base, not to exceed 1 g. Each is given in a single dose and repeated in 2 weeks. The vulvovaginitis caused by coliform organisms carried on pinworms is treated the same as in other cases of nonspecific vulvovaginitis caused by poor perineal hygiene (see earlier discussion).

Vulvovaginitis secondary to vaginal foreign bodies.

Foreign bodies account for approximately 4% of cases of vaginal discharge in premenarcheal girls. When a foreign body remains in the vagina for some time, it inevitably causes nonspecific vulvovaginitis. Many types of vaginal foreign bodies, including safety pins, glass beads, coins, beans, bits of crayon, and parts of toys, have been reported. The most common objects are bits of toilet paper or shreds of cloth from nightclothes or bedding ( Fig. 42.6 ).

Bits of paper or cloth are the vaginal foreign bodies most frequently found in children.

The history does not contribute to the diagnosis unless the child is known to have previously put objects in her vagina. The child usually is brought to a physician because of a profuse, foul-smelling, sometimes blood-tinged discharge. The presence of such a discharge is almost pathognomonic for the presence of a foreign body. Even without a profuse discharge or bleeding, a foul odor from the vagina suggests a foreign body. In addition a foreign body should be suspected when a recurrent discharge is reported.

Examination reveals inflammation of the vulvar and vaginal mucosa. Soft foreign bodies, such as toilet paper, can be flushed out of the vaginal canal. Although foreign material may be seen when the labia are separated, a vaginoscopy may also be necessary to explore the full length of the vagina. A topic anesthetic agent such as xylocaine jelly can be helpful in such situations. Rarely a metallic object that has been in the vagina for some time erodes the mucosa and becomes hidden in granulation tissue. When such a condition is suspected, a radiograph should be obtained. Most foreign bodies, such as glass, plastics, paper, or cloth, are not radiopaque, however, and radiographic examination fails to detect the foreign material. An examination under anesthesia may also be necessary when a larger foreign body has to be extracted.

The nonspecific vulvovaginitis caused by a foreign body disappears gradually after removal. Recovery can be hastened by using the hygienic treatments previously described. Repeat episodes are common.

Specific Non–Sexually Transmitted Vulvovaginitis

Mycotic (fungal) vulvovaginitis

Prepubertal.

The role of Candida spp. as a causative agent of vulvovaginitis in healthy prepubertal children has been controversial. While diaper dermatitis with Candida spp. colonization or secondary infection is common in infants, co-occurrence with vulvovaginitis is unusual.

Candida vulvovaginitis is rare in prepubertal children and is more likely to occur in girls starting with pubertal development.

Risk factors for developing recurrent and persistent fungal vulvovaginitis in prepubertal children include a history of recent antibiotic use, uncontrolled diabetes mellitus, or immunosuppression. Mycotic infections are not considered STIs.

A study in Turkey among children 8 to 12 years of age with type 1 diabetes mellitus Candida spp. was reported in 50% of vaginal specimens; C. albicans in 50%, C. glabrata in 37%, and other Candida spp. in 13% ( C. dubliniensis, C. krusei ). A higher prevalence rate of Candida spp. was reported in postpubertal versus prepubertal children; 30% versus 6%.

Mycotic vulvovaginitis in prepubertal children, when it does occur, usually causes severe persistent and/or recurrent episodes of vulvar and vaginal itching. When a discharge is present it is white, thick, and curdled and has a yeasty sour odor. The patient may have pain during and after voiding or external dysuria as a result of urine coming in contact with excoriated areas on the urethra and vulva ( Fig. 42.7 ).

Mycotic vulvovaginitis. The child had diabetes.

Postpubertal.

Prevalence studies of Candida spp. in asymptomatic and symptomatic postpubertal adolescent females are few. In 198 adolescents 15 to 19 years of age at a sexually transmitted disease clinic in the northwestern United States, 30% were positive for C. albicans . In another study of 200 sexually active adolescents (mean age, 19 years) at an adolescent health center in Sweden, a history of vulvovaginal candidiasis was reported at least once by 60% and recurrent candidiasis (at least three or more episodes) by 22%. C. albicans was isolated by culture in 43% and C. glabrata in 3 adolescents; 15% of adolescents with culture positive for Candida spp. were asymptomatic. Several factors play roles in causing the increased incidence of vaginal candidiasis after menarche: menstruation, oral-genital sex, fecal contamination of the vulva, wearing tight-fitting underclothes, widespread use of antibiotics, and the use of oral contraceptives. Other predisposing factors include pregnancy, obesity, uncontrolled diabetes mellitus, immunosuppressive therapy, and illicit drug addiction. Candida vulvovaginitis can occur concomitantly in sexually active adolescents.

Mycotic vulvovaginitis in the postpubertal period causes severe vulvar and vaginal itching and external dysuria. The discharge is white, thick, and curdled and has a sour odor. Sexually active adolescents can report painful sexual intercourse. Examination in the acute stage reveals intense inflammation of the vulva and vagina with shiny and beefy red mucosa with linear excoriations and edema. Long-standing infection can cause lichenification and hyperpigmentation of the perineal skin. Vaginal pH usually is less than 4.5.

Diagnosis.

The diagnosis in all age groups is frequently based on clinical findings. It can be established by finding hyphae and buds of the fungus in vaginal fluid by a vaginal saline wet preparation under microscopy ( Fig. 42.8 ). If debris and cellular material render identifying the fungus difficult, a smear using 10% potassium hydroxide solution is helpful. The potassium hydroxide solution dissolves other extraneous material without affecting the fungus. Even with an experienced microscopist, this method yields a sensitivity range of 40% to 86% in symptomatic girls; however, the yield may be only 40%. Further confirmation can be obtained by identifying fungus by culture of material from the vagina or vulva on Sabouraud or Nickerson media and is helpful in recurrent candida vulvovaginitis. Culture remains the gold standard. Nucleic acid amplification tests for Candida spp. have not been cleared by the U.S. Food and Drug Administration (FDA). In sexually active adolescents, testing for Chlamydia and gonorrhea infection should be considered.

Hyphae of Candida albicans discovered on a wet smear of vaginal discharge.

Prepubertal

Gonococcal infections of the prepubertal genital tract are manifested as vulvovaginitis. The alkaline environment of the unestrogenized vaginal tissues of young girls apparently limits spread of infection to the upper genital tract. Gonorrhea is found less commonly in children now than in the past but must be considered whenever a girl has vulvovaginitis.

In infants, perinatal nonsexual transmission is considered the most likely cause of gonococcal infection. In 1965, Branch and Paxton reported that, in 1- to 11-month-old infants, all the mothers were found to have gonococcal infection and no history of sexual contact could be elicited. The authors concluded that transmission of the infection was perinatal from freshly contaminated hands or through fomites. They also reported that 93% of children aged 1 to 9 years with gonorrhea had sexual contact with relatives in the household.

N. gonorrhoeae has been shown to survive for 20 to 24 hours in infected secretions on towels and handkerchiefs. Although N. gonorrhoeae has survived on toilet seats for 2 hours, no gonococci were recovered from toilet seats in public restrooms or in a clinic for STIs. Nonsexual transmission to adults is rare.

Prepubertal children with gonococcal infection frequently are found to have a history of sexual contact. The rate of eliciting a history of sexual contact in prepubertal children with gonorrhea ranges from 36% to 93%. Ingram and colleagues found that 35% of 1- to 4-year-old children and 100% of children older than 4 years with gonorrhea reported having sexual contact with an older male family member. Folland and coworkers elicited a history of sexual contact from 34% of children with gonococcal urethritis and vaginitis.

Testing of household members in an infected child’s environment can detect infected adults at a rate of 18% to 29%. In a retrospective study of 14 Native Alaskan children with gonococcal infection, 3 reported having sexual contact. Seven children slept with their parents, one or both of whom had gonorrhea; the authors assumed that these children acquired the infection by nonsexual means. Nonsexual transmission conceivably occurs in children who sleep and bathe with their parents.

N. gonorrhoeae was the most common cause of vulvovaginal discharge among prepubertal girls in Rwanda in the late 1980s. Sexual contact was considered likely in all cases because of a cultural belief that a man with a purulent urethral discharge could be cured by rubbing his penis on the external genitalia of a prepubertal girl. In a prospective study of girls 12 months to 12 years of age in the mid-1990s in Cincinnati, Ohio, who had vaginal discharge and no suspicion of sexual abuse, 4 of 43 had positive cultures for N. gonorrhoeae . Such cases should lead to investigation for probable sexual abuse.

In summary, sexual transmission is the more common and most likely mode of transmission, and the presence of gonorrhea should be considered diagnostic of sexual abuse. Thus an investigation for sexual abuse must be pursued in a child with gonorrhea by reporting the case to the appropriate legal authority.

The acute stage of gonorrheal vulvovaginitis is characterized by inflammation and a purulent discharge. The child may complain of vulvar discomfort, dysuria, frequent urination, and pain on walking. The child usually is well otherwise. Asymptomatic vaginal infection is rare. On examination, the vulvar tissues are edematous, hyperemic, and covered by a profuse, thick, yellowish discharge that exudes from the vagina. The entire vaginal mucosa is inflamed.

The urethra, paraurethral glands, and major vestibular (Bartholin) glands rarely are involved in a premenarcheal gonorrheal infection. Vulvovaginal infections, including gonorrhea, in prepubertal children rarely if ever affect the upper genitalia (uterus, uterine tubes, ovaries, or pelvic peritoneum). Symptoms suggestive of pelvic peritonitis have been reported in premenarcheal children who had gonorrheal vulvovaginitis; all the patients recovered promptly after the administration of penicillin.

Diagnosis

The diagnosis of gonorrheal vulvovaginitis and its differentiation from other types of vulvovaginitis are established by vaginal cultures. Gram stain of a vaginal specimen is not an appropriate diagnostic test. Specimens from the pharynx and rectum to test for N. gonorrhoeae also should be obtained. Cervical specimens are not recommended from prepubertal girls. Because of the potential medicolegal use of the test results for N. gonorrhoeae among children, standard culture systems should be used for the diagnosis of N. gonorrhoeae in children. Nucleic amplification testing for gonorrhea using urine and vaginal swabs was conducted in 485 premenarcheal girls with alleged sexual abuse from four cities in the United States. The sensitivity of urine nucleic acid amplification testing (NAAT) for gonorrhea relative to vaginal swabs was 100%. The Centers for Disease Control and Prevention (CDC) states that consultation with an expert is necessary prior to obtaining a NAAT test to minimize cross-reactivity with other Neisseria spp. and to assure correct interpretation of positive results.

Treatment

The presence of gram-negative intracellular diplococci in vaginal smears from a child with a history of exposure or with typical clinical findings is sufficient reason to start treatment, but it does not establish a definitive diagnosis. Further details on treatment are addressed in Chapter 89 .

Prepubertal

Although C. trachomatis appears to be an uncommon cause of vaginitis in prepubertal girls, vaginal infection with C. trachomatis can occur in children. In contrast to prepubertal gonorrhea infections, chlamydial vaginitis in children often seems to be asymptomatic. Although coinfection with C. trachomatis has not been studied well in prepubertal children, experience from adult populations has shown that it should be suspected in children with N. gonorrhoeae infection. In one study in prepubertal girls, 30% with N. gonorrhoeae also tested positive for C. trachomatis.

Perinatally acquired genital Chlamydia infection is a strong possibility in children younger than 1 year. C. trachomatis has been isolated from the conjunctiva, nasopharynx, vagina, and rectum of infants born to infected mothers. Subclinical infections have been reported in 14% of infants of mothers with active C. trachomatis infection. However, perinatal transmission is possible in children up to 3 years of age. This may be due to persistence of perinatal infection. Infants infected with C. trachomatis at birth have remained infected for up to 372 days in the vagina; 383 days in the rectum; and 866 days in the conjunctiva, nasopharynx, and oropharynx. Thus persistent chlamydial infection of the pharynx in infants can persist for 2 years. Persistence of perinatal infection for 18 months and for 6 years has been reported in other studies as well.

Studies of C. trachomatis infection in prepubertal girls have involved mostly children being evaluated for sexual abuse or vulvovaginal symptoms, or both, and some have included a control group in an attempt to control for either a history of sexual abuse or vaginal symptoms.

The variation in rates among studies may reflect differences in the prevalence of C. trachomatis in different communities. The highest rates of C. trachomatis infection were seen in a Los Angeles study, in which 47 prepubertal girls were examined for alleged sexual abuse and 17% had vaginal C. trachomatis . In other studies evaluating children suspected of being sexually abused, rates of recovery (pharyngeal and rectal infection included) tend to be higher (6–8%) than those seen in children with vaginitis or controls (0–2%). Initial evaluations of children presenting with vaginitis or in the control groups may not elicit a history of sexual abuse, but further questioning or testing of all orifices (pharyngeal and rectal) may elicit suspicion or a history of sexual abuse. For example, a history of sexual abuse was discovered in two control children only after C. trachomatis was identified. Initially, 2% of children with a history of sexual abuse versus 4% of healthy controls had positive vaginal cultures for C. trachomatis . On further questioning, however, the two children in the control group with C. trachomatis were siblings who were sexually abused 3 years earlier, increasing the rate of C. trachomatis vaginal infection in the sexual abuse group to 6% and decreasing the rate in the control group to zero. This report illustrates the importance of thoroughly investigating the possibility of sexual abuse whenever a sexually transmitted pathogen is isolated in a young child.

In studies evaluating premenarcheal children presenting with vulvovaginitis, recovery of C. trachomatis has been low in children with symptoms and healthy control groups. In one study, none of the 35 children with symptoms had C. trachomatis, whereas 1 of 35 without symptoms had C. trachomatis isolated. In another study conducted in a pediatric gynecology clinic, 4 of 29 (14%) premenarcheal girls were found to have C. trachomatis. All four had a homogeneous white discharge, and one had a bloody discharge. Sexual abuse occurred in two of the children and was considered possible in another. In a Cincinnati study evaluating vaginitis in girls younger than 12 years in whom sexual abuse was not suspected, none of the 87 children had a positive culture for C. trachomatis. Similarly, in a smaller study of 11 girls with vaginitis, none was found to have C. trachomatis.

In summary, although persistence of perinatal infection can occur, when C. trachomatis is identified in vaginal specimens, sexual abuse as a potential mode of transmission of C. trachomatis infection should be considered in children older than 1 year. There are no data demonstrating survival of C. trachomatis on fomites or its coexistence in family members of infected children. Thus an investigation for sexual abuse must be pursued in a child with Chlamydia infection by reporting the case to the appropriate legal authority.

Diagnosis

Numerous diagnostic methods for Chlamydia are available. Direct tissue culture isolation of C. trachomatis remains the gold standard and is the only test that should be used in prepubertal children or in cases in which sexual abuse is under consideration. Culturing for Chlamydia requires isolation of the organism in tissue culture and confirmation of the characteristic intracytoplasmic inclusions by fluorescent monoclonal antibody staining. Although the specificity of tissue culture approaches 100%, tissue culture is only 70% to 85% sensitive in contrast to DNA amplification techniques. The low recovery rate in studies of prepubertal children may be due to the low sensitivity of tissue culture or the use of vaginal cultures in young children. Isolation rates from the vagina usually are lower than rates of recovery from the endocervix.

Nonculture tests for Chlamydia, including enzyme immunoassays, direct fluorescent antibody tests, DNA hybridization, and DNA amplification tests, have not been field tested for large numbers of vaginal specimens or rectal or pharyngeal specimens from premenarcheal girls. False-positive results have been reported in vaginal specimens for some of these tests in children, and these tests should not be used in premenarcheal children. False-positive results probably are caused by cross-reactivity with common anogenital organisms, such as group A and B streptococci , N. gonorrhoeae, G. vaginalis, E. coli, and Proteus, Acinetobacter, and Staphylococcus spp.

However, more recently, NAAT for C. trachomatis using urine and vaginal swabs was conducted in 485 premenarcheal girls with alleged sexual abuse from four cities in the United States. The sensitivity of urine NAAT for Chlamydia relative to vaginal swabs was 100%. The CDC states that consultation with an expert is necessary prior to obtaining a NAAT test to assure correct interpretation of a positive result.

Treatment

Treatment for Chlamydia infection is addressed in Chapter 194 .

Prepubertal

Vaginal trichomoniasis is reported infrequently in prepubertal children. This low prevalence may be accurate or could be due to lack of appropriate testing or limitations of the diagnostic techniques used in studies in prepubertal children.

Trichomoniasis in newborns has been described in several case reports through the acquisition of T. vaginalis from the mother’s vagina during delivery, with recovery of T. vaginalis from urine, vaginal, and respiratory tract specimens. The prevalence of T. vaginalis in healthy, vaginally delivered infants of mothers with T. vaginalis is unknown. In one study of 868 infants, T. vaginalis could not be identified in any of the 14 female infants of mothers in whom T. vaginalis was diagnosed. The overall prevalence of T. vaginalis was 4%, but the denominator of mothers of female infants was not described. In another study of 984 female infants, direct smear or culture (or both) of infant vaginal specimens identified three infants with T. vaginalis, a prevalence of 0.3%. Of the three infants, two had a vaginal discharge. The overall prevalence of infection in the mothers of the 984 infants was not reported. Of the three infants with T. vaginalis, one mother had a history of vaginal discharge and a negative direct smear for T. vaginalis, and the other two mothers had no history of T. vaginalis. In conclusion, transmission of T. vaginalis in infants aged 1 year probably is perinatal.

The mode of transmission in children older than 1 year is controversial. Numerous reports confirm the occurrence of T. vaginalis in prepubertal girls evaluated for vaginitis but no history of sexual abuse with prevalence rates ranging from 0% to 4%. In studies with a healthy control population, T. vaginalis was not identified in any of the children in the asymptomatic control group.

A case report in 1985 described T. vaginalis in two sexually abused children with vaginal discharge ; however, in studies systematically evaluating children for sexual abuse regardless of symptoms, T. vaginalis has not been recovered. In an Australian study evaluating 160 children younger than 10 years and 95 healthy age-matched controls, none of the children had T. vaginalis isolated from vaginal cultures. Similarly, none of the 119 prepubertal girls evaluated for sexual abuse in a Cincinnati, Ohio, study had T. vaginalis identified by urinalysis or wet mount of vaginal secretions. Without additional studies using culture techniques and conducted in diverse populations of prepubertal girls, determining the true prevalence of T. vaginalis in prepubertal girls who have vaginitis, with or without a history of sexual abuse, is difficult.

Nonsexual transmission within a family without sexual abuse or contact can conceivably occur. In a case report, T. vaginalis was diagnosed in the mother, and her three prepubertal daughters were symptomatic with a vaginal discharge. Two of the three girls had T. vaginalis identified on wet-mount evaluation of their vaginal specimens. They had no history or evidence of sexual abuse, the father was asymptomatic, and microscopy of an early morning urine specimen was negative for T. vaginalis.

A study from Poland found one case of T. vaginalis infection in children aged 2 to 7 years and a significantly higher number of cases in 8- to 10-year-old girls. The numbers increased even further for children older than 10 years, suggesting a strong association between T. vaginalis and the presence of an estrogenic environment, which promotes glycogen production and decreases vaginal pH.

The Polish investigation tested families of women infected with T. vaginalis and found that almost a third of their sexual partners and 8% of the children (mostly girls) had T. vaginalis. When families of men infected with T. vaginalis were tested, 91% of their sexual partners and 13% of the children had T. vaginalis. When families of children (mostly girls) infected with T. vaginalis were tested, 72% of the mothers and 43% of the fathers had the infection. The investigators considered that the infection in the latter group originated from mothers and that the primary mode of transmission was nonsexual (beds, sponges, towels, overcrowding). Information regarding sharing of potentially infected fomites, sexual abuse, or physically intimate behavior between parents and children was not gathered in these cases.

Although T. vaginalis has been known to survive on fomites in controlled experiments, its ability to spread by these means is unknown. No cases of adults being infected by fomites have been documented. T. vaginalis has been found to survive for 6 hours on droplets of discharge and enameled surfaces of wood blocks. It has been isolated from droplets of water splashed from toilets containing the urine of an infected individual. T. vaginalis also has been found to survive in mud baths, bathing waters, and warm mineral waters and on moist bathing implements. In rural India, a survey found that young girls who bathed in tanks or rivers had a significantly higher risk for acquiring T. vaginalis than did girls who used piped or well water.

In summary, the likelihood of perinatal transmission of T. vaginalis is high in infants younger than 1 year. In a child older than 1 year, T. vaginalis infection may have resulted from transmission within a family without sexual abuse; however, the probability of sexual abuse must be considered highly suspicious, and the case must be investigated and reported for possible sexual abuse. Perinatal transmission and transmission through fomites should not be assumed without an investigation for sexual abuse. Additionally if T. vaginalis is recovered from a child, the child should be evaluated for other STIs, including syphilis, N. gonorrhoeae, C. trachomatis, hepatitis B, and HIV infection.

Postpubertal

Trichomoniasis is common and frequently is asymptomatic in sexually active adolescents (see Chapter 215 ). When it is symptomatic, patients complain of a profuse, irritating discharge. The discharge and the pruritus tend to be more severe just before and immediately after a menstrual period. Patients occasionally report dysuria and abdominal pain. Recurrent exacerbations of the infection occur commonly.

Examination reveals diffuse vulvitis with erythema and excoriations and copious leukorrhea that covers the vulvar tissues. The discharge typically is frothy or bubbly, grayish yellow, and watery or mucopurulent. It has a pH of 5.0 to 7.0 and an acrid or musty odor. A “strawberry” or punctate vaginal eruption with hemorrhagic spots has been described as being typical of trichomoniasis. Such eruptions frequently are not present, however, even in severe cases. More often, diffuse inflammation causes the vaginal mucosa to be brilliant red.

Diagnosis

There are numerous diagnostic methods available to diagnose trichomoniasis. The diagnosis of trichomoniasis usually is confirmed clinically by finding trichomonads in a wet saline smear of vaginal fluid. It is important that the slide be viewed under the microscope (dry high power) promptly because the organisms do not remain viable for long outside the vagina and are difficult to detect when they cease to be motile. The observer sees numerous ovoid-shaped, motile organisms (see Fig. 42.9 ). The sensitivity of this test with immediate evaluation is 60% to 70%. A Papanicolaou (Pap) smear to detect trichomoniasis is not recommended because of the high rate of error in identifying trichomonads in stained smears. Other methods used to diagnose trichomoniasis include isolation by special culture medium, direct fluorescent immunoassay, NAAT, rapid antigen test, and nucleic acid probe. The choice of test is often based on availability. The NAATs are highly sensitive and specific and have become the gold standard for diagnosing trichomoniasis. Culture also has high sensitivity and specificity, but it is not routinely available. The NAAT is available in some clinical settings (point-of-care test); however, a false-positive result may occur in low-prevalence populations.

Treatment

Treatment for trichomoniasis is addressed in Chapter 215 .