39 D. Keith Edmonds1,2 1 Imperial College London, London, UK 2 Queen Charlotte’s and Chelsea Hospital, London, UK Gynaecological problems in the child and at adolescence can create anxiety in parents particularly, but fortunately very few of these disorders could be considered common or serious. However, when they do present, it is important that the clinician has an appropriate understanding of the various conditions so that the correct advice may be given to the patient. Management is frequently through simple means, with education and a sympathetic approach being essential. The disorders fall into two groups: those related to pre‐puberty and those of adolescence. Examination of the prepubertal child requires cooperation from both the patient and the mother and requires extreme sensitivity if a successful examination is to be carried out. Positioning the child for examination may require considerable time in order to gain the confidence of the child to allow examination. External examination should be performed with minimal handling of the vulva and, in order to expose the vaginal orifice, gentle traction on the buttocks to expose the vaginal opening can be performed. This can often be more effectively achieved by the mother rather than the physician. Specimens can be obtained using syringes with flexible catheters or occasionally a swab may be inserted if the hymenal orifice allows. In adolescents, vaginal examination should be avoided unless there is good evidence that it is absolutely necessary in order to make a diagnosis. Imaging is the preferred investigation if further information is required. This is the only gynaecological disorder of childhood which can be thought of as common. Its aetiology is based on opportunistic bacteria colonizing the lower vagina and inducing an inflammatory response. At birth the vulva and vagina are well oestrogenized due to the intrauterine exposure of the fetus to placental oestrogen. This oestrogenization causes thickening of the vaginal epithelium, which is entirely protective against any bacterial invasion. However, within 2–3 weeks of delivery the resultant hypo‐oestrogenic state leads to changes in the vulval skin, which becomes thinner, and the vaginal epithelium also becomes much thinner. The vulval fat pad disappears and the vaginal entrance becomes unprotected. The vulval skin is thin, sensitive and easily traumatized by injury, irritation, infection or any allergic reaction that may ensue. The lack of labial protection and the close apposition of the anus mean that the vulva and lower vagina are constantly exposed to faecal bacterial contamination. The hypo‐oestrogenic state in the vagina means that there are no lactobacilli and therefore the vagina has a resulting pH of 7, making it an ideal culture medium for low‐virulence organisms. The complaint is usually of discharge which may be offensive, yellow or green in colour and parents often bring stained underwear as evidence of the condition. It occurs most commonly between the ages of 2 and 7 years. Examination of the vulva reveals inflammation and occasionally excoriation. Children also have the habit of exploring their genitalia and in some cases masturbating. This chronic habit may lead to vulvovaginitis, which can prove extremely difficult to treat. Vulvovaginitis may also occur in childhood in those who have an impaired local host defence deficiency due to the lack of an innate local protective response from neutrophils. The causes of vulvovaginitis in children are shown in Table 39.1. The vast majority of cases are due to non‐specific bacterial contamination, which in the majority of cases is due to poor hygiene. If a specific pathogen is isolated, for example Streptococcus pneumoniae, Staphylococcus aureus or Haemophilus influenzae, antibiotics can be considered. Escherichia coli is a contaminant from poor hygiene. Table 39.1 Causes of vulvovaginitis in children. Candidal infection in children is extremely rare, although as a common cause of vulvovaginitis in the adult, it is a common misdiagnosis in children. Candida in children is usually associated with diabetes mellitus or immunodeficiency and almost entirely related to these two medical disorders. The presence of viral infections, for example herpes simplex or condylomata acuminata, should alert the clinician to the possibility of sexual abuse. Vulval skin disease is not uncommon in children, particularly atopic dermatitis in those children who also have eczema. Referral to a dermatologist is appropriate in these circumstances. Lichen sclerosus is also seen in children and may cause persistent vulval itching. The skin undergoes atrophy and fissuring and is very susceptible to secondary infection. Sexual abuse in children may present with vaginal discharge. Any child who has recurrent attacks of vaginal discharge should alert the clinician to this possibility. However, as non‐specific bacterial infection is a common problem in children, the clinician must proceed with considerable caution in raising the possibility of sexual abuse. Only those bacterial infections related to venereal disease, for example gonorrhoea, may be cited as diagnostic of sexual abuse. It is important that the clinician remembers that many girls suffer from urinary incontinence, particularly at night, and this creates a moist vulva allowing secondary infection by bacteria leading to vulvovaginitis. There are two aspects of the diagnosis in this condition in children. The first is inspection of the vulva and vagina. It is imperative that the clinician has good illumination, particularly if there is a history of a vaginal foreign body. It is usually possible to examine the vagina through the hymen using an otoscope. This may well allow the diagnosis of a foreign body to be made. The second aspect of diagnosis involves the taking of bacteriological specimens. This can be extremely difficult in a small child, as it is unlikely that the child will be cooperative. Any object which touches the vulva causes distress. The best way to take a bacteriological specimen is to use a pipette, which is much less irritating than a cottonwool swab. The pipette allows 1–2 mL of normal saline to be expelled into the lower part of the vagina, the tip of the pipette having been passed through the hymenal orifice. The fluid is then aspirated and sent for bacteriology. If a diagnosis of pinworms is to be excluded, then a piece of sticky tape over the anus early in the morning before the child gets out of bed will reveal the presence of eggs on microscopy. The vast majority of children do not have a pathological organism. The primary treatment in this group is advice about perineal hygiene. All parents of children with chronic vaginal disease are extremely worried that this may cause long‐term detrimental effects to their daughters, particularly the fear of sexual dysfunction or subsequent infertility. There is no evidence that this is the case and therefore parents should be reassured that this is a local problem only. Management of these children is directed towards diligent hygiene of the perineum. The child must be taught to clean her vulva, particularly after defecation, from front to back, as this avoids the transfer of enterobacteria to the vulval area. After micturition the mother and child should be instructed to clean the vulva completely and not to leave the vulval skin wet, as this damp warm environment is an ideal culture surface for bacteria that cause vulvovaginitis. The mother must also be informed that vulval hygiene through daily washing should be performed, but that the soap should be gentle and not scented. Excessive washing of the vulva must be avoided as this leads to recurrent exfoliation and vulval dermatitis. During acute attacks of non‐specific recurrent vulvovaginitis, children often complain of burning during micturition due to the passage of urine across the inflamed vulva. The use of barrier creams in these circumstances may be very useful. There is no evidence that topical oestrogen and antibiotic creams are of any benefit and should not be prescribed. Foreign bodies are occasionally found in the vagina and may lead to vaginal discharge. In patients who have persistent vaginal discharge despite treatment, an ultrasound scan may detect a foreign body or, if a history of a foreign body is forthcoming, it is probably best to carry out an examination under anaesthetic and remove any foreign body at that time. Vaginal bleeding in childhood is extremely rare and should always be treated with suspicion. The causes of genital bleeding in childhood include a vaginal foreign body, trauma, a neoplasm, premature menarche or urethral prolapse and the diagnosis can almost always be made on clinical inspection. Treatment should be appropriate but if trauma is suspected, sexual abuse must always be considered with referral to the appropriate team. Labial adhesions are usually an innocent finding and a trivial problem, but its importance is that it is frequently misdiagnosed as congenital absence of the vagina. They occur most frequently in children aged between 3 months and 3 years, with a prevalence of about 3%. The physical signs of labial adhesions are easily recognized. It is believed that labial adhesions result from vulvar inflammation in a hypo‐oestrogenic environment. The labia minora stick together in the midline, usually from posterior to anterior until only a small opening is left through which urine is passed. Similar adhesions sometimes bind down the clitoris. It may be difficult to distinguish the opening at all. The vulva has the appearance of being flat, and there are no normal tissues beyond the clitoris evident. However, a translucent, dark, vertical line in the midline where the adhesions are thinnest can usually be seen, and these appearances are quite different from congenital absence of the vagina. There are usually no symptoms associated with this condition, although older children may complain that there is some spraying when they pass urine. As late childhood ensues and ovarian activity begins, there is spontaneous resolution of the problem in 80% of children. In the majority of cases no treatment is required and the parents should be reassured that their daughters are entirely normal. In those children in whom there are some clinical problems, local oestrogen cream can be applied for about 2 weeks. There is complete resolution of the labial adhesions in 90% of cases. In the case of failure of oestrogen treatment, topical betamethasone 0.05% may be used and success in this group is about 70%. In the small minority of unresolved cases, surgical separation may be needed but this is extremely rare and should be avoided if possible as recurrence rates are high. Application of a bland barrier cream at this stage may help to prevent further adhesion formation. Finally, in taking a history it is important to establish that there has not been any trauma to the vulva, as very rarely labial adhesions may be the result of sexual abuse.
Gynaecological Disorders of Childhood and Adolescence
Prepubertal child
Vulvovaginitis
Diagnostic procedures
Treatment
Foreign body
Vaginal bleeding
Labial adhesions
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