An 18-year-old female presented to her physician with vulvar and vaginal itching associated with a vaginal discharge. On examination, the patient is noted to have redness and excoriations on her vulva (Figure 74-1). She also had a thick white discharge was seen covering cervix and vaginal sidewallson speculum exam. The pH of the discharge was 4.2, and <10 percent of the epithelial cells on her wet prep were clue cells (Figure 74-2), but yeast and hyphae were noted. She was diagnosed with candida vulvovaginitis and was treated with oral fluconazole.

Vaginal discharge is a frequent presenting complaint in primary care. The three most common causes in adolescents and adults are bacterial vaginosis, candidiasis, and trichomoniasis. Providers must refrain from “diagnosing” a vaginitis based solely on the color and consistency of the discharge, as this may lead to misdiagnosis and may miss concomitant infections.¹

Vulvovaginal complaints in prepubertal children may be result from infection, congenital abnormalities, trauma, or dermatologic conditions. Vaginitis is the most commont gynecologic problem in prepubertal girls, often presenting with symptoms including vaginal discharge, erythema, soreness, pruritus, dysuria, or bleeding.²

Adolescence is a developmental period with rapid changes in physical characteristics, sexual development, emotional development, and sexual activity. These changes may result in potential increased risk for acquiring sexually transmitted diseases.

The reported rates of chlamydia and gonorrhea are highest among females ages 15 to 19 years. Adolescents are at greater risk for sexually transmitted diseases (STDs) because they frequently have unprotected intercourse, are biologically more susceptible to infection, are often engaged in partnerships of limited duration, and face multiple obstacles to utilization of health care.¹

Cross-sectional data from the 2003 to 2004 US National Health and Nutrition Examination Survey (NHANES) shows 24 percent of female adolescents (aged 14 to 19 years) had laboratory evidence of infection with human papillomavirus (HPV, 18%), Chlamydia trachomatis (4%), Trichomonas vaginalis (3%), herpes simplex virus type 2 (HSV-2, 2%), or Neisseria gonorrhoeae. Among girls who reported ever having had sex, 40 percent had laboratory evidence of one of the four STDs, most commonly HPV (30%) and chlamydia (7%).³

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  The quantity and quality of normal vaginal discharge in healthy adolescents vary. Physiologic leukorrhea refers to generally nonmalodorous, mucousy, white or yellowish vaginal discharge in the absence of a pathologic cause. It is not accompanied by signs and symptoms, such as pain, pruritus, burning, erythema, or tissue friability. However, slight malodor and irritative symptoms can be normal for some women at certain times.⁴ Physiologic leukorrhea is usually a result of estrogen-induced changes in cervicovaginal secretions.

  
  
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  Nonspecific vulvovaginitis accounts for 25 to 75 percent of vulvovaginitis in prepubertal girls.⁵ Potential factors that increase their risk of vulvovaginitis in children include poor hygiene, lack of labial development, unestrogenized thin mucosa, more alkaline vaginal pH, bubble baths, deodorant soaps, obesity, and tight-fitting clothes.

  
  
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  Foreign bodies in children can cause acute and chronic recurrent vulvovaginitis. Toilet paper is the most common foreign body found in the vaginas of children but small toys, hair bands, beads, and paper clips are also common. ⁶

  
  
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  Sexual abuse may also result in nonspecific vulvovaginitis. Not finding STDs does not rule out abuse.⁷

  
  
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  Noninfectious causes of vaginitis include irritants (e.g., scented panty liners, spermicides, povidone-iodine, soaps and perfumes, and some topical drugs) and allergens (e.g., latex condoms, topical antifungal agents, and chemical preservatives) that produce hypersensitivity reactions.

  
  
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  Before starting an examination, determine whether the patient douched recently, because this can lower the yield of diagnostic tests and increase the risk of pelvic inflammatory disease.⁸ Patients who have been told not to douche will sometimes start wiping the vagina with soapy washcloths, which also irritates the vagina and cervix and may cause a discharge. Douching is associated with increases in bacterial vaginosis and acquisition of sexually transmitted infections when exposed. However, recent studies indicate that douching with plain water once a week or less did not disturb normal flora.^9,10

  
  
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  There are many causes of vaginitis. Infectious causes include bacterial vaginosis (40% to 50% of cases) (Figure 74-2), vulvovaginal candidiasis (20% to 25%) (Figure 74-1), and trichomonas (15% to 20%) (Figure 74-3).¹¹ Less common causes include atrophic vaginitis, cytolytic or desquamative inflammatory vaginitis, streptococcal vaginitis, ulcerative vaginitis, and idiopathic vulvovaginal ulceration associated with HIV infection.

  
  
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  Streptococcus pyogenes is the most commonly identified pathogen in prepubertal girls occuring in about 20 percent of girls with vulvovaginitis. ⁷

  
  
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  Pinworms infestation can cause vulvar symptoms, especially itching (see Chapter 179, Intestinal Worms and Parasites). Children with recurrent episodes of vulvar and/or perianal itching, especially when most symptomatic at night, should be examined for pinworms and possibly treated empirically.⁷

  
  
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  In addition to classic STDs, Mycoplasma genitalium infections are increasingly recognized as causes of sexually transmitted discharge in adolescents and young adults.¹²

  
  
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  More rare noninfectious causes include chemicals, allergies, hypersensitivity, contact dermatitis, trauma, postpuerperal atrophic vaginitis, erosive lichen planus, collagen vascular disease, Behçet syndrome, and pemphigus syndromes.