Differential diagnosis

Vaginal discharge in a pediatric patient may be physiologic. Estrogen of maternal origin present in the first 2 or 3 weeks of life or in early puberty produces a physiologic leukorrhea which is characterized as a milky-white, yellow or clear mucus discharge without an offensive odor or vulvar involvement. During this interval, under the influence of estrogen, the vaginal epithelium of the newborn is several layers thick and the vaginal pH is acidic. An increase in endogenous estrogen normally occurs in early puberty.

There are several pathologic causes of vulvovaginitis in children (Box 55.1). Poor perineal hygiene may result in the transfer of coliform bacteria and other enteric pathogens to the vagina. Sexually transmitted diseases can occur in prepubertal girls of all ages. A foreign body placed in the vagina may lead to a vaginal discharge and contact irritants can cause vulvar-vaginal symptomatology. Candidiasis, enterobiasis, and shigellosis are infrequent specific causes of vaginal leukorrhea. β-Hemolytic streptococcus and coagulase-positive staphylococcus may be spread manually from their primary site, the nasopharynx, to the vagina. Congenital anomalies of the urogenital system very rarely produce symptoms which may be interpreted as vaginal discharge.

Wiping the perineum in a direction from the anus to the vagina may allow a mixture of enteric organisms to invade the vagina, including gram-negative coliform bacteria, enterococcus and anerobic bacteria secondary to fecal contamination. Mixed enteric organisms, also referred to as nonspecific vulvovaginitis, is the most common cause of leukorrhea in prepubescent girls.

Vaginal discharge may be a clinical manifestation of a sexually transmitted disease (STD) and typically result from sexual abuse. A study of 1538 children known to have been sexually abused reported the following types and frequencies of sexually transmitted infections: Neisseria gonorrhoeae (2.8%), Chlamydia trachomatis (1.2%), human papilloma virus (1.8%). Members of the immediate family or caregivers should be evaluated and cultured in case the disease was acquired from one of them. When one STD is diagnosed it is possible the child may be co-infected with one or more other STDs and appropriate screening must be conducted. Some infants may acquire these vaginal infections through maternal colonization at the time of delivery. The incubation period for these infections may last up to 2 years. The most reliable diagnostic test for gonorrhea or chlamydia vaginitis in a prepubertal girl is a culture.

Condylomata acuminatum (venereal warts) are dry warty lesions caused by the human papilloma virus (HPV), usually type 6 or 11 in children. These lesions are likely the result of mother-to-child transmission during vaginal birth in children younger than 3 years of age, It is not necessary for the mother to be symptomatic or to report a history of HPV for transmission to occur. Herpes simplex is characterized as small vesicular lesions on an erythematous base caused by the herpes simplex virus, type 2. Examination under magnification of the scrapings taken from the herpetic lesions and prepared with Wright stain demonstrates multinucleated giant cells. Trichomonas vaginalis is expressed clinically as a frothy, watery, yellow or green discharge. The motile flagellated parasites are identified in a saline wet-mount preparation. Trichomonas vaginalis is very uncommon in prepubertal females.

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