Vaginal Discharge (Vulvovaginitis)
Sara Pentlicky
Courtney Schreiber
INTRODUCTION
Vulvovaginitis, a common problem for both pediatric and adolescent patients, is an entity consisting of vaginal and vulvar irritation associated with vaginal discharge. A lack of estrogen, which protects and toughens the skin in the genital region, renders premenarchal girls particularly susceptible to vulvovaginitis. Poor hygiene, a common problem in young girls, also contributes to the problem. Some causes of vulvovaginitis are more prevalent in adolescents (e.g., Candida vulvovaginitis).
DIFFERENTIAL DIAGNOSIS LISTInfectious Causes
Bacterial Infection
Group A β-hemolytic streptococci
Staphylococcus aureus
Gardnerella vaginalis
Streptococcus pneumoniae
Neisseria gonorrhoeae, N. meningitidis
Chlamydia trachomatis
Shigella flexneri
Yersinia enterocolitica
Haemophilus influenzae
Fungal Infection
Candida albicans
C. glabrata
Parasitic Infection
Trichomonas vaginalis
Enterobius vermicularis (pinworm)
Viral Infection
Herpes simplex virus (HSV)
Neoplastic Causes
Sarcoma botryoides
Traumatic Causes
Sexual abuse
Local irritants—bubble bath, harsh soaps, tight-fitting clothes, nylon underwear, allergy to laundry detergent or fabric softener
Congenital or Vascular Causes
Hemangioma
Ectopic ureter
Miscellaneous Causes
Nonspecific vulvovaginitis
Foreign body
Labial adhesions
Physiologic leukorrhea of the adolescent
Predisposing diseases—diabetes mellitus, immunosuppression
Systemic illness—roseola, varicella, scarlet fever, Stevens-Johnson syndrome, Kawasaki syndrome
Dermatologic disorder—seborrhea, eczema, psoriasis, lichen sclerosis et atrophicus
Physiologic discharge of the newborn
Urethral prolapse
DIFFERENTIAL DIAGNOSIS DISCUSSION
Group A β-Hemolytic Streptococcal Infection
Group A β-hemolytic streptococci can cause vulvovaginitis that may be associated with a bloody vaginal discharge. The vulvovaginitis typically develops 7 to 10 days after an upper respiratory tract infection or sore throat. Examination reveals a beefy red vulvar erythema. Diagnosis is via vaginal culture. Treatment is with penicillin VK (125 to 250 mg four times daily for 10 days) or amoxicillin.
Bacterial Vaginosis
Etiology
Bacterial vaginosis results from the overgrowth of normal bacteria including anaerobes, G. vaginalis, and Mycoplasma hominis. This overgrowth results from the imbalance between normal lactobacillus and anaerobes, which could be precipitated by changes in alkalization by sex or douches, for example. The significance of G. vaginalis infection or bacterial vaginosis in children is uncertain, but one should consider the possibility of sexual abuse.
Clinical Features
The patient may complain of a vaginal discharge or a “fishy” odor after coitus or menses, and a gray or yellow, thin, homogeneous discharge is noted on physical examination.
Evaluation
Using Amsel’s criteria, patients must have three of the following four criteria to make the diagnosis:
Thin, homogeneous discharge
Clue cells seen on a saline preparation (>20% of all epithelial cells)
A positive “whiff” test (a fishy odor noted before or after discharge is mixed with potassium hydroxide [KOH] stain)
Vaginal secretions with a pH > 4.5
Treatment
Treatment of bacterial vaginosis is with metronidazole, 500 mg orally twice daily for 7 days; metronidazole vaginal gel 0.75%, one applicator (5 g) intravaginal at bedtime for 5 days; clindamycin cream 2%, one applicator (5 g) intravaginal at bedtime for 7 days; or clindamycin, 300 mg orally twice daily for 7 days.
Shigella Vulvovaginitis
Etiology
S. flexneri is most often responsible for this inflammation, which is rare in children.
Clinical Features and Evaluation
A mucopurulent vaginal discharge is seen; it is bloody in 40% to 50% of patients. Fewer than 25% of patients have associated diarrhea. Vaginal culture reveals the organism.
Treatment
The infection is treated with trimethoprim and sulfamethoxazole, twice daily for 7 days.
Candida Vulvovaginitis
Etiology
The most common pathogen is C. albicans. However, in difficult to treat cases, C. glabrata should be suspected. The disorder is more common in adolescents than in prepubescent girls.
Predisposing factors include diabetes mellitus, recent antibiotic or steroid use, immunosuppression, pregnancy, use of oral contraceptives, and tight-fitting clothes.
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