CHAPTER 59

Vaginitis

Monica Sifuentes, MD

Vaginal discharge is not an uncommon occurrence in prepubescent and pubescent girls. Primary care physicians are largely responsible for differentiating between a physiologic discharge, or leukorrhea, and a pathologic discharge, which occurs, for example, with a bacterial or yeast infection. In cases of an abnormal discharge, the possibility of sexual abuse must be considered and investigated appropriately (see Chapter 145). Primary care physicians should become familiar with the various causes of vaginal discharge in prepubescent and pubescent girls. More importantly, they should be comfortable performing age-appropriate gynecologic examinations in these patients so that the appropriate treatment can be initiated.

Vulvovaginitis, a term that often is used interchangeably with vaginitis or vulvitis, signifies inflammation of the perineal area, often accompanied by vaginal discharge. The discharge may be bloody, malodorous, or purulent, depending on the etiology (Table 59.1).

Epidemiology

Vulvovaginitis is a common gynecologic complaint in prepubescent girls. Most cases of vulvovaginitis in this age group result from nonspecific inflammation; vaginal cultures show normal flora in 33% to 85% of such cases. The incidence of more specific bacterial causes, such as group A β-hemolytic streptococcus, has been reported in approximately 10% to 20% of patients. Its occurrence seems to be seasonal, however, and confirming the diagnosis depends on the use of proper culturing techniques using the appropriate media. Other bacterial causes include respiratory pathogens, such as Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae, and enteric organisms, such as Escherichia coli, Shigella, and Yersinia enterocolitica. A positive culture for sexually transmitted pathogens such as Chlamydia trachomatis or Neisseria gonorrhoeae is found in approximately 5% of children who are evaluated for child sexual abuse. Higher figures have been reported from select centers and when data from adolescent victims are included. These organisms are not considered part of the normal flora in prepubescent girls. Vaginal and rectal infections with C trachomatis can be acquired perinatally but usually are not considered perinatally acquired after 2 to 3 years of age.

Parasitic infections may also cause vaginal symptoms. Twenty percent of females with a rectal infestation of Enterobius vermicularis, the organism known as pinworm, have vulvovaginitis. Affected patients often complain of anal pruritus in addition to the vaginal discharge. Mycotic infections with organisms such as Candida albicans also can cause symptoms in prepubescent girls, although many of these girls have a previous history of recent oral antibiotic use, diabetes mellitus, immunosuppression, or other risk factors.

Clinical Presentation

Prepubescent and pubescent girls with vulvovaginitis most commonly present with a vaginal discharge, which may be white, purulent (ie, yellow or green), or serosanguineous. Consistency of the discharge can range from smooth and thin to thick and cottage cheese-like. The discharge may also be malodorous. In addition, girls may complain of associated pruritus, erythema, urinary problems such as dysuria and increased frequency, and abdominal pain (Box 59.1). Sexually active pubescent girls with vaginitis from a sexually transmitted infection (STI) (eg, gonorrhea) generally have a more profuse, purulent discharge.

Pathophysiology

Prepubescent girls are at risk for developing vulvovaginitis for anatomic and physiologic reasons. Unlike pubertal girls and young adult women, prepubescent girls have no pubic hair and a smaller labial fat pad to protect the vaginal introitus. The labia minora are small and tend to open when girls are in a squatting position, thereby exposing the vaginal introitus. The relative proximity of the anus to the vagina in young girls also contributes to vaginal contamination with enteric organisms. More importantly, poor hygienic practices (ie, wiping back to front after urination or defecation) can further compound the problem.

In addition, the normal physiology of the vaginal epithelium in prepubescent girls predisposes to vaginitis and vulvar inflammation. The unestrogenized vaginal epithelium is relatively thin, immature, and easily traumatized. Additionally, unlike the acidic environment of the vagina in adult females, in prepubescent girls the pH of the vagina is neutral to alkaline, which allows overgrowth of pathogenic fecal and oropharyngeal bacteria. Local antibody production also may be lacking in the vagina of prepubescent girls. Vulvar skin is also easily irritated by harsh soaps, medications, chemicals such as bubble baths, and tight-fitting clothing or synthetic underwear. Girls who are overweight may be particularly susceptible to perineal irritation and subsequent inflammation of the area.

Differential Diagnosis

A vaginal discharge is normal at 2 distinct times in prepubescent girls: shortly after birth, secondary to the effects of maternal estrogen, and approximately 6 months to 1 year before the onset of menarche (physiologic leukorrhea), which occurs, in most girls, by sexual maturity rating (SMR) (ie, Tanner stage) 4. Other causes of vaginal discharge in prepubescent and pubescent girls are presented in Box 59.2.

Evaluation

Prepubescent Girls

History

A complete history should be obtained in all girls with a vaginal discharge (Box 59.3). Practitioners should inquire about the appearance of the discharge, its duration, and the relative amount. A profuse, purulent discharge is probably more consistent with 1 specific etiology (eg, N gonorrhoeae) than is a scant, thin discharge, which is suggestive of a nonspecific etiology. The existence of urinary problems also should be determined. Pooling of urine in the vagina secondary to labial fusion can result in vulvovaginitis in addition to a urinary tract infection. Changes in bowel or bladder habits and sudden changes in behavior, such as nightmares or inappropriate stranger anxiety, also should be noted. Such changes in behavior warrant a further inquiry into the possibility of sexual abuse, regardless of the practitioner’s index of suspicion. Depending on the information disclosed and the age of the patient, a decision might be made to interview the child and parents or guardians independently. Other points to discuss include the type of detergents or soaps used for laundry as well as for bathing, because these may be irritating. Any recent illnesses also should be documented as a possible source of autoinoculation or, if oral antibiotics were prescribed, as a reason for the alteration of the normal vaginal flora. Additionally, patients’ hygienic practices should be reviewed. Adolescent patients should always be interviewed alone (see Chapter 4). In particular, a confidential reproductive history must be obtained, keeping in mind that puberty and sexual activity alter normal vaginal flora.

Physical Examination

Although the genital examination is the priority, a complete physical examination should be performed. Doing so not only allows physicians to identify other abnormal physical findings, but also alleviates some of the anxiety often associated with a genital examination. Because most vaginal discharges in prepubescent girls result from nonspecific vulvovaginitis, visualization of the cervix with a speculum is not indicated. Regardless of the sex of the examiner, a chaperone is required during the genital examination, particularly in postpubertal patients.

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