Fiona M. Lewis The normal bacterial environment of the vulva differs in the child as it is poorly oestrogenised with a lack of lactobacilli and a more alkaline pH. This can make the genital tract more prone to bacterial infection, but infections that are very common in adults such as candidiasis are rare in children. The inner aspect of the vulva is relatively exposed in the child as the fat pads of the labia majora and mons pubis have not developed, and organisms can readily spread. In post‐pubertal adolescents, the adult pattern of infection evolves as the microbiota change. Infection in children can occur via several routes. Transplacental (e.g. congenital syphilis) and perinatal transmission in the birth canal (e.g. herpes simplex, streptococcal infections, and lower genital tract warts) is important in neonates and infants. In older children, poor hygiene can spread threadworms and bacteria on towels and flannels by direct contact. Another factor is that the distance between the anus and perineum in a child is short, and poor hygiene habits such as back to front wiping after defecation can lead to the introduction of organisms from the bowel to the vulva. Sexually transmitted infections are a problem in some countries with high rates of child trafficking and prostitution [1]. Abuse is very likely if syphilis or gonorrhoea is diagnosed. In one series of 127 children with an STI, 74% had been abused [2]. However, infection can also occur with contact with an infected individual, and in those under the age of 2 years, perinatal transmission should be considered. Trichomonas vaginalis vulvovaginitis may occur in children through sexual contact, but female infants born to women with trichomoniasis can acquire the infection during delivery, although the risk is low [3]. The approach to history taking and examination of the child is discussed in Chapter 5. If infection is suspected, a vulval swab will often grow the causative organism if there is a discharge. Swabs should not be taken in direct contact with the hymen, as this is painful. For persistent infection, or where a foreign body is suspected, referral to a paediatric gynaecologist for formal examination under anaesthesia and possible vaginal lavage may be needed. The symptoms, signs, and management of several infections is exactly the same in children as in adults. Infections such as folliculitis, staphylococcal scalded skin syndrome, and pinworm/threadworm infection are discussed in Chapter 19. This chapter will look at specific infective conditions in children and paediatric manifestations of other less common infections. Vaginal foreign bodies are included here as they are an important cause of persistent vaginal discharge, bleeding, and secondary infection. In one series, a foreign body was responsible for 3% of cases of persistent vaginal discharge in children [4]. Toilet paper is the most common foreign body removed, but small toys, hair balls, and other small objects can be the cause [5]. Plain X‐rays are not helpful as the foreign body is often not radio‐opaque, but MRI may give more information [6]. Examination under anaesthetic is often required. Removal can be straightforward and is sometimes possible as an outpatient in older children. Symptoms and signs resolve rapidly after removal. If the diagnosis is delayed, there is a higher rate of complications, which can lead to fistulae and abscesses [7]. Complex surgery can be required if structures are damaged, with one case of vaginal perforation abutting the rectum reported [8]. Inflammation of the vulva (vulvitis) and vagina (vaginitis) can occur separately, but it is rare for the vulva not to be involved in vaginal infection as the associated discharge causes an irritant reaction on the vulva. The term vulvovaginitis is often used to describe non‐specific vulval symptoms when there is no vaginal involvement at all, and it should therefore be reserved for inflammation at both sites. The common pathogens in children are Group A (S. pyogenes) and B streptococci, S. aureus, Haemophilus influenzae, E. coli, and Shigella and Klebsiella species [9]. Group A streptococci are the most common cause of infection [10]. The main symptoms are itching, soreness, and dysuria [11], but Group A streptococcal and Shigella infections may cause bleeding [12]. When the primary problem is a vaginitis, the child may present with few symptoms, the parents being more concerned by the discharge. A useful sign suggesting a heavy discharge is a degree of pigmented erythema and scaly rim on the inner dependent parts of the labia majora [13]. Clinical findings include a discharge and erythema. In severe cases, erosions can develop secondary to a severe irritant dermatitis. In children who present with vulval inflammation accompanied by a discharge, an infective cause is most likely. If there is no discharge, a dermatosis is the usual cause (see Chapter 49). Eczema, psoriasis, and other causes of a napkin eruption can have similar clinical features. A persistent, malodorous, purulent, or blood‐stained discharge raises the possibility of a retained foreign body.
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Vulval Infection in Children
Investigation of infection in children
Common vulval infections in children
Foreign bodies
Bacterial infections
Infective vulvovaginitis
Pathophysiology
Clinical features
Differential diagnosis
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