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PERSONAL PRACTICE

Vulvovaginitis in the adolescent, who should interviewed alone. Questions that


may give a clue to ongoing sexual abuse should also be asked
(behavioural changes, nightmares, fears, abdominal pain, head-
Tamar Stricker
aches, enuresis, encopresis, and compulsive masturbation).

Physical examination
Abstract The physical examination should look for evidence of chronic
The evaluation of vulvovaginitis, which is common in pediatric practice, illness or dermatological disease and include determination of
depends on the pubertal development of the patient, keeping the possi- the pubertal stage. The genitalia should be inspected in the frog-
bility of sexual abuse in mind. Prepubescent girls are especially suscep- leg supine position, with attention to the vulva, introitus, hymen
tible to vulvovaginitis because of anatomic and hormonal factors and and anterior vagina, including gentle lateral retraction of the
because of their tendency to have poor local hygiene. If symptoms persist labia as well as gripping of the labia and pulling anteriorly and
despite hygienic measures vaginal secretions should be investigated laterally. Signs of inflammation or injury should be sought as
microbiologically and specific antimicrobial treatment prescribed accord- well as the presence of a foreign body. For further assessment of
ingly. When the major complaint is of perineal pruritus, especially at the vagina and the hymen the girl can also be examined in the
night, empirical treatment with Mebendazole can be considered. In knee chest position. In a rectal examination a foreign body or
adolescents, who usually present with vaginal discharge, pruritus or mass may be palpated. If sexual abuse is suspected careful
dysuria, the pH of vaginal secretions should be tested and the secretions documentation of the appearance of the hymen and introitus are
should be examined under the light microscope and sent for microbiolog- necessary. In a sexually active adolescent, a complete pelvic
ical investigations. Physiologic leukorrhea is a common cause of vaginal examination with speculum should be performed.
discharge in adolescents. In the sexually active adolescent a complete
pelvic examination with speculum should be performed including evalua- Investigations
tion of endocervical specimen for sexually transmitted pathogens. Treat-
ment is then directed at the specific cause. The diagnosis of one sexually Vaginal secretions should be obtained for examination under the
transmitted disease necessitates investigation for others and treatment of light microscope and for microbiological investigation in both the
the partner. prepubertal and adolescent patient. The specimen can be
collected with a saline-moistened swab or using a sterile
Keywords acute vaginitis; adolescent; cervicitis; pediatrics; prepubertal; newborn suction catheter carefully inserted 2e3 cm into the
sexual abuse; review; sexually transmitted diseases; vaginal foreign vagina. Vaginal fluid should be evaluated microscopically for
body; vulvovaginitis epithelial cells, white cells, motile trichomonads, clue cells, and
for hyphae or spores on a potassium hydroxide wet mount. A
‘‘whiff’’ test is performed by adding 10% potassium hydroxide to
wet mount and smelling for the distinctive amine odor. If sexual
abuse is a consideration, appropriate cultures should be
Definitions collected. In the adolescent, vagina pH should be measured by
Vulvar inflammation, vulvitis, may precede or accompany vagi- touching a swab to the sidewall of the vagina and then to a pH
nitis, which is inflammation of the squamous epithelial tissues paper and in the sexually active adolescent endocervical spec-
lining the vagina. The hallmarks of the former are irritation and imen should be tested for Chlamydia trachomatis and Neisseria
redness of the vulva causing itching, pain and dysuria, whereas gonorrhoeae.
the major symptom of vaginitis is vaginal discharge. Usually
patients suffer from concurrent inflammation of both the vulva Vulvovaginitis in the prepubescent girl
and the vaginal tissues, namely, from vulvovaginitis. Vulvovag- Vulvovaginitis is the most common gynecological problem in
initis is common in the pediatric practice. The differences in prepubertal girls. Factors that explain the increased susceptibility
cause and presentation between prepubescent and adolescent of children to vulvovaginitis include: The close anatomic prox-
girls should guide the evaluation. imity of the rectum; lack of labial fat pads and pubic hair; small
labia minora; thin and delicate vulvar skin; thin, atrophic,
History anestrogenic vaginal mucosa; and children’s tendency to have
History should include questions about itching, discharge poor local hygiene and to explore their bodies. Most cases of
(colour, quantity, odour, consistency and duration), dysuria and vulvovaginitis are of nonspecific etiology. However in some
redness. Other issues which should be discussed are: Perineal patients the symptoms are caused by infections with specific
hygiene, exposure to irritants such as bubble baths and soaps, respiratory, enteral or skin pathogens. Candida albicans vulvo-
the possibility of a vaginal foreign body, the use of medications, vaginits is uncommon in prepubescent girls and occurs mostly in
underlying diseases, anal pruritus, recent infections in the child association with diapers, treatment with antibiotics, diabetes
or family, and obviously sexual activity and use of contraception mellitus and immunosuppression.

Differential diagnosis & management


Tamar Stricker MD University Children’s Hospital Steinwiesstrasse 75, Girls suffering from vulvovaginitis should be treated with
CH-8032 Zurich, Switzerland. hygienic measures: Avoiding tightly fitting clothing or other

PAEDIATRICS AND CHILD HEALTH 20:3 143 Ó 2009 Elsevier Ltd. All rights reserved.

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PERSONAL PRACTICE

Clinical Features of vulvovaginitis Pathogens causing Specific Vulvovaginitis in


Prepubertal Girls
C Vaginal discharge
Respiratory Enteral Skin
C Genital itching
C Genital redness Group A b-hemolytic Shigella Group A b-hemolytic
C Dysuria streptococcus streptococcus
C Genital pain (Streptococcus (Streptococcus
C Vaginal bleeding pyogenes), pyogenes),
Staphylococcus aureus Yersinia Staphylococcus aureus
entercolitica
Haemophilus influenzae Enterobius
irritants like harsh soaps to the vulva, front-to-back wiping after vermicularis
using the toilet, sitz baths and protective ointments. If symptoms (Pinworms)
persist vaginal secretions should be investigated and specific Moraxella catarrhalis
antimicrobial treatment prescribed according to microbiological Streptococcus pneumoniae
results. Pinworms (Enterobius vermicularis) should be consid- Neisseria meningitidis
ered in girls whose major symptom is perineal pruritus especially
at night. Attempting to collect eggs using a Sellotape slide test is
difficult for the parents and has a relatively low yield. Therefore, Acute vaginitis
in suspected cases the patients should receive empirical treat-
The three most common types of acute vaginitis are vulvovaginal
ment with a single dose of 100 mg Mebendazole, repeated
candidiasis, bacterial vaginosis and trichomoniasis. In the non-
2 weeks later. Vaginal foreign bodies can cause symptoms of
sexually active teenager, candidiasis is the major cause of vaginal
vulvovaginitis, however, in the vast majority of cases suggestive
complaints and inflammation, most cases being caused by
features are present. Other diagnosis which should be considered
Candida albicans. The vaginal discharge is typically white, thick
based on the clinical findings include: Vulvar manifestations of
and curdy (‘‘cottage cheese like’’), without odour. It is accom-
skin disease, especially lichen sclerosus; herpes simplex virus
panied by pruritus, dysuria and burning. The vaginal pH is lower
infection and urethral prolapse,
than 4.5 and microscopic evaluation reveals hyphae or spores on
When evaluating girls with vulvovagintis the possibility of
a potassium hydroxide wet mount. Vaginal culture for Candida
sexual abuse should be kept in mind, especially when sexually
albicans is useful if the clinical features are suggestive and the
transmitted pathogens are isolated, when findings typical or
wet mount is negative.
suggestive of sexual abuse are seen in the physical examination
Bacterial vaginosis reflects a shift in vaginal flora from lac-
or in cases of vaginal foreign bodies. The majority of girls who
tobacilli-dominant to mixed flora, including genital myco-
have validated histories of victimization, however, have normal
plasmas, Gardnerella vaginalis, and anaerobes. It is classically
genital examinations.
associated with a thin, whitish-grey, fishy-smelling discharge.
Vaginal pH is elevated at 4.5 or greater. Microscopic evaluation
Vulvovaginits in the adolescent shows typical clue cells and ‘‘amine’’ odour test is positive.
Trichomonas vaginalis is an intracellular parasite which is the
Vaginal complaints in the adolescent are common, consisting
most common sexually transmitted infection in the United States.
mostly of vaginal discharge, pruritus and dysuria. The major
It is typically associated with a yellow discharge that may have
causes of vaginal discharge in the adolescent are: Physiologic
leukorrhea, vaginitis, cervitis and foreign body, mostly a retained
tampon. In the case of a foreign body the discharge is usually
foul-smelling and bloody. Physiologic leukorrhea, which typi-
cally starts before menarche and has a cyclic variation, is Features of Acute Vaginits in Adolescents
a whitish mucoid discharge resulting from the normal estrogen
Infection Symptoms pH Wet mount
effect on the vaginal mucosa. Vaginal wet preparation reveals
epithelial cells and lack of inflammation. Bacterial Malodorous, >4.5 >20% clue-cells,
Vaginosis thin, whitish- Whiff test positive
gray discharge
Trichomoniasis Malodorous, >4.5 [ WBC’s, motile
Features suggesting a vaginal foreign body green-yellow trichomonads,
discharge, pruritus, Whiff test variably
C Recall of insertion of foreign body dysuria positive
C Vaginal bleeding/blood stained vaginal discharge Candidiasis Thick, adherent, 4 - 4.5 [ WBC’s, hyphae
C Foul smelling discharge white discharge, or spores
C Visualization of foreign body in inspection of the genitalia. pruritus, dysuria,
C Palpation of the foreign body in rectal examination. burning

PAEDIATRICS AND CHILD HEALTH 20:3 144 Ó 2009 Elsevier Ltd. All rights reserved.

Downloaded for FK UMI Makassar (mahasiswafkumi05@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on March 30, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
PERSONAL PRACTICE

genital tract (endometrium, fallopian tubes, and adjacent


Treatment Recommendations of Vulvovaginitis and structures).
Cervicitis in the Adolescent It is important to remember, however, that most gonorrhea- and
chlamydia-infected females do not have mucopurulent cervicitis
Diagnosis Treatment and that the highest report rates of these bacteria are found among
Bacterial Metronidazol 500 mg orally twice daily for 7 d adolescents and young adults. Therefore routine screening in
Vaginosis OR Metronidazol gel 0.75% one applicator (5 g) asymptomatic sexually active adolescents is very important. The
intravaginally once a day for 5 d OR Clindamycin diagnosis of one sexually transmitted disease necessitates investi-
cream 2% one applicator (5 g) intravaginally at gation for others and treatment of the partner. A
bedtime for 7 d.
Trichomoniasis Metronidazol 2 g orally in a single dose OR
Tinidazole 2 g orally in a single dose
Candidiasis Topical azole preparations OR topical Nystatin FURTHER READING
OR Fluconazole 150 mg orally in a single dose Burstein GR, Murray PJ. Diagnosis and management of sexually trans-
C Trachomatis Azithromycin 1 g PO X1 OR Doxycycline mitted diseases among adolescents. Pediatr Rev 2003; 24: 119e26.
100 mg PO twice daily X 7 d Center for Disease Control and Prevention. 2006 Guidelines for treatment
N gonorrhoeae Ceftriaxone 125 mg IM x 1 OR Cefixime of sexually transmitted diseases, 2007 for gonococcal infections.
400 mg PO X 1 PLUS treatment for Eckert LO. Acute vulvovaginitis. N Engl J Med 2006; 355: 1244e52.
Chlamydia if Chlamydial infection is Emans SJ. Vulvovaginal problems in the prepubertal child. In: Emans SJ,
not ruled out Laufer MR, Goldstein DP, eds. Pediatric and adolescent gynecology.
5th edn. Philadelphia: Lippincott Williams & Wilkins, 2005: 83e119.
Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr
a foul odour. Additional symptoms are pruritus and dysuria. Child Health 2004; 40: 205e7.
Vaginal pH is elevated at 4.5 or greater and a wet mount shows Stricker T, Navratil F, Sennhauser FH. Vulvovaginitis in prepubertal girls.
motile trichomonads and white cells. Arch Dis Child 2003; 88: 324e6.
Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent.
Cervicitis Pediatr Rev 1993; 14: 141e7.

The sexually active adolescent presenting with vaginal discharge


might be suffering from mucopurulent cervicitis, which is char-
acterized by mucopurulent discharge from an inflamed cervix. It
can be caused by Chlamydia trachomatis and Neisseria gonor- Practice points
rhoeae, by herpes simplex or by Trichomonas vaginalis. Addi-
tional symptoms include itching, irregular vaginal bleeding and C In the evaluation of vulvovaginitis, the pubertal development
dyspareunia. If there is lower abdominal pain pelvic inflamma- is more important than the chronological age.
tory disease (PID) must be considered. In this serious conse- C Sexual activity or sexual abuse predispose to sexually trans-
quence of sexually transmitted diseases micro-organisms from mitted pathogens.
the lower genital tract (vagina or endocervix) spread to the upper

PAEDIATRICS AND CHILD HEALTH 20:3 145 Ó 2009 Elsevier Ltd. All rights reserved.

Downloaded for FK UMI Makassar (mahasiswafkumi05@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by Elsevier on March 30, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.

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