June 19, 2019
Vulvovaginitis is a common condition that causes irritation or inflammation of the genital area. Vulva is a word girls might not have heard before. Most girls will use the word vagina to refer to their genitalia. The vulva is actually the external part of the female genitalia and the vagina is the internal part.
Vulvovaginitis occurs frequently in young girls because of anatomic differences and behavioral factors. Anatomy in pediatric patients is different than adults. The skin on the vulva and vaginal mucosa is thinner due to having less estrogen making these areas more sensitive to allergic exposures. The vulva is also underdeveloped, lacking pubic hair and labial fat pads, which leaves the vagina unprotected from external irritants including bacteria from the anus. Their vaginas have a neutral pH, unlike adults, whose pH is moderately acidic. All these factors contribute to bacterial growth in girls.
Finally, young girls tend to have poor hygiene with both hand washing and vulvar and perianal cleaning, and wiping after bowel movements. These can lead to fecal bacteria or other organisms associated with urinary tract causing infections. Young girls may also rush to urinate and do not wipe themselves carefully. This can result in urine collecting in the vagina giving bacteria a medium to grow. Scratching, thumb sucking and nose picking can also introduce oral and skin bacteria to the vagina.
Girls with vulvovaginitis can present with vaginal discharge, itching, prepubertal vaginal bleeding, redness, or complaints of discomfort when urinating or wiping. Parents might report an odor or staining in a child’s underwear. Asking a girl’s history from both the parent and the patient is helpful in making the diagnosis and determining the best treatment. Your pediatric and adolescent gynecologist, pediatrician, or family medicine physician will ask many questions at the office visit. Some questions include the onset, timing and duration of symptoms, what measures or remedies have been used to improve symptoms, and what prior testing or evaluation for the condition has been performed.
Discussion of acute or chronic irritant exposures such as fabric softeners, bubble baths, hair products, and lotions should be addressed. Inquiring how the child is wiping after urinating and bowel movements is important. The possibility of sexual abuse should also be assessed.
The evaluation is guided by both the patient’s age and her associated symptoms. A physical exam of the genital area is important to identify if there is an infection. An internal examination is usually not necessary. A small cotton swab might be used to obtain a culture. If a foreign object is seen – the most common is toilet paper – this can sometimes be gently irrigated using sterile water. If the object isn’t removable in a doctor’s office, an exam under anesthesia might be warranted.
The most common bacteria associated with vulvovaginitis are respiratory and gastrointestinal organisms. Medical management is targeted toward the underlying pathogen. Yeast infections are uncommon outside of the diaper period and can be identified with a vaginal swab. Sexually transmitted infections are obtained in patients with a concern and treated according to the Centers for Disease Control and Prevention guidelines.
Some patients who present with vulvovaginitis might have symptoms as a result of a pinworm infection. In these patients, pinworm testing can be performed and if positive the child, all household contacts and caregivers should be treated.
To prevent future infections girls should be counseled to wash their hands before and after going to the bathroom, particularly when they have upper respiratory infections to prevent autoinoculation. Girls should use unscented soap to wash the external vulva and should not place soap inside the vagina. Avoiding irritating products such as bubble baths can be helpful. Instruct girls to use careful hygiene after using the restroom and to wipe from front to back. Wearing loose cotton underwear and changing out of a wet swimsuit as soon as possible are recommended.
Dr. Rachael L. Polis is a pediatric and adolescent gynecologist at Crozer-Keystone Health System. She sees patients from newborn to 25 years old in Crozer-Keystone OB/GYN offices in Broomall, Media and Upland. Call 610-619-8300 for an appointment.