Evidence Based Strategies: Vulvovaginitis in the Prepubertal Female

Column Author: Kalyn Erickson, DO | Resident PGY 3

Column Editor: Angela D. Etzenhouser, MD, FAAP | Associate Director, Pediatric Residency Program

Vulvovaginitis is a term that is often used to describe many causes of vulvar inflammation. Here, we will discuss many of the various causes of vulvovaginitis in prepubertal females, including their common presentations. 

Many factors predispose prepubertal females to vulvovaginitis. Their prepubertal anatomy, including lack of pubic hair and labial fat pads, provides less protection of the vulvar area. Lack of estrogen keeps the epithelium thin and the pH more neutral, as opposed to a more acidic pH during and after puberty. In addition, ensuring adequate hygiene in a prepubertal female is challenging due to diaper use and lack of supervision when transitioning to independent toileting.

The most common form is nonspecific vulvovaginitis, which causes up to 75% of cases.¹ Exam findings include vulvitis, likely with sparing of the vagina, and the main complaints will be irritation, itching and burning. The common culprits are irritants of the vulvar area secondary to lack of adequate hygiene. A common contributor to the irritation is urine being trapped by the labia and then spilling into the vagina or onto the underwear. Suggestions such as sitting backward on the toilet can help adequately expel any urine that might otherwise be trapped. Additional treatment considerations include avoiding harsh soaps, bubble baths, scented detergents, and using loose cotton underwear or unscented topical emollients such as petroleum jelly.

Other less common causes of vulvovaginitis include infectious and autoimmune etiologies. Bacterial infections are most often caused by respiratory or enteric pathogens. Clinical presentation is similar to that noted above but with the addition of vaginal discharge. Patients will often have rapid onset of symptoms and will present soon after symptoms start. If a bacterial infection is suspected, cultures should be obtained to guide treatment. Sexually transmitted infections should also be considered in the differential diagnosis. Another common infection is Enterobius vermicularis, or pinworms. Pinworms should be suspected in children having itching predominantly at night or not responding to typical treatments for other causes of vulvovaginitis. Yeast infections are rare for prepubertal children who are not in diapers due to the neutral pH of the vagina at this age. Risk factors for yeast infection should be considered, including previous antibiotic use, type 1 diabetes or other immunocompromised states. If a yeast infection is suspected, cultures should be obtained prior to treatment. Lichen sclerosis can present similarly to a yeast infection and is a chronic inflammatory disorder, likely with an autoimmune component. A child will present with dysuria, vulvar discomfort, itching and often constipation. Exam findings include clearly demarcated hypopigmented skin in a “key hole” distribution that appears atrophic and shiny. Ecchymosis or fissures may also be present. This condition is treated with high potency topical steroids and often requires referral to a pediatric gynecologist.

Labial adhesions may present similarly to vulvovaginitis. Inflammation creates a surface for adhesions to form in the setting of the low estrogen state causing the labia minora to form a thin avascular raphe between them. This adhesion usually does not run the entire length of the labia minora allowing for urine to exit; however, it can lead to postvoid dripping that causes irritation. Most children are asymptomatic, with adhesions incidentally noted by caregivers. When cases are asymptomatic, reassurance and time are the best treatment as up to 80% of adhesions will resolve spontaneously within one year.² Adhesions will often recur when children are still in diapers due to continued irritation of the area but should resolve on their own when children are no longer in diapers and almost always when estrogen rises during puberty. If necessary, topical estrogen can be used to treat labial adhesions but is reserved for symptomatic or complicated cases.

Finally, foreign body should be considered in the child presenting with vulvovaginitis. They may present with irritation or burning but will also likely have vaginal discharge, with or without odor. The most commonly found foreign body is toilet paper. Physical exam is the best diagnostic modality as most foreign bodies will not show up on imaging. If you are unable to visualize a foreign body, but have a high suspicion based on symptoms, referral to a pediatric gynecologist may be helpful.

Vulvovaginitis is common in the pediatric population. The differential diagnosis is broad and, in addition to the above, can include contact dermatitis, manifestations of systemic or dermatologic diseases, and behavioral causes. It is important to consider other diagnoses that may require further evaluation and treatment. However, most often the diagnosis is nonspecific vulvovaginitis and is treated with lifestyle modifications.

References:

1. Emans SJ, Laufer MR, DiVasta A. Emans, Laufer, Goldstein’s Pediatric and Adolescent Gynecology. 7th ed. Wolters Kluwer (United States); 2020.
2. Bacon JL, Romano ME, Quint EH. Clinical recommendation: labial adhesions. J Pediatr Adolesc Gynecol. 2015;28(5):405-409. PMID: 26162697. doi:10.1016/j.jpag.2015.04.010
3. Bercaw-Pratt JL, Boardman LA, Simms-Cendan JS; North American Society for Pediatric and Adolescent Gynecology. Clinical recommendation: pediatric lichen sclerosus. J Pediatr Adolesc Gynecol. 2014;27(2):111-116. doi:10.1016/j.jpag.2013.11.004
4. Schlosser BJ. Contact dermatitis of the vulva. Dermatol Clin. 2010;28(4):697-706. doi:10.1016/j.det.2010.08.006
5. Zuckerman A, Romano M. Clinical recommendation: vulvovaginitis. J Pediatr Adolesc Gynecol. 2016;29(6):673-679. doi:10.1016/j.jpag.2016.08.002