Background and Presentation

Nonspecific vulvovaginitis generally presents with mucoid discharge, itching, erythema, rash, and/or odor. The drainage specifically is mucoid, thin, and non-purulent. Purulent or green drainage is concerning for a vaginal foreign body. On exam you will note a mild erythematous vulva, and the surrounding skin (labia majora) can be irritated as well. The child may complain of mild discomfort when wiping or voiding if they are able to articulate that and have been potty trained. You may also note signs of poor hygiene such as fecal matter around the anus, and bits of toilet paper

Even if you obtain a bacterial culture the results are generally respiratory, skin, or enteric bacteria and are rarely the cause of an out and out infection. You can however have perianal strep infection, which is generally denoted by a bright red perianal rash. We suspect that prepubertal girls are more likely to develop nonspecific noninfectious vulvovaginitis because of the following contributing factors:

  • Poor hygeine and diaper wearing
  • More alkaline vaginal pH
  • Use of bubble baths or other soaps
  • Obesity
  • Tight clothing
  • Foreign bodies (toilet paper is #1)
  • Itching and scratching from eczema, lichen sclerosis, or pinworms
  • Masturbatory behaviors
  • Sexual abuse

Note that sexual abuse is on there. I have evaluated countless patients who present to the ED with parents who are concerned for sexual abuse because they noticed that “it doesn’t look right down there.” In most of these situations there is not a specific event, but often one parent noticed after the child spent time with the other. In these situations be compassionate, take a good history, and advocate for the child by having a low threshold to involve social work. And remember, a normal exam does not preclude the possibility of sexual abuse – and vulvovaginitis can be seen in a child who has been abused.

Treatment

The mainstays of treatment are hygiene measures. The most important of which are keeping the perivaginal area clean (changing diapers frequently) and wiping FRONT to BACK (vagina to rectum). Wiping the other way around introduces bacteria into the vulva. Here is a list of recommendations:

  • Keep vulva clean, dry, and well aerated – wipe front to back
  • Avoid sleeper and tight pajamas and tight leggings
  • Do not use fabric softeners for underwear and swimsuits.
  • Don’t let children sit in a wet swimsuit
  • Daily warm water only baths – sit waist high for 10-15 minutes then use soap on everywhere else right before the kid gets out of the tub
  • Cool compresses and water based emollients can be soothing
  • Sit backwards on the toilet seat to void
  • Use flushable wet wipes

There are infectious causes, though you’d expect to see these more rarely. Causes include respiratory flora such as Group A Strep, nontypeable H. flu, S. pneumoniae, and even N. meningiditis! GI flora include E.coli, E. faecalis, Klebsiella pneumoniae, Proteus mirabellis and others – you know the UTI rogues gallery. Candida and Gardnerella are NOT usually associated with vulvovaginitis in prepubertal females. If you are concerned about sexual abuse Chlamydia and Gonorrhea are always worrisome among others. Warts and herpes lesions can be due to auto-inoculation – but these patients need to have a child abuse specialist involved.

So if there’s bacteria you treat right? Not necessarily. I generally don’t culture a single episode of vulvovaginitis since hygiene measures work so well. In recurrent or chronic antibiotics and or low potency topical steroids are used. Here are a few scenarios where you might elect to treat.

Strep pyogenes – Generally this is inoculation from another site. You would follow treatment guidelines for strep pharyngitis or scarlet fever. Oral amoxicillin for 10 days is generally recommended. Cephalosporins or Clinda for allergic patients.

Staph aureus – This is generally persistent purulent drainage. Direct treatment towards local MRSA sensitivities, Bactrim and Clinda. If you see local impetigo you can go with topical Mupirocin.

Shigella and Yersinia – These are the only enteric organisms that may not get better with hygiene measures alone. Treat with local sensitivities in mind – and follow treatment for enteric infections – and remember that even enteric infections with this duo don’t always need antibiotics.

References

Garden AS. Vulvovaginitis and other common childhood gynaecological conditions. Arch Dis Child Educ Pract Ed 2011; 96:73.

Jarienė K, Drejerienė E, Jaras A, et al. Clinical and Microbiological Findings of Vulvovaginitis in Prepubertal Girls. J Pediatr Adolesc Gynecol 2019; 32:574.

Zuckerman A, Romano M. Clinical Recommendation: Vulvovaginitis. J Pediatr Adolesc Gynecol 2016; 29:673.