These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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To guide PCH Emergency Department (ED) staff with the assessment and management of vulvovaginitis.


Vulvovaginitis is the general term which refers to many types of vaginal/vulva inflammation or infection.


In prepubertal girls usually 2-8 years, non-specific vulvovaginitis is responsible for 25-75% of vulvovaginitis.

Causal factors of non-specific vulvovaginitis in prepubertal child

  • Unoestrogenised thin vaginal mucosa with lack of labial development
  • More alkaline pH (pH 7) than post-menarchal girls
  • Moisture to area (aggravated by synthetic fibre underwear, tight clothing, wet bathers, obesity, poor hygiene)
  • Irritants (e.g. bubble baths, shampoos, soaps, antiseptics).


Signs Symptoms
  • Redness
  • Swelling to area
  • Bleeding
  • Vaginal discharge
  • Pruritis
  • Dysuria


  • Examine the perineum of prepubertal child in 'frog leg' position (girl supine with heels together and hips abducted). Ensure hand hygiene and appropriate PPE is used.
  • A nurse chaperone must be in attendance throughout the examination.
  • Do not perform an internal vaginal examination or take vaginal swabs.


  • Mild Vulvovaginitis
    • No investigations (e.g. swabs) are necessary
  • Profuse/offensive discharge take an introital swab (not vaginal).

Differential diagnosis1,3

If persistent, offensive or bloody discharge, consider the following:

  • Threadworm - if pruritus (vulval and/or perianal) is prominent especially at night.
  • Foreign body - if chronic vaginal discharge, intermittent bleeding, offensive odour. Toilet paper commonest foreign body. Refer to paediatric gynaecologist as required.
  • Specific organisms if discharge is profuse/offensive take an introital swab.

Table: Differential diagnosis1,3

Bacterial vulvovaginitis
  • See treatment options below.
  • Unusual (3%) in > 2 year old prepubertal girls
  • Usually if recent antibiotic therapy, immunocompromised or wearing nappies
Sexually Transmitted Infections
  • Typically the result of sexual abuse with some exceptions
  • All cases of Neisseria gonorrhoea, Chlamydia trachomatis, HPV, Herpes simplex must be referred to Child Protection Unit for further assessment.
Systemic Illness
  • Measles, Chickenpox, Kawasaki disease, Steven-Johnson syndrome, and Crohn’s disease may be associated with vulvovaginal symptoms.
Lichen Sclerosus
  • Dermatological abnormality - unclear aetiology.
  • Presents with pruritus, discharge and/or bleeding. It usually consists of pale atrophic patches on the labia and perineum. The patches can be confluence and extensive.
    • If asymptomatic – no treatment required.
    • If symptomatic (itchy, uncomfortable and bleeding) - avoid irritants/use barrier cream +/- 1% hydrocortisone (twice daily for 2 weeks) then review by paediatric gynaecologist/dermatologist.


Management of non-specific vulvovaginitis once the above differential diagnoses are excluded:

  • Explanation that symptoms should resolve within 2-3 weeks
  • Avoid excess moisture and irritants
  • Daily warm baths (not hot)
    • Add half a cup of white vinegar to a shallow bath and soak for 10 to 15 minutes
    • Pat dry
  • Review hygiene with child:
    • Emphasize wiping from front to back after bowel motions
    • May use wet wipes instead of toilet paper if sensitive
  • Cool compresses may relieve discomfort
  • Emollients (soft paraffin or a zinc oxide paste may help with pain and protect the skin
  • Steroid cream can be prescribed if severe excoriation / dermatitis
  • Consider treatment for threadworm
  • Current evidence suggests that in prepubertal girls with clinical features of vulvovaginitis, antibiotics should only be used if a pure or predominant growth of a pathogen is identified. Choice of agent should be based on culture and susceptibility results.
  • For culture-negative vulvovaginitis, the majority of cases with resolve with hygiene measures alone. For refractory cases a 10 day course of amoxicillin or amoxicillin with clavulanic acid may be considered. Contact Infectious Diseases for advice in patients with documented beta-lactam allergy.


  1. Grover SR and Brabyn C (2019) Paediatric gynaecology, Textbook of Paediatric Emergency Medicine 3rd Edition, p389-90.
  2. Stricker,T,et al. Vulvovaginitis in prepubertal girls. Arch Dis Child 2003;88:324
  3. Laufer MR and Emans SJ (2014) Vulvovaginal complaints in the prepubertal child. UpToDate. Accessed at
  4. Joishy M et al. Do we need to treat vulvovaginitis in prepubertal girls? BMJ 2005;330:186

Endorsed by:  CAHS Drug and Therapeutics Committee  Date:  Dec 2021

 Review date:   Dec 2024

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