Vulvovaginitis

Disclaimer

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. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of vulvovaginitis.

Definition

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

Background

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)

Assessment

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

Examination

  • Examine the perineum of prepubertal child in 'frog leg' position (girl supine with heels together) and always wear gloves.
  • A nurse chaperone must be in attendance throughout the examination.
  • Do not perform an internal vaginal examination or take vaginal swabs

Investigations

  • Mild Vulvovaginitis
    • No investigations (e.g. swabs) are necessary.
  • Profuse/offensive discharge take an introital swab.

Differential diagnosis

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.
Group A Streptococcus
  • Treat with penicillin. 
S. aureus, H. influenzae, Shingella
  • May resolve with hygienic measures but culture-negative persistent vaginitis may resolve with 10 days of Amoxycillin/Clavulanic Acid.
Candida 
  • 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 (b.d. for 2 weeks) then review by paediatric gynaecologist/dermatologist.

Management

The resolution of non-specific mucoid discharge and/or odour within 2 to 3 weeks should result from the following:

  • Explanation.
  • 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.
    • Emphasise wiping from front to back after bowel motions.
    • May use wet wipes instead of toilet paper if sensitive.
  • Cool compresses may relieve discomfort.
  • Soft paraffin or Nappy-Mate® paste (zinc oxide paste) may help with pain and protect the skin.
  • Occasionally steriod cream if severe excoriation/dermatitis.

Bibliography

  1. Laufer MR and Emans SJ (2014) Vulvovaginal complaints in the prepubertal child. UpToDate. Accessed at www.uptodate.com
  2. Joishy M et al. Do we need to treat vulvovaginitis in prepubertal girls? BMJ 2005;330:186
  3. Stricker,T,et al. Vulvovaginitis in prepubertal girls. Arch Dis Child 2003;88:324
  4. Textbook of Emergency Medicine 2nd edition J Raftos 347-348

Endorsed by:  Director, Emergency Department  Date:  Aug 2017


 Review date:   Aug 2020


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