PERSONAL PRACTICE

Vulvovaginitis

in the adolescent, who should interviewed alone. Questions that

may give a clue to ongoing sexual abuse should also be asked
(behavioural changes, nightmares, fears, abdominal pain, headaches, enuresis, encopresis, and compulsive masturbation).

Tamar Stricker

Physical examination
Abstract

The physical examination should look for evidence of chronic

illness or dermatological disease and include determination of
the pubertal stage. The genitalia should be inspected in the frogleg supine position, with attention to the vulva, introitus, hymen
and anterior vagina, including gentle lateral retraction of the
labia as well as gripping of the labia and pulling anteriorly and
laterally. Signs of inflammation or injury should be sought as
well as the presence of a foreign body. For further assessment of
the vagina and the hymen the girl can also be examined in the
knee chest position. In a rectal examination a foreign body or
mass may be palpated. If sexual abuse is suspected careful
documentation of the appearance of the hymen and introitus are
necessary. In a sexually active adolescent, a complete pelvic
examination with speculum should be performed.

The evaluation of vulvovaginitis, which is common in pediatric practice,

depends on the pubertal development of the patient, keeping the possibility of sexual abuse in mind. Prepubescent girls are especially susceptible to vulvovaginitis because of anatomic and hormonal factors and
because of their tendency to have poor local hygiene. If symptoms persist
despite hygienic measures vaginal secretions should be investigated
microbiologically and specific antimicrobial treatment prescribed accordingly. When the major complaint is of perineal pruritus, especially at
night, empirical treatment with Mebendazole can be considered. In
adolescents, who usually present with vaginal discharge, pruritus or
dysuria, the pH of vaginal secretions should be tested and the secretions
should be examined under the light microscope and sent for microbiological investigations. Physiologic leukorrhea is a common cause of vaginal
discharge in adolescents. In the sexually active adolescent a complete
pelvic examination with speculum should be performed including evaluation of endocervical specimen for sexually transmitted pathogens. Treatment is then directed at the specific cause. The diagnosis of one sexually
transmitted disease necessitates investigation for others and treatment of
the partner.

Investigations
Vaginal secretions should be obtained for examination under the
light microscope and for microbiological investigation in both the
prepubertal and adolescent patient. The specimen can be
collected with a saline-moistened swab or using a sterile
newborn suction catheter carefully inserted 2e3 cm into the
vagina. Vaginal fluid should be evaluated microscopically for
epithelial cells, white cells, motile trichomonads, clue cells, and
for hyphae or spores on a potassium hydroxide wet mount. A
whiff test is performed by adding 10% potassium hydroxide to
wet mount and smelling for the distinctive amine odor. If sexual
abuse is a consideration, appropriate cultures should be
collected. In the adolescent, vagina pH should be measured by
touching a swab to the sidewall of the vagina and then to a pH
paper and in the sexually active adolescent endocervical specimen should be tested for Chlamydia trachomatis and Neisseria
gonorrhoeae.

Keywords acute vaginitis; adolescent; cervicitis; pediatrics; prepubertal;

sexual abuse; review; sexually transmitted diseases; vaginal foreign
body; vulvovaginitis

Definitions
Vulvar inflammation, vulvitis, may precede or accompany vaginitis, which is inflammation of the squamous epithelial tissues
lining the vagina. The hallmarks of the former are irritation and
redness of the vulva causing itching, pain and dysuria, whereas
the major symptom of vaginitis is vaginal discharge. Usually
patients suffer from concurrent inflammation of both the vulva
and the vaginal tissues, namely, from vulvovaginitis. Vulvovaginitis is common in the pediatric practice. The differences in
cause and presentation between prepubescent and adolescent
girls should guide the evaluation.

Vulvovaginitis in the prepubescent girl

Vulvovaginitis is the most common gynecological problem in
prepubertal girls. Factors that explain the increased susceptibility
of children to vulvovaginitis include: The close anatomic proximity of the rectum; lack of labial fat pads and pubic hair; small
labia minora; thin and delicate vulvar skin; thin, atrophic,
anestrogenic vaginal mucosa; and childrens tendency to have
poor local hygiene and to explore their bodies. Most cases of
vulvovaginitis are of nonspecific etiology. However in some
patients the symptoms are caused by infections with specific
respiratory, enteral or skin pathogens. Candida albicans vulvovaginits is uncommon in prepubescent girls and occurs mostly in
association with diapers, treatment with antibiotics, diabetes
mellitus and immunosuppression.

History
History should include questions about itching, discharge
(colour, quantity, odour, consistency and duration), dysuria and
redness. Other issues which should be discussed are: Perineal
hygiene, exposure to irritants such as bubble baths and soaps,
the possibility of a vaginal foreign body, the use of medications,
underlying diseases, anal pruritus, recent infections in the child
or family, and obviously sexual activity and use of contraception

Differential diagnosis & management

Girls suffering from vulvovaginitis should be treated with
hygienic measures: Avoiding tightly fitting clothing or other

Tamar Stricker MD University Childrens Hospital Steinwiesstrasse 75,

CH-8032 Zurich, Switzerland.

PAEDIATRICS AND CHILD HEALTH 20:3

143

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PERSONAL PRACTICE

Clinical Features of vulvovaginitis

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Pathogens causing Specific Vulvovaginitis in

Prepubertal Girls

Vaginal discharge
Genital itching
Genital redness
Dysuria
Genital pain
Vaginal bleeding

Respiratory

Enteral

Skin

Group A b-hemolytic
streptococcus
(Streptococcus
pyogenes),
Staphylococcus aureus

Shigella

Group A b-hemolytic
streptococcus
(Streptococcus
pyogenes),
Staphylococcus aureus

Haemophilus influenzae

irritants like harsh soaps to the vulva, front-to-back wiping after

using the toilet, sitz baths and protective ointments. If symptoms
persist vaginal secretions should be investigated and specific
antimicrobial treatment prescribed according to microbiological
results. Pinworms (Enterobius vermicularis) should be considered in girls whose major symptom is perineal pruritus especially
at night. Attempting to collect eggs using a Sellotape slide test is
difficult for the parents and has a relatively low yield. Therefore,
in suspected cases the patients should receive empirical treatment with a single dose of 100 mg Mebendazole, repeated
2 weeks later. Vaginal foreign bodies can cause symptoms of
vulvovaginitis, however, in the vast majority of cases suggestive
features are present. Other diagnosis which should be considered
based on the clinical findings include: Vulvar manifestations of
skin disease, especially lichen sclerosus; herpes simplex virus
infection and urethral prolapse,
When evaluating girls with vulvovagintis the possibility of
sexual abuse should be kept in mind, especially when sexually
transmitted pathogens are isolated, when findings typical or
suggestive of sexual abuse are seen in the physical examination
or in cases of vaginal foreign bodies. The majority of girls who
have validated histories of victimization, however, have normal
genital examinations.

Moraxella catarrhalis
Streptococcus pneumoniae
Neisseria meningitidis

Acute vaginitis
The three most common types of acute vaginitis are vulvovaginal
candidiasis, bacterial vaginosis and trichomoniasis. In the nonsexually active teenager, candidiasis is the major cause of vaginal
complaints and inflammation, most cases being caused by
Candida albicans. The vaginal discharge is typically white, thick
and curdy (cottage cheese like), without odour. It is accompanied by pruritus, dysuria and burning. The vaginal pH is lower
than 4.5 and microscopic evaluation reveals hyphae or spores on
a potassium hydroxide wet mount. Vaginal culture for Candida
albicans is useful if the clinical features are suggestive and the
wet mount is negative.
Bacterial vaginosis reflects a shift in vaginal flora from lactobacilli-dominant to mixed flora, including genital mycoplasmas, Gardnerella vaginalis, and anaerobes. It is classically
associated with a thin, whitish-grey, fishy-smelling discharge.
Vaginal pH is elevated at 4.5 or greater. Microscopic evaluation
shows typical clue cells and amine odour test is positive.
Trichomonas vaginalis is an intracellular parasite which is the
most common sexually transmitted infection in the United States.
It is typically associated with a yellow discharge that may have

Vulvovaginits in the adolescent

Vaginal complaints in the adolescent are common, consisting
mostly of vaginal discharge, pruritus and dysuria. The major
causes of vaginal discharge in the adolescent are: Physiologic
leukorrhea, vaginitis, cervitis and foreign body, mostly a retained
tampon. In the case of a foreign body the discharge is usually
foul-smelling and bloody. Physiologic leukorrhea, which typically starts before menarche and has a cyclic variation, is
a whitish mucoid discharge resulting from the normal estrogen
effect on the vaginal mucosa. Vaginal wet preparation reveals
epithelial cells and lack of inflammation.

Features of Acute Vaginits in Adolescents

Infection
Bacterial
Vaginosis

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Recall of insertion of foreign body

Vaginal bleeding/blood stained vaginal discharge
Foul smelling discharge
Visualization of foreign body in inspection of the genitalia.
Palpation of the foreign body in rectal examination.

PAEDIATRICS AND CHILD HEALTH 20:3

Symptoms

pH

Malodorous,
>4.5
thin, whitishgray discharge
Trichomoniasis Malodorous,
>4.5
green-yellow
discharge, pruritus,
dysuria
Candidiasis
Thick, adherent,
4 - 4.5
white discharge,
pruritus, dysuria,
burning

Features suggesting a vaginal foreign body

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Yersinia
entercolitica
Enterobius
vermicularis
(Pinworms)

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Wet mount
>20% clue-cells,
Whiff test positive
[ WBCs, motile
trichomonads,
Whiff test variably
positive
[ WBCs, hyphae
or spores

2009 Elsevier Ltd. All rights reserved.

PERSONAL PRACTICE

genital tract (endometrium, fallopian tubes, and adjacent

structures).
It is important to remember, however, that most gonorrhea- and
chlamydia-infected females do not have mucopurulent cervicitis
and that the highest report rates of these bacteria are found among
adolescents and young adults. Therefore routine screening in
asymptomatic sexually active adolescents is very important. The
diagnosis of one sexually transmitted disease necessitates investigation for others and treatment of the partner.
A

Treatment Recommendations of Vulvovaginitis and

Cervicitis in the Adolescent
Diagnosis
Bacterial
Vaginosis

Treatment
Metronidazol 500 mg orally twice daily for 7 d
OR Metronidazol gel 0.75% one applicator (5 g)
intravaginally once a day for 5 d OR Clindamycin
cream 2% one applicator (5 g) intravaginally at
bedtime for 7 d.
Trichomoniasis Metronidazol 2 g orally in a single dose OR
Tinidazole 2 g orally in a single dose
Candidiasis
Topical azole preparations OR topical Nystatin
OR Fluconazole 150 mg orally in a single dose
C Trachomatis Azithromycin 1 g PO X1 OR Doxycycline
100 mg PO twice daily X 7 d
N gonorrhoeae Ceftriaxone 125 mg IM x 1 OR Cefixime
400 mg PO X 1 PLUS treatment for
Chlamydia if Chlamydial infection is
not ruled out

FURTHER READING
Burstein GR, Murray PJ. Diagnosis and management of sexually transmitted diseases among adolescents. Pediatr Rev 2003; 24: 119e26.
Center for Disease Control and Prevention. 2006 Guidelines for treatment
of sexually transmitted diseases, 2007 for gonococcal infections.
Eckert LO. Acute vulvovaginitis. N Engl J Med 2006; 355: 1244e52.
Emans SJ. Vulvovaginal problems in the prepubertal child. In: Emans SJ,
Laufer MR, Goldstein DP, eds. Pediatric and adolescent gynecology.
5th edn. Philadelphia: Lippincott Williams & Wilkins, 2005: 83e119.
Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr
Child Health 2004; 40: 205e7.
Stricker T, Navratil F, Sennhauser FH. Vulvovaginitis in prepubertal girls.
Arch Dis Child 2003; 88: 324e6.
Vandeven AM, Emans SJ. Vulvovaginitis in the child and adolescent.
Pediatr Rev 1993; 14: 141e7.

a foul odour. Additional symptoms are pruritus and dysuria.

Vaginal pH is elevated at 4.5 or greater and a wet mount shows
motile trichomonads and white cells.

Cervicitis
The sexually active adolescent presenting with vaginal discharge
might be suffering from mucopurulent cervicitis, which is characterized by mucopurulent discharge from an inflamed cervix. It
can be caused by Chlamydia trachomatis and Neisseria gonorrhoeae, by herpes simplex or by Trichomonas vaginalis. Additional symptoms include itching, irregular vaginal bleeding and
dyspareunia. If there is lower abdominal pain pelvic inflammatory disease (PID) must be considered. In this serious consequence of sexually transmitted diseases micro-organisms from
the lower genital tract (vagina or endocervix) spread to the upper

PAEDIATRICS AND CHILD HEALTH 20:3

Practice points
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145

In the evaluation of vulvovaginitis, the pubertal development

is more important than the chronological age.
Sexual activity or sexual abuse predispose to sexually transmitted pathogens.

2009 Elsevier Ltd. All rights reserved.