Pediatric Vulvovaginitis

Infrequently in the general gynecologist’s office, you may be asked to evaluate a child for concern of vulvovaginitis. Today’s episode will review some common questions regarding approach in pediatric gynecology, and be specific to a pre-pubertal population.

Many times this is the first time that the young patient has seen a gynecologist! It’s going to be a scary and unfamiliar environment, as the only context for physicians for many children at this point are their pediatrician or family physician. You’ll likely have to lean in to the parent/close relative/guardian for history and more information regarding chronicity, anxieties, and specific complaints.

Common complaints can include:

• Itching or discharge.

• Pain or irritation.

• Issues with going to the bathroom (ie. some children may have issues of leaking urine, seemingly losing the developmental milestone of urinary continence).

The approach in pediatrics is somewhat different:

• Getting the trust of the patient - this may be harder for us as Ob/Gyns, since we are not always used to dealing with a pediatric population.

  1. Stickers, coloring books, asking about school and friends etc.

• If they are old enough to speak for themselves, always ask them what’s going on!

• Then ask/tell them that you are going to talk to their parent/guardian who is with them that you’d like to ask them as well what is going on — this is respectful of the child and keeps them involved.

• For adolescent patients, usually have the parents/guardian step out of the room for some time for sensitive questions 

  1. Assess risk: safety at school, home, people they don’t get along with or who may be hurting them 

  2. Drug/alcohol/tobacco use - kids may feel guilty about using. Ask if friends/family use, then can broach the subject with them.

  3. Sexual activity (usually approached with “Do you have anyone at school that you might like? Have you held hands or kissed them?).

Specific questions related to the complaint:

• Assessment of vulvar hygiene

  1. Showering/bathing habits - bubble baths? What types of soaps? 

  2. Toileting - how do they wipe? Have them demonstrate 

  3. Choice of clothing/clothing due to hobbies/activities - leotards, tights, swimsuits, etc - how long are they wearing them during the day? What kind of underwear? What about pajamas? 

• The exam

  1. Most children will not have had a pelvic exam, and most (read: almost all) do not require a speculum exam!

  2. Check for abnormal breast development (ie. early breast development) in younger children.

  3. Check for abdominal masses.

  4. Pelvic exam:

     1. Child can be laid back on the table in frog leg position, can also have parent sitting on exam table and holding child on lap in this position.

     2. Careful external examination, also can spread labia from lower legs/bottom and look at urethra/hymenal ring.

        1. Look for skin changes on the labia - red? White? Thin? 

        2. Also, see if there is labial adhesions.

        3. Purulent discharge/other types of discharge can be seen on underwear as well 

     3. Q-tip test to evaluate for vaginal potency.

     4. Foreign objects that cannot be easily removed should not be done in the office with smaller children, may require vaginoscopy  

Now let’s review some differential diagnoses that may present in young children.

Infectious 

1. Candida 

   1. Possible to have yeast infection in children who have had recent antibiotic treatment or if they wear diapers.

   2. Usually uncommon in normal prepubertal girls, unlike in women.

   3. If mostly on the outside, or diaper dermatitis, can use topical antifungal agents like nystatin, clotrimazole, miconazole, etc.

2. Gardnerella - also possible, but it is not common. Treat like BV. 

3. STI - suspect if purulent discharge with evidence of sexual abuse on interview/exam

   1.  Evidence includes anal or genital tears, evidence of ejaculation.

   2. Laceration to lower half of the hymenal ring, usually 3-9 o’clock is consistent with penetrating injury.

   3. Suspicion of child abuse is something that requires mandatory reporting to authorities.

   4. Things to test for include gonorrhea, chlamydia, trichomonas.

   5. Genital warts: can be diagnosed clinically and usually with biopsy.

Noninfectious 

• Foreign body

  1. Can cause acute and chronic vulvovaginitis with purulent discharge, foul smell, and even bleeding.

  2. Most common things are toilet paper, small toys, etc → can usually be removed with warm vaginal lavage (ie. obtaining thin catheter and attach to 60cc syringe). Place the tip of catheter into the vaginal canal, and can lavage several times 

  3. Can treat introitus with small amount of Xylocaine jelly if needed for pain / local anesthetic.

  4. If large object or not easily removed, may need sedation/anesthesia for extraction.

  5. If there is suspicion for battery within the vagina, this is a reason for anesthesia, vaginoscopy for possible burns 

• Trauma 

  1. Vulvar trauma can cause significant bleeding - area is highly vascular 

  2. Interview is important - was there recent straddle injuring/skating injury?

     1. History should correlate with physical finding - otherwise suspect abuse.

  3. Straddle injury: injury usually anterior area of the vulva, including mons, clitoral hood, and anterior aspect of the labial 

     1. Should not have injury to the posterior fourchette and hymenal areas - this would suggest sexual abuse.

     2. Assess ability to urinate and presence of hematoma; if unable to urinate,, need to drain bladder, ice, and give pain medication if large hematoma.

        1. If not obstructive, can ice and give pain medication. Most hematomas will resolve spontaneously 

     3. Surgery is rarely needed and can result in introduction of skin → infection 

Skin issues 

• Lichen sclerosus 

  1. We talked about lichen sclerosus in postmenopausal women previously!

  2. It can cause itching, discomfort, even discharge.

  3. Usually appears white, thin skin (onion skin, cigarette-paper), and usually around the vulva and perianal regions.

     1. Can usually diagnose with visual inspection, and biopsy is rarely needed, though in adults you should biopsy (can be associated with malignancies in adulthood).

  4. Treatment: superpotent topical steroids → first start with more frequent treatment, then maintenance therapy.

• Labial adhesions

  1. Most frequently in infants and young children, peak incidence up to 3% in second year of life in girls.

  2. Usually due to inflammation + low estrogen.

  3. Can lead to discomfort and possible issues with urination, recurrent urinary tract infection.

  4. If asymptomatic, no treatment is necessary especially if it only involves a small portion of the labia.

  5. If symptomatic - initial treatment with topical estrogen/estradiol cream twice a day with fingertip or Q-tip, sometimes with a little pressure, but do not try to manually separate the adhesion as this can cause tearing/pain/bleeding.

     1. Usually can see a thin, translucent raphe in the middle (location of placing estrogen) 

     2. Another option is topical betamethasone as alternative or adjunctive topical treatment  

  6. Surgical separation - rarely indicated. Usually only for those with severe obstruction to urinary flow or who have urinary retention. 

• Vulvar ulcers 

  1. Can be non-sexually transmitted ulcers and can present with systemic symptoms like fatigue, malaise, fever, etc.

  2. Etiology may not always be determined, but viruses can sometimes cause them (ie. flu A, EBV, mycoplasma, CMV).

     1. Take a careful sexual history to rule out other STDs, HSV - but perform these tests as well just in case.

  3. Can also test with CBC and monospot test.

  4. If continues to be painful, unable to urinate, some girls may need to be admitted for pain control and foley placement.

  5. Other things to rule out: Behcet’s syndrome (if chronic ulcers), Crohn’s disease.

Nonvaginal issues 

• Urethral prolapse

  1. Distal end of the urethra can prolapse either partially or in a complete circumferential fashion (“donut-like”).

  2. Tissue can be friable and can become infected.

  3. Usually will have pain with urination, bleeding, etc. 

  4. May need to differentiate from other things like sarcoma botryoides or prolapsed ureterocele (may need a urologist!).

  5. If symptomatic, can be treated with topical estrogen 2x/day for two weeks, and then reassess.

• Pinworm 

  1. Can cause vulvar symptoms as well, like itching, but usually is perianal itching.

  2. Caused by the worm enterobiasis.

  3. Can be diagnosed with visual inspection or “paddle test” where there is a plastic paddle sometimes with adhesion pressed to perianal area → then place on glass slide to see worms.

  4. Treatment is with albendazole or mebendazole, and should think about treating the entire household.

  5. Wash all bedding and clothes!

Benign Vulvar Dermatoses

So back in December 2019 (episode 66), we talked about vulvovaginal itching and gave a broad differential for workup of this very common symptom. Today, we thought we might focus on a few of the commonly tested and supremely confusing vulvar dermatoses, based on the new ACOG PB 224.

A quick refresher on diagnosis and workup: 

• History and physical are supreme in helping you establish acute vs. chronic and narrowing down most likely suspects.

• Labs beyond a wet mount are usually not needed, unless suspecting immunocompromise or needing a genital culture for persistent vaginitis symptoms.

• Biopsies in general are reserved for ruling out possible premalignant or malignant areas.

Lichen Simplex Chronicus (LSC)

• Chronic, nonscarring, inflammatory condition characterized by intense itch-scratch.

  • Most commonly reported symptom is chronic or intermittent intense itch, most commonly in the evening or night.

• Very common - accounting for up to a third of vulvar clinic visits, and often is a secondary condition of other “itchy” vulvar disease like contact dermatitis. 

• Most commonly encountered in middle aged women or elderly, and in women with a history of environmental allergies, asthma, or childhood eczema.

• On exam, appearance is often erythematous, scaling, and/or lichenified (thickened/leathery) plaques, with variable degrees of excoriation due to the intense itching associated with the condition. 

  • The skin with longstanding disease is often described as “bark-like” it’s so thick! 

• Consideration can be given to identifying other diseases that may be contributing to itching, such as candidiasis, but biopsy is not generally indicated.

• Treatment is multipronged:

  • Education on stopping the itch-scratch cycle.

  • Removal of offending/worsening factors, such as contact dermatitis, excessive heat/moisture, or treatment of infection.

  • Medium or high-potency topical corticosteroid, applied once or twice daily. If started on steroid, should be seen again within 4 weeks to assess response and adjust course. 

  • Oral anti-pruritic medications.

Lichen Sclerosus

• Chronic, scarring disorder that is bimodal in age distribution -- affects most commonly the anogential skin of prepubertal girls and postmenopausal women. 

• Often asymptomatic and goes unrecognized by many clinicians.

• If symptomatic, most common presenting symptoms include itching/irritation/burning, dyspareunia, and tearing.

• On exam, the skin often has the classic “cigarette paper” appearance - thin, whitened, and crinkled. 

  • Extensive involvement from the superior vulva to the perianal tissue may create an “hourglass shape” of involvement which is classic for this disease.

  • Due to the scarring nature of the condition, the introitus may be narrowed, there may be phimosis (inability to retract skin around) of the clitoral hood, and presence of fissures. 

• Biopsy is generally warranted in postmenopausal patients - patients with LS have increased risk of vulvar squamous cell carcinoma, ranging from 2-5%. 

  • Biopsy should be undertaken in areas which appear to be high risk -- i.e., if presence of any ulcers/erosions, or hyperpigmented or hyperkeratotic areas.

• Treatment of LS is important in order to halt and prevent further scarring. Initially, a high potency corticosteroid should be used, generally clobetasol propionate 0.05% or mometasone furoate 0.1%. 

  • Dosing / application schedule is not well studied, but the PB recommends nightly for 4 weeks, every other night for 4 weeks, and then twice weekly for 4 weeks.

  • Maintenance therapy is generally needed until puberty in girls, or lifelong in older patients, and should be the most infrequent dosing that maintains resolution. 

  • For disease not responding to steroids, it is most important to ensure the diagnosis is correct! You don’t want to treat VIN/ vulvar SCC with steroids. 

    • Intralesional steroid injections or topical calcineurin inhibitors such as tacrolimus can be used for particularly resistant disease, but consider vulvar specialist referral before you are doing these.

Lichen Planus

• Multisystem scarring dermatosis affecting the skin, oral mucosa, and vulvovaginal area, likely as a consequence of a dysfunctional cell-mediated immune system. 

  • Autoimmune disorders have been seen in up to a third of patients with LP.

• Rare, with incidence in general population less than 1%. 

• Most common in perimenopausal and menopausal women. 

• Common presenting symptoms are dyspareunia, burning, soreness, itching, and vaginal discharge.

• Diagnosis is complicated as there are multiple potential presentations; However, over 70% with vulvovaginal disease will also have oral involvement, so if suspected an oral exam should also be performed. 

  • Classic (papulosquamous): white, reticular, lacy, fernlike striae.

    • Dusty pink, poorly demarcated papules may also be present.

    • Occasionally with extensive involvement can “white out” vulvar skin and make picture confusing versus lichen sclerosus.

  • Erosive deep, painful, and erythematous lesions appear in posterior vestibule extending to labia minora. Architecture is often distorted and vaginal epithelium may be completely denuded. Lesions are extremely friable. 

  • Hypertrophic is the least common presentation, though with white, thick, warty plaques. 

• Wet mount performed for diagnosis will often demonstrate an abundance of immune cells in addition to parabasal and basal epithelium, as well as increased pH (5-6)

• Biopsy may be indicated based on the presentation, and may be helpful for distinguishing from rarer diagnosis like bullous pemphigoid / pemphigus vulgaris (ask your derm friends).

• Treatment is based on expert opinion but is high-potency topical corticosteroids, generally twice daily and tapered back over time. 

  • For erosive disease, also should be treated with intravaginal steroid therapy, such as hydrocortisone suppositories, and followed by vulvar specialist. 

  • Often will also need dilator therapy along with steroids due to scarring nature of disease. 

A quick word on topical corticosteroids

• So medium and high-potency corticosteroids feature heavily in the treatment of benign vulvar dermatoses… so review PB 224 for a list of them! 

  • Ointments are the preferred treatment compared to creams, lotions, or gels, as the ointments have the least additional additives that can make skin more sensitive and also allow for highest effective dose to penetrate the skin. 

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ACOG PB 224