Vulvovaginitis can occur along a spectrum.
Mild vulvovaginitis can occur very commonly, a child may have several episodes, and in most cases can be managed using simple steps.
Sometimes there can be local skin infection, e.g. Group A streptococcal infection, however this is rarer in younger girls as the non-oestrogenised hymen protects the vagina.
N.B. Vulvovaginitis can occur for a variety of reasons, many of which are unconcerning, however if you have any concerns around the child’s safety or safeguarding then you must discuss this via your normal protocols (on call Paediatric Consultant in working hours, Paediatric Registrar OOH)
Important things to clarify in the history; these questions can also be directed to the child in an age-appropriate way.
- Duration of symptoms
- Clarify the symptoms: is it itching, burning, dysuria / soreness when passing urine, bleeding, etc.
- Is there any bleeding or discharge?
- Any history of trauma?
- Any other perianal symptoms ?( e.g. nocturnal itching)
- Any other household members with symptoms?
- Any changes to toiletries / laundry products?
- Any other skin changes? E.g. eczema or psoriatic type changes
- Is the child potty-trained? Do they wipe their own bottom / privates when they go to the toilet?
In adolescents it may be appropriate to ask about sexual history and to discuss safe sex with signposting to your local GUM services.
Inspection is usually sufficient, but should only take place with the consent of the child.
There may be vulval or peri-vulval erythema, excoriation, or possibly some discharge.
Discharge may be associated with a foreign body.
Poor perineal / peri-anal hygiene may be seen, and this is a common cause.
With consent, the perianal area should also be inspected. Possible signs may include peri-anal excoriation, or the presence of threadworms (more likely in an evening / OOH examination).
- Poor hygiene (if the area is wet or dirty for a protracted length of time this can cause irritation, or if there is contamination of the vulval area if a child wipes front-to-back instead of back-to-front)
- Irritant dermatitis secondary to use of toiletries / bubble baths / laundry products
- Infection (Streptococcal, candida, or threadworms travelling from the anus causing itching and local irritation)
- Foreign body
- Consider safeguarding differentials; e.g. child sexual abuse, physical abuse, or neglect.
- Vulvovaginitis is a differential in “recurrent UTI”. (A child might complain of pain while passing urine, but they often lack the vocabulary to explain exactly where the pain is. Rather than true dysuria they may be describing the symptoms from urine passing over an inflamed area of skin. In these instances a urine dipstick showing leucocytes alone may be due to contamination from the skin, and it would be prudent to await urine culture before giving antibiotic treatment)
Management / Investigations
Simple management is often most effective.
Advice on hygiene and symptomatic relief can be useful. Most children don’t need to use soap or bubble-baths for washing, and non-biological laundry powders should be used on their clothes with no fabric softeners.
Children may need supervision or help with their toileting and hygiene; wiping after a wee or poo should be from front-to-back. Some girls may need to rinse with water and then dry after having a poo or a wee.
Ideally, girls should not wear pants or knickers to sleep in. This will allow better airflow around the area and prevent dampness. Soft, breathable fabrics can be helpful for clothes.
Girls can continue all their usual hobbies and activities, e.g. swimming, but may need some extra help to ensure they are dried completely before re-dressing. Some girls can be allergic to the chlorine in swimming pool water, but a thorough shower afterwards can often help with this.
Barrier creams (eg nappy rash creams, or soft paraffin) can be helpful to prevent urine passing over the inflamed skin.
The shape of the pre-pubescent vagina / vulva can cause urine to pool and then come out later on, which may irritate skin.
Some girls may benefit from sitting backwards on the toilet (i.e. facing the cistern) to help urine drain more easily.
If there is any evidence of threadworms then the whole house should be treated, according to local formulary.
Hand hygiene advice, including keeping nails short and clean, should be offered.
Swabs are often not helpful, but if there are persistent symptoms despite hygiene advice then treatment of infection with appropriate anti-microbial could be trialled.
Persistent symptoms including discharge may be indicative of a foreign body, and further investigation may be required.
If there are any safeguarding concerns then these need to be escalated appropriately as per local protocol.