Prepubescent Gynaecology
See also Adolescent Gynaecology
Background
The perineum is best examined either with the girl supine with heels together and knees flexed and hips abducted, or in the lateral position with knees drawn up to the chest.
Do not perform an internal vaginal examination or take vaginal swabs.
Vaginal Discharge
- Most newborn girls have some mucoid white vaginal discharge. This is normal and usually disappears by 3 months of age.
- From 3 months of age until puberty, vaginal discharge is usually minimal.
Mild Vulvovaginitis
Mild vulvovaginitis, comprising itch, discharge, redness, and sometimes dysuria, is a very common problem.
The causal factors are:
- Thin vaginal mucosa (the normal prepubescent state)
- Moisture (especially from synthetic fibre underwear, tight clothing, wet swimming costumes, obesity)
- Irritants (soap residue, bubble baths, antiseptics etc)
In mild cases, no investigations are necessary (swabs, if taken, usually grow a mixture of perineal organisms).
Management
- Explanation / reassurance
- Avoid causal factors (see above)
- Vinegar baths may help (add 1/2 cup white vinegar to a shallow bath and soak)
- Soothing creams (eg soft paraffin, nappy rash creams) may help as a short-term measure.
Provide vulvovaginitis parent information sheet (see below).
Moderate / Persistent Vulvovaginitis
- If perianal / vulval itch (or soreness) is a major symptom, consider threadworms. See worms guideline.
- If discharge is profuse / offensive - take an introital swab (do not take vaginal swabs). Sometimes one organism (eg group A Streptococcus, Haemophilus, Gardnerella) has overgrown in the area and treatment with an appropriate antibiotic will help. Candida infection is unusual in children in the 2 years to puberty age range.
- If discharge is bloody, or offensive and persistent, consider a foreign body and refer to paediatric gynaecologist / urologist.
- If there is skin disease elsewhere, consider eczema, psoriasis etc as possible causes.
- Sexual abuse occasionally presents as vulvovaginitis (See Child Abuse Guidelines).
Notes
- If the problem is persistent or recurrent - offer family an appointment for review in the General Paediatric Outpatient Clinics.
Vaginal Bleeding
- Many girls have some vaginal bleeding in the first week of life. This is caused by withdrawal of maternal oestrogens and is a normal variant requiring no investigation or treatment.
Blood stained discharge in an older girl may indicate:
- a vaginal foreign body (see above)
- more severe vulvovaginitis,
- trauma (including straddle injury and sexual abuse)
- excoriation associated with threadworms
- onset of first menstruation. Consider as premature if age less than 8 years.
- Haematuria.
- urethral prolapse (an inflammed "doughnut" of tissue is visible at the urethral meatus)
Labial Adhesions (Labial agglutination)
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Sometimes the medial edges of the labia minor become adherent. This is probably due to a combination of thin vaginal mucosa (the normal prepubescent state) and minor irritation.
This is a normal variant and will resolve spontaneously in late childhood. Provided the child is able to void easily, no treatment is needed other than reassurance.
Other treatment options include manual separation of adhesions (distressing for the child and followed by a high risk of recurrence), or use of oestrogen creams (also followed by a high risk of recurrence). These options are not recommended.
Lichen Sclerosus et Atrophicus
This condition of unknown cause may present with the same symptoms as vulvovaginitis. Sometimes it is asymptomatic but presents when first noticed by a carer.
It usually consists of pale atrophic patches on the labia and sometimes more extensive areas of the perineum. The patches can be confluent and extensive. The condition is often itchy and uncomfortable. Scratching and other minor trauma may lead to further inflammation and purpuric haemorrhage into the skin. Occasionally this is mistaken for sexual abuse.
For asymptomatic cases, no treatment is required other than reassurance.
In symptomatic cases, avoidance of potential irritants (as for vulvovaginitis) is important. Barrier ointments (eg paraffin ointment, nappy rash creams) may help as a short-term measure. In more severe cases a brief course of topical steroid may be used to settle the inflammation. Start with 1% hydrocortisone ointment.
The condition is usually persistent with episodic symptoms. Most cases resolve before puberty but some may continue with problems into adult life.
Parent information sheet (Print version - PDF)
Parent information sheet (HTML version)
