from RCH website

Normal anatomy and development

• Genitalia will change in appearance between infancy, prepuberty and puberty due to the hormonal environment
• Newborns are affected by maternal oestrogens crossing the placenta. It is common to have breast buds, mucoid white vaginal discharge, small volume vaginal blood loss and/or hymenal skin tags
• From 3 months of age until puberty, vaginal discharge is usually minimal
• Menarche usually occurs 2-3 years after thelarche

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Vulval and vaginal pain

Vulval and vaginal pain is common in prepubertal children and many conditions affecting the vulva can be painful including

• Vulvovaginitis
  • Environmental eg poor hygiene, excess moisture or contact irritants
  • Pinworms
  • Bacterial overgrowth
  • Foreign body
  • Sexually transmitted infections
• Vaginal foreign body
• Trauma, including straddle injuries or sexual abuse
• Vulvodynia
  • Persistent pain in vulval area for ≥3 months without an identifiable cause
• Candida infection (unusual in children from 2 years to puberty)
• Systemic conditions eg eczema, psoriasis

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Vaginal bleeding

Vaginal bleeding in the first week of life can be caused by the normal withdrawal of maternal oestrogens (requires no investigation or treatment)

Abnormal vaginal bleeding in children may be caused by

• Vaginal foreign body (toilet paper, small toys or money)
• Excoriation due to moderate-to-severe vulvovaginitis, lichen sclerosus et atrophicus or pinworms
• Trauma, including straddle injuries or sexual abuse
• Precocious puberty (consider when secondary sexual characteristics <8 yo)
• Urethral prolapse (an inflamed “doughnut” of vascular tissue is visible at the urethral meatus)
• Tumour (rare)

Consider causes of non-vaginal bleeding eg Haematuria

Assessment and management

Be aware of signs of sexual abuse based on history or examination

History

• Quality, location and triggers of pain
  • Burning, stinging, unusual sensation or raw discomfort
  • Shooting vaginal or perineal pain at night
  • Inability to insert tampons due to pain
• Itch
• Bleeding
• Discharge
• Dysuria and urinary frequency
• Bowel habit to exclude constipation
• Pubertal stage (to assess for precocious puberty: Tanner staging)
• Sexual history (including superficial dyspareunia in sexually active adolescents)

Examination

If relevant, examine non-genital areas first eg for evidence of systemic skin conditions

Perineal examination

Carefully consider the purpose / need for a perineal examination

• Discuss with a senior clinician
• If perineal examination is necessary, it should only be performed once, by the most suitable clinician
• Senior clinician should be present to supervise and/or chaperone along with the parent
• Provide explanation to the child and parent of the purpose of the examination and obtain consent
• Ensure privacy is maintained and discomfort and distress minimized

The perineum is best examined with the child supine (or semi-supine in a parent’s lap) in a frog-leg position: heels together, knees flexed and hips abducted; or lying on their side with knees drawn up to the chest
The child can assist with separating their labia if they prefer

Do not perform an internal vaginal examination or take internal vaginal swabs in prepubescent children. Discuss with senior clinician if felt necessary

Assess the perineum for

• Anatomy: labial adhesion, urethral prolapse, integrity of hymen and introitus (vaginal entrance)
• Colour: erythema (it is normal for prepubertal children to have mild erythema of the vulva), pale atrophic patches (lichen sclerosis), bruising
• Swelling, dryness, excoriation
• Discharge
• Bleeding
• Pain: using a cotton bud, gently touch the vulval skin, start laterally (away from the labia), moving towards peri-hymenal area. Altered sensation or pain whilst progressively approaching the peri-hymenal area is suggestive of vulvodynia

Carefully document examination findings (describe appearance rather than interpreting findings). Using a clock face diagram can be useful to describe the location (see figure above)

Offensive vaginal discharge and bleeding in pre-menstrual children may be suggestive of foreign body in vagina

Labial adhesion	Urethral prolapse	Lichen sclerosis

Investigations

• Investigations should be directed to the underlying cause
  • If the cause is not clear or if there is concern for a vaginal foreign body, discuss with gynaecologist
• Consider urine MCS
• If profuse / offensive discharge: take a swab for MCS at the introitus (vaginal entrance), do not take internal vaginal swabs. See Sexually transmitted infections to guide other possible investigations

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Vulvovaginitis

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

• Normal prepubescent development
  • Thin vaginal mucosa (secondary to lack of oestrogen)
    • More alkaline pH (pH 7) than post-menarchal girls
• Environmental
  • Moisture (synthetic fibre underwear, tight clothing, wet swimming costumes, obesity)
  • Poor hygiene
  • Irritants (soap residue, bubble baths, fabric softeners, antiseptics etc)
• Infection:
  • Pinworms
  • Bacterial overgrowth
  • Sexually transmitted infections
• Foreign body

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 hips abducted). Ensure hand hygiene and appropriate PPE is used.
• 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 (not vaginal).

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.

Table: Differential diagnosis

Bacterial vulvovaginitis	See treatment options below.
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 (twice daily for 2 weeks) then review by paediatric gynaecologist/dermatologist.

Management of Non-Specific Vulvovaginitis

Explanation and Reassurance

• Explain to the patient that symptoms should resolve within 2-3 weeks with proper management.

Avoidance of Irritants and Moisture

• Advise avoiding excess moisture and irritants that can exacerbate symptoms.

Hygiene Measures

• Review proper hygiene practices, emphasizing wiping from front to back after bowel movements.
• Suggest using wet wipes instead of toilet paper if the area is sensitive.

Bathing Recommendations

• Recommend daily warm baths (not hot).
• Add half a cup of white vinegar to a shallow bath and soak for 10 to 15 minutes.
• Pat the area dry gently after bathing.

Symptomatic Relief

• Cool compresses can be applied to relieve discomfort.
• Emollients such as soft paraffin or zinc oxide paste can help with pain and protect the skin.

Topical Treatments

• Vinegar baths (as mentioned above) can be soothing.
• Prescribe a mild steroid cream if there is severe excoriation or dermatitis.

Pinworm Treatment

• For nocturnal vaginal shooting pain or itch, consider treating for threadworm/pinworms.
  • Mebendazole: 50 mg for children > 6 months and ≤10 kg or 100 mg for those >10 kg, as a single oral dose, repeating after 2 weeks.
  • Advise precautions to minimize the spread, including treatment of all household contacts.

Bacterial Overgrowth

• If significant erythema and pain are caused by respiratory or enteric flora (e.g., group A streptococci or E. coli), consider treatment with cefalexin.
• Antibiotics should be used only if a pure or predominant growth of a pathogen is identified.
  • Culture-Negative Vulvovaginitis: Most cases resolve with hygiene measures alone. For refractory cases, a 10-day course of:
    • Amoxicillin or
    • Amoxicillin with Clavulanic Acid can be considered.
  • Contact Infectious Diseases for advice in patients with documented beta-lactam allergy.

Non-Pharmacological Advice

• Encourage wearing loose-fitting, cotton underwear to reduce moisture and irritation.
• Recommend avoiding bubble baths, scented soaps, and other potential irritants.
• Suggest maintaining a healthy diet and hydration to support overall skin health.
• Emphasize the importance of regular follow-up visits to monitor progress and address any concerns.

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Labial adhesions (labial fusion)

• Normal variant which develops from 3 months (not present at birth) and resolves spontaneously by 6 to 8 years old when oestrogen levels increase at puberty
• Occur when the medial edges of the labia minora become adherent due to a combination of thin vaginal mucosa (normal prepubescent state) and minor irritation
• Usually asymptomatic, rarely may present with urinary frequency and postvoid dribbling if urinary outflow obstruction
• Treatment
  • Provided the child is able to void easily, no treatment is needed
  • Majority resolve spontaneously, provide reassurance
  • Other treatment options such as oestrogen creams or manual separation of adhesions (distressing and painful) have a high risk of recurrence, and are not recommended
    • If there is urinary outflow obstruction, a short course of oestrogen cream may be considered, discuss with gynaecology

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Lichen sclerosus et atrophicus

• Onset 5-7 years old, painless itch, bleeding or discharge; may be asymptomatic. Usually persists with episodic symptoms
• Pale atrophic patches on labia and perineum, which may be confluent and extensive
• Scratching and other minor trauma may lead to further inflammation and purpuric haemorrhage into the skin. Occasionally this is mistaken for sexual abuse
• Treatment
  • Provide reassurance
  • Avoid irritants eg soap residue, bubble baths, antiseptics
  • Treat secondary constipation
  • Barrier ointments (eg paraffin, zinc paste) may help as a short-term measure
  • Course of high potency (then medium potency) topical steroids is often required. Recommend specialist consultation
• Most cases resolve before puberty, but some may continue with problems into adult life

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Vulvodynia

• Vulvodynia is suspected in adult women when vulvar pain or discomfort persists for more than three months and occurs in the absence of any evident pathology.
• The same applies in the case of prepubertal girls
• May be generalised (involving the whole vulva) or localised to part of the vulva or perihymenal area
• May be provoked (caused by touch or any specific stimulus) or spontaneous (occurring without touch as a trigger)
• Management
  • Vulval care is key
  • Pelvic floor physiotherapy can be effective
  • Psychologist input if associated anxiety or depression
  • Ensure any constipation is appropriately managed
  • Medications
    • Topical creams with local anaesthetic agent for short term relief only
    • Consult specialist (gynaecology or pain) for advice on suitability of agents for neuropathic pain eg amitriptyline, gabapentin or pregabalin
  • Complementary therapies such as acupuncture and hypnosis may also be helpful in some children

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Urethral prolapse

• Chronic onset, bleeding, pain, dysuria, constant need to strain
• Treat precipitant eg cough, constipation
• Refer to gynaecology for assessment and consideration of topical oestrogen cream